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Keywords late preterm infant breastfeeding neonatal intensive care unit premature infant

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Establishing Breastfeeding with the Late Preterm Infant in the NICU Carrie-Ellen Briere, Ruth Lucas, Jacqueline M. McGrath, Mary Lussier, and Elizabeth Brownell

ABSTRACT Objective: To describe challenges that late preterm infants (LPIs) face with breastfeeding and to provide an overview of current policy statements and practice guidelines that support breastfeeding for LPIs. In addition, we describe current breastfeeding research related to the LPI and combine this research with policies and practice guidelines to provide evidence-based recommendations to guide practice and future research in the NICU. Data Sources: Cumulative Index to Nursing and Allied Health Literature and PubMed databases. Study Selection: Policies, guidelines, and research relevant to breastfeeding the LPI were selected if they were published between January 1, 2009 and March 1, 2014. All documents were published in English and related to breastfeeding management or breastfeeding outcomes for the LPI. Data Extraction: Information from articles, policies, and guidelines were chosen for their relevance to breastfeeding the LPI. Data Synthesis: Policy statements and practice guidelines were reviewed to provide an understanding of breastfeeding recommendations for the LPI. Additionally, recent research studies were reviewed and combined with the policy statements and practice guidelines to provide practice recommendations for NICU providers. Conclusions: LPIs require a unique set of interventions for breastfeeding success; though they might be perceived as small, full-term infants, these infants often have greater challenges with breastfeeding than their term counterparts. Future research should be directed at identifying and testing specific strategies that will best support this at-risk population. Findings from this article are applicable for the LPI in the NICU as well as other care areas such as special care and transitional nurseries.

JOGNN, 44, 102-113; 2015. DOI: 10.1111/1552-6909.12536 Accepted July 2014

Correspondence Carrie-Ellen Briere, PhD, RN, CLC, Department of Nursing Research, Connecticut Children’s Medical Center, 282 Washington Street, Hartford, CT 06106. CBriere@ ConnecticutChildrens.org The authors and planners for this activity report no conflict of interest or relevant financial relationships. The article includes no discussion of off-label drug or device use. No commercial support was received for this educational activity.

n 2010, almost a half million late preterm infants (LPIs) (born between 34 0/7 and 36 6/7 weeks gestation) were born in the United States (Hamilton, Martin, & Ventura, 2010). These infants constitute 71% of all preterm births (Medoff Cooper et al., 2012), and though most LPIs are initially admitted to the wellborn nursery, 20% of these infants are later admitted to the NICU for complications and medical interventions (Pulver, Denney, Silver, & Young, 2010). LPIs have 4 times more medical complications than full-term infants (Pulver et al., 2010). The stress of delivery and the LPIs’ physical immaturity places them at greater risk for respiratory distress, temperature instability, hypoglycemia, sepsis, jaundice, and hyperbilirubinemia (Medoff Cooper et al., 2012); they often require intravenous fluids, enteral, or

I

bottle feeding after delivery (Medoff Cooper et al., 2012; Walker, 2008). During the last month of fetal gestation, full-term infants undergo rapid growth of brain tissues and peak synaptogenesis in the medulla; LPIs experience a lack of rapid development and are born with only 65% of term infant brain development (Guihard-Costa & Larroche, 1990; Hallowell & Spatz, 2012; Huppi et al., 1998). The rapid ¨ brain development then occurs after birth, which places LPIs at risk for neuronal injuries such as periventricular leukomalacia and other abnormal lesions in the white matter (Hallowell & Spatz, 2012; Kinney, 2006). Breast milk is vital in the development and protection of the immature brain; it provides long-chain fatty acids and other nutrients

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not present in full-term milk or formula (Hallowell & Spatz, 2012; Reynolds, 2001).

Late preterm infants are neurologically immature and are at increased risk for breastfeeding challenges.

Why Breast Milk is Important for the LPI Breast milk is established as the best nutrition for all infants to support optimal growth and brain development (American Academy of Pediatrics [AAP], 2012; Association of Women’s Health, Obstetrics and Neonatal Nurses [AWHONN], 2007b; Hallowell & Spatz, 2012; Medoff Cooper et al., 2012; Nyqvist et al., 2013). In addition, infants who receive breast milk have decreased risk of necrotizing enterocolitis, acute infant respiratory and gastrointestinal diseases, asthma, obesity, and type 2 diabetes (AAP, 2012; Bakewell-Sachs, Medoff-Cooper, Escobar, Silber, & Lorch, 2009). Colostrum, the first human milk, is pivotal to establish the microbiome of the gut, is an essential building block of lifelong nutrition and appears to lower the risk of necrotizing enterocolitis in low birth weight (fewer than 2500 grams) infants (Arboleya et al., 2012; Lee et al., 2012; Sisk, Lovelady, Dillard, Gruber, & O’Shea, 2007). Direct breastfeeding, which is defined as infants feeding directly at their mother’s breasts (vs. by another method such as bottle or cup feeding), provides optimal immunological and nutritional benefits of breast milk without losing any benefit from the use of freezing and thawing (Garc´ıa-Lara et al., 2012). Breastfeeding has a positive effect on mother/infant bonding (Buckley & Charles, 2006).

Breastfeeding Challenges with the LPI Infant Challenges. The neurological immaturity of LPIs limits their ability to regulate sleep/wake cycles and results in inconsistent communication with their caregivers, especially the demonstration of feeding cues (Meier, Furman, & Degenhardt, 2007). Many LPIs weigh ࣙ 2500 grams and appear to parents and providers to be full-term infants; given their size, LPIs are perceived as more competent and, as such, fatigue during breastfeeding may be misinterpreted as satiation (Radtke, 2011; Walker, 2008). The neurological maturation to coordinate appropriate suck, swallow, and breathing during feeding emerges closer to infants born at term (Gewolb & Vice, 2006). At 32 weeks postmenstrual age (PMA) the gag reflex emerges allowing infants to suck and swallow but requires them to pause throughout the feeding to breathe (Gewolb & Vice, 2006; McGrath & Braescu, 2004; White-Traut et al., 2013). Therefore, LPIs should not be compared to full- term infants in demonstrating mature sucking behaviors or transferring a set amount of volume until they reach 40 weeks PMA (Nyqvist, 2013). As infants mature, they incorporate breathing without JOGNN 2015; Vol. 44, Issue 1

pausing during feeding (Bakewell-Sachs et al., 2009). During direct breastfeeding, LPIs are able to better regulate the milk flow resulting in less variation in heart and respiratory rates and better oxygenation than during bottle feeding (Buckley & Charles, 2006; Meier, 1988). Compared to full-term infants, LPIs have weaker suction while eating, which leads to a cascade of events. The uncoordination of the LPIs’ suck, swallow, and breathing places them at risk for fatigue and subsequently insufficient caloric intake because they may be mistaken as being satiated (Walker, 2008; White-Traut et al., 2013). In addition, LPIs who lack a strong suck during breastfeeding may not transfer enough milk volume to meet their nutritional and hydration needs (Walker, 2008). Due to inadequate milk volume to support growth, clinical recommendations for LPIs unable to meet nutritional and hydration needs are often to supplement by either gavage, bottle, spoon, cup, or finger feeding (AAP, 2012; Meier et al., 2007; Nyqvist et al., 2013; Walker, 2008).

Maternal Challenges. Success for exclusive breastfeeding LPIs is also dependent on maternal milk supply (Meier, Patel, Wright, & Engstrom, 2013). Maternal milk supply is best established by proximity of the mother and infant for frequent direct breastfeeding, skin-to-skin contact, and maternal sensitivity to infant feeding, sleep, and alert states (Meier, Patel, Wright, et al., 2013; Walker, 2008). However, many LPIs and their mothers are separated immediately after delivery for necessary medical interventions (Hamilton et al., 2010). In addition, even if LPIs are able to initiate early direct breastfeeding, many infants may not adequately stimulate the maternal breast, and the production of maternal milk supply may be decreased (Lucas, Gupton, Holditch-Davis, & Brandon, 2014; Meier et al., 2007; Meier, Patel, Bigger, Rossman, & Engstrom, 2013). To provide an adequate supply of milk for their LPI’s normative growth and development during separation and when the LPI is not able to effectively direct breastfeed, many mothers will need to use a hospital- grade breast pump soon after delivery and often continue at home after discharge. This process should continue until their infant is mature enough to transfer adequate milk volume, which may take several weeks or months (Lucas et al., 2014;

Carrie-Ellen Briere, PhD, RN, CLC, is a postdoctoral fellow with a joint appointment in nursing research at the School of Nursing, University of Connecticut, Storrs, CT and Connecticut Children’s Medical Center, Hartford, CT. Ruth Lucas, PhD, RNC, CLS, is an assistant professor in the School of Nursing, University of Connecticut, Storrs, CT and a nurse scientist at Connecticut Children’s Medical Center, Hartford, CT. Jacqueline M. McGrath, PhD, RN, FNAP FAAN, is associate dean for Research and Scholarship and a professor in the School of Nursing, University of Connecticut, Storrs, CT and director of Nursing Research at Connecticut Children’s Medical Center, Hartford, CT. Mary Lussier, BSN, RN, IBCLC, is the coordinator of Lactation Services, Neonatology, Connecticut Children’s Medical Center, Hartford, CT. Elizabeth Brownell, PhD, is a perinatal epidemiologist in the Division of Neonatology, Connecticut Children’s Medical Center, Hartford, CT and an assistant professor of pediatrics in the Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT.

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Meier, Patel, Wright, et al., 2013; Radtke, 2011; Sables-Baus et al., 2013; Walker, 2008).

Practices to Support Breastfeeding the LPI Regardless of when breastfeeding is initiated, skin-to-skin contact between mother and infant has been found to increase breastfeeding success and needs to be an immediate goal after delivery as the infant’s and mother’s condition allow (Flacking, Ewald, & Wallin, 2011; Nyqvist et al., 2013). Many LPIs are unable to establish exclusive direct breastfeeding before discharge due to late initiation of breastfeeding, physical separation from their mothers, physical inability to create adequate suction, and neurological immaturity to signal cues for hunger (Sables-Baus et al., 2013; Walker, 2008). An additional barrier to establishing breastfeeding is the importance of providing adequate caloric intake to support LPIs’ normative growth and maturation (Meier, Patel, Bigger, et al., 2013; Walker, 2008). Many LPIs are unable to transfer adequate calories by exclusive direct breastfeeding, and the standard of care for choice of supplement is first expressed maternal breast milk, then donor human milk, and thirdly if no breast milk is available formula to provide adequate calories for growth before and after discharge (AAP, 2012; Nyqvist et al., 2013; SablesBaus et al., 2013). As mentioned previously, mothers of LPIs, especially those in the NICU, will likely need to begin breast milk expression after delivery to provide colostrum and establish maternal milk supply until their LPIs are physiologically able to completely direct breastfeed (Nyqvist et al., 2013; Spatz, 2004).

Results Recent Policy Statements

To identify current policy statements, practice guidelines, and research on breastfeeding LPIs, we searched the websites of public health agencies such as the World Health Organization and the Centers for Disease Control and Prevention

As described previously, LPIs are at an increased risk of health complications, and the benefits of breast milk may be even greater for this at-risk group than for healthy term infants. A NICU admission often means the infant will spend more days in the hospital than a typical well-baby nursery admission, and it is imperative that these extra days be used to increase breastfeeding and create appropriate plans for breastfeeding after discharge. AWHONN (2007a) supports breastfeeding the LPI and AAP (2012) and the World Health Organization (WHO; 2001) recommend exclusive breastfeeding until six months of age, followed by continued breastfeeding for one year or longer as mutually desired by the motherinfant dyad. The AAP’s policy statement highlights the importance of breastfeeding in the term and preterm population and recommends strategies to promote successful breastfeeding. Strategies to protect and promote breastfeeding include the WHO and UNICEF’s Baby-Friendly Hospital Initiative (BFHI) with the Ten Steps to Successful Breastfeeding (WHO, 1989; WHO & United Nations International Children’s Emergency Fund, 2009). The recommendations within the Ten Steps program are based mostly on the needs of the well mother/infant dyad, and considerations for the NICU have been suggested more recently (Nyqvist et al., 2013). A NICU admission has been

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The LPI faces many health and breastfeeding challenges as described above. The purpose of this article is to describe challenges that LPIs face with breastfeeding and to review current policy statements and practice guidelines that support breastfeeding LPIs. In addition, we provide an overview of current breastfeeding research related to the LPI and combine this research with policies and practice guidelines to provide evidencebased recommendations to guide practice and future research in the NICU.

Methods

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(CDC) for policy statements on breastfeeding LPIs, and we searched for practice guidelines from maternal/infant organizations. We identified five policy statements and three practice guidelines using this method. In addition, we searched the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed for original research and published practice guidelines. Our search strategy included the terms breastfeeding, breast feeding, and late preterm infant with publication dates between January 1, 2009 and March 1, 2014 and was limited to the English language. Our CINAHL search yielded 33 articles that were reviewed, and 11 met our eligibility criteria (original research or practice guideline on breastfeeding management or breastfeeding outcomes with late preterm infants). Our PubMed search yielded 61 articles that were reviewed; 11 articles were eligible for inclusion, but nine were repeated from the CINAHL search, resulting in two additional articles for inclusion. Our combined search methods yielded five policy statements, six practice guidelines, and 10 original research studies that focused on breastfeeding the LPI.

Briere, C.-E., Lucas, R., McGrath, J. M., Lussier, M., and Brownell, E.

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identified as a unique challenge to breastfeeding and potential variables with the LPI need to be considered when implementing appropriate breastfeeding support and care in this population. For example, if an LPI is admitted to the NICU, the ability to initiate breastfeeding within one hour of birth may be affected. The initial recommendation for the NICU BFHI is to increase skin-to-skin contact when breastfeeding is not possible due to an infant’s health status (Nyqvist et al., 2013). Other steps that may be affected by a LPI birth and NICU admission include the ability to room-in, breastfeeding on demand, and avoidance of artificial nipples or pacifiers. The NICU-specific BFHI guidelines address common issues in the NICU and how to best support breastfeeding mother/infant dyads (Nyqvist et al., 2013). The CDC (2013) provides recommendations for breastfeeding success for all breastfeeding dyads, and support for the BFHI, professional education and support, and peer support are also applicable to the LPI population. The CDC guidance should be viewed as important for all breastfeeding dyads, and for LPIs, the concepts of consistent caregiver education, follow-up care, and appropriate professional and peer support need even greater attention. The Academy of Breastfeeding Medicine (2011) created a clinical protocol on breastfeeding specific to the LPI. The protocol includes specific recommendations for health care providers who care for LPIs in the mother/infant dyad. Due to multiple risk factors for ineffective milk transfer and low milk volume, mothers are recommended to use a combination of frequent skin-to-skin contact, direct breastfeeding, and breast milk expression with a hospital-grade electric pump. Close examination of breastfeeding within the hospital, specific discharge instructions, and early and frequent postdischarge follow-up are essential components in managing breastfeeding in the late preterm population (Academy of Breastfeeding Medicine, 2011).

Practice Guidelines AWHONN (2014a) published evidence-based guidelines that provide care management practices with LPIs. These guidelines reaffirm the common breastfeeding issues faced by the LPI as described previously. In particular, these guidelines focus on feeding challenges with the LPI and recommend assessment of feeding readiness at each feeding as well as assessment of sleep and wake cycles (AWHONN, 2014a).

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Breastfeeding the LPI requires health care providers to practice consistent care-giving and maintain current knowledge of breastfeeding challenges in this population.

In addition, AWHONN (2014a) recommended ongoing close monitoring of breastfeeding challenges that may require increased lactation support to identify infant intake and milk supply as well as ongoing maternal breastfeeding education. Other authors have published practice guidelines for the LPI and provide supportive strategies in conjunction with the AWHONN (2014a) guidelines. The National Association of Neonatal Nurses has provided guidelines in introducing and advancing oral feeding based on infant cues, and these guidelines should be consulted for use with the LPI (Sables-Baus et al., 2013). Meier, Patel, Wright, et al. (2013) summarized common breastfeeding challenges for mothers of LPIs. Common challenges can include a delay in onset of lactation and the inability of the preterm infants to maintain appropriate suction pressure to allow for most milk transfer (Meier, Patel, Wright, et al., 2013). Important considerations for health care providers are addressed, including as the concept that, during hospitalization, the infant should be able to breastfeed well for 15 minutes at least 8 times per day. If the recommended duration and frequency of feeds is not achieved, use of an electric hospitalgrade pump may be used to stimulate and increase milk production (Meier, Patel, Wright, et al., 2013). In addition to noting the importance of identifying maternal coping with the feeding plan and adjusting accordingly, this research group identified difficulties that mothers of LPI encounter related to triple feeding (direct breastfeeding, pumping, and then bottle feeding) and suggested an alternative discharge plan (Meier, Patel, Wright, et al., 2013). This plan outlines a more manageable approach to the challenges of triple feeding the late preterm infant by suggesting separating each day into periods of breastfeeding (during the day) and bottle feeding and pumping (during the night) to meet breastfeeding and nutritional goals (Meier, Patel, Wright, et al., 2013). Two of the most important considerations for discharge planning are to achieve appropriate infant nutrition and maintenance of an adequate maternal milk supply (AWHONN, 2014a; Lee et al., 2012). Discharge plans to facilitate successful breastfeeding along with appropriate professional support may include pumping, in-home test weights, and nipple shields

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(Meier, Patel, Wright, et al., 2013; Nyqvist et al., 2013). Follow-up care providers need to be aware of the special breastfeeding needs of LPIs, and ongoing education on breastfeeding in this special population is important. Ahmed (2010) highlighted the important role of the pediatric nurse practitioner in preserving breast milk feeding in the LPI after hospital discharge. Pediatric nurse practitioners need to be aware of specific breastfeeding challenges with the LPI and be able to identify potential issues early to prevent longer term breastfeeding difficulties. The first visit should occur within 2 days of NICU discharge during which time a full history related to breastfeeding and pumping is suggested with careful consideration of feeding method, frequency, and duration, infant behavioral state, urine and stool output, and weight (Ahmed, 2010). Early office visits should also include an assessment of a feeding directly at breast (Ahmed, 2010). Ahmed (2010) also recommended that LPIs have at least weekly check-ups until they reach 40 weeks PMA or until full breastfeeding is established. These guidelines are important for pediatric nurse practitioners but are also relevant to family nurse practitioners, postpartum nurses, NICU nurses, midwives, pediatricians, family practice physicians, and breastfeeding specialists. In the hospital and after discharge practitioners must educate mothers on typical problems and management strategies with breastfeeding LPIs so that families can anticipate and identify issues when they occur.

Current Research Over the past 5 years, researchers have focused on breastfeeding outcomes in LPIs, and many have compared them to other gestational age groups. Investigators have examined breastfeeding initiation, exclusivity, and issues related to duration, such as maternal experience, support, and follow-up. Initiation of breastfeeding is the first step in providing breast milk for an infant. LPIs have many more breastfeeding risk factors than term infants, and initiation can be examined in research as identification of one aspect of differences. Ayton, Hansen, Quinn, and Nelson (2012) found that LPIs (n = 147) were 70% less likely than their 37- week PMA counterparts (n = 80) to initiate breastfeeding within the first hour after birth (odds ratio [OR] = 0.3, p < .01). One important concept that is missing from this research is whether this accounts for all LPIs in the hospital or only

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those not admitted to a NICU. Essentially, those infants admitted to a NICU would be at greatest risk for not initiating breastfeeding within the first hour because of their medical complications. The researchers also found that LPIs are less likely to be discharged home exclusively breastfeeding (OR = 0.4, p = .04). These findings are supported by the work of Hwang et al. (2013) who found LPIs are less likely than term infants to initiate breastfeeding (n = 242,471; OR = .95; p < .01). These researchers also found that LPIs have lower rates of continued breastfeeding (defined as continued breastfeeding to at least 10 weeks). In addition, another research team supported the breastfeeding risk that LPIs face at discharge and showed that they are significantly less likely to receive exclusive direct breastfeeding when compared to their term counterparts (80.9% vs. 21.4%, p < .01) (Zanardo et al., 2011). Demirci, Sereika, and Bogen (2013) examined predictors of breastfeeding noninitiation in LPIs (n = 7,012) and found that marital status, age, race/ethnicity, education, parity, participation in the Supplemental Nutrition Program for Women, Infants and Children (WIC), and smoking were significantly associated with breastfeeding noninitiation. Overall initiation in the LPI group was lower than for their term counterparts. Interestingly, initiation was higher in mothers of late preterm multiple than singleton births. McDonald et al. (2013) also found that mothers of LPIs are more likely to report breastfeeding difficulties immediately after birth, such as unsuccessful first breastfeeding attempt, not breastfeeding in the first 24 hours of life, and not breastfeeding before hospital discharge. In regards to duration, these researchers also found that mothers of LPIs were more likely to discontinue breastfeeding by 4-months postpartum. The risk of early breastfeeding cessation in the late preterm population was also supported by Nagulesapillai et al. (2013) who found that LPIs are at increased risk of exclusive breastfeeding cessation by 4-months postpartum compared to term infants. Mothers identified the most significant breastfeeding difficulties related to infant issues, such as a sleepy infant. Another research team examined the impact of hospital readmission in the first 2 months of life and observed hospital readmission did not significantly affect continued predominant breastfeeding in the LPI (McNeil et al., 2013). Late preterm infants have specific breastfeeding needs when discharged from the hospital. In a published case study, one mother/infant dyad

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2) Mothers are provided consistent education about the benefits of breastfeeding for the LPI

possible) and as often as the mother is available to facilitate bonding and milk production.

partnership with mothers, adjust the feeding schedule to best support mothers in

7) Encourage oral feedings at the breast whenever possible; using a collaborative

activities, volume of milk provided, and number of infant feedings at breast.

providing direct breast feedings.

Meier, Patel, Wright, et al., 2013; Sables-Baus et al., 2013

ABM, 2011a ; Meier, Patel, Wright, et al., 2013; Sables-Baus et al., 2013

AWHONN, 2014a; ABM, 2011a ; Sables-Baus et al., 2013

Demirci et al., 2012

AWHONN, 2014a; Nyqvist et al., 2013

Meier, Patel, Wright, et al., 2013

ABM, 2011a ; Sables-Baus et al., 2013

Supporting Breastfeeding During Hospitalization

6) Regularly monitor breast milk production through consistent assessment of pumping

their infants progress from alternative feedings toward oral feedings.

5) Facilitate first oral feeding directly at the breast by encouraging mothers to be nearby as

if the infant is unable to suckle at the breast during that time to stimulate lactogenesis.

4) Facilitate breast pumping within first 2 hours after birth with a hospital-grade electric pump

stimulation, and demonstration of hunger cues.

breastfeeding, including sleep–wake regulation, tolerance of the environment and

3) A systematic assessment of oral feeding readiness is used to guide introduction of

and themselves.

References Initiating Breastfeeding After Birth

1) Encourage skin-to-skin holding soon after birth (within first 2 hours of birth whenever

Summary of Clinical Practice Recommendations

Table 1: Specific Recommendations for Supporting Breastfeeding for Late Preterm Infants (LPI) in the NICU

VII

I; VII; VII

VII; VII

Continued

I; VII; VII; VII

I: VIII; VII; VII

VI

I; VII; VII

Level of Evidence

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follow-up care (weekly until 40 weeks PMA is recommended), and more attention to

professional and peer support prior to and following discharge from the NICU.

ABM, 2011a ; Lucas et al., 2014

Lucas et al., 2014; Meier, Patel, Wright, et al., 2013

Nyqvist et al., 2013

Ahmed, 2010; ABM, 2011a ; CDC, 2013

Supporting Breastfeeding After Discharge

13) Mothers of LPIs may require more consistent caregiver education, early and frequent

medical history/treatment.

breast feedings in the NICU because they lack confidence and due to the infant’s size and

12) Mothers of late preterm infants may require more encouragement and support to provide

(PMA).

achieve this degree of breastfeeding at approximately 40–44 weeks postmenstrual age

with appropriate infant growth). An appropriate goal for mothers of LPIs would be to

breastfeeding is defined as direct-breastfeeding for 15 minutes at least 8 times per day

feedings at the breast. This could be until well after discharge from the NICU (successful

11) Breast pumping needs to be continued until the infant is mature enough to take all

normal for the maturing LPI.

must be encouraged not to see this supplementation as a failure on their part but as

10) Supplementation during transition to breastfeeding is important to growth and mothers

should be used to accurately measure milk transfer.

include gavage feedings, spoon, cup or finger feedings, and bottle feedings. Milk weights

9) Supplementation for infants unable to transfer enough milk by direct breastfeeding may

suck affects feeding so they don’t misinterpret feeding fatigue for satiation. AAP, 2012a ; AWHONN, 2014a; ABM, 2011a ; Meier et al., 2007; Sables-Baus et al., 2013

Continued

VIII; VII; VII; VII

I; VII; VI

VI; VII

VII

I;VII; VIII; VII; VII; VII

8) Assess for the strength of the infant’s suck during breastfeeding; consider the use of a

nipple shield. Provide additional information to the mothers about how the strength of the

Level of Evidence VII; VI

References Meier, Patel, Wright, et al., 2013; Demirci et al., 2012

Summary of Clinical Practice Recommendations

Table 1: Continued

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IV

VII; VI; V

Note. a Recommendations are from a combination of systematic reviews and expert opinion. ABM = Academy of Breastfeeding Medicine; AAP = American Academy of Pediatrics; AWHONN = Association of Women’s Health, Obstetric and Neonatal Nurses.

Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Level VI: Evidence from a single descriptive or qualitative study

Level V: Evidence from systematic reviews of descriptive and qualitative studies

Level IV: Evidence from well-designed case-control and cohort studies

Level III: Evidence obtained from well-designed controlled trials without randomization

Level II: Evidence obtained from at least one well-designed RCT

Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs.

Rating System for the Hierarchy of Evidence

readmission does not need to be factor in cessation of breastfeeding.

greater risk for readmission than their term counterparts; with careful management

16) Continued monitoring of breast milk production is essential. Although LPI infants are at

feeding plan to best support mother and infant needs.

includes management of triple feeding which may require institution of an alternative

15) Maternal coping with the feeding regimen after discharge with a late preterm infant

state, urine and stool output, and weight. Ahmed, 2010; Lucas et al., 2014; Meier, Patel, Bigger, et al, 2013

14) Postdischarge assessment of breastfeeding success is recommended with careful

consideration of feeding method, frequency, and duration, as well as infant behavioral

Level of Evidence VII; V

References Ahmed, 2010; Meier, Patel, Bigger, et al, 2013

Summary of Clinical Practice Recommendations

Table 1: Continued

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Table 2: Recommendations for Research Supporting Breastfeeding Specifically for Late Preterm Infants (LPIs) Recommendations for Future Research 1. Exploration of strategies with targeted interventions to support LPI to go to breast sooner after birth or as is medically possibly is needed. 2. Exploration of barriers to breastfeeding the late preterm infant in the NICU. 3. Exploration related to why breastfeeding and or breast pumping often ends within the first few weeks of infant’s life with exploration of strategies to change this phenomenon. 4. Exploration of breastfeeding behaviors in the LPI that either promote or discourage continuation of breastfeeding by the mother. 5. Given the unique needs and attribute of the LPI, exploration of LPI breastfeeding peer support where the peer is also a mother of a LPI. 6. Development of a pathway for typical transition of a LPI infant to exclusive breastfeeding with better understanding and study of targeted interventions to support this transition in the NICU and beyond. Specific content areas needed include · Use of alternative oral feeding methods in supplementation with the LPI · Donor human milk use in the LPI · Duration of breastfeeding at each feeding that is developmentally appropriate for the LPI

Demirci, Happ, Bogen, Albrecht, and Cohen (2012) used grounded theory to examine the maternal experience of breastfeeding the LPI. Ten mothers participated in the study, and many identified challenges with breastfeeding, such as sleepy infants and difficult latches. The authors found that differences in motivation related to setting maternal breastfeeding goals (reason for wanting to breastfeed) were related to whether the mothers had the internal drive to keep going with breastfeeding even when it was challenging. Mothers who chose to breastfeed for convenience or because of guilt were more likely to change breastfeeding goals over time or to stop breastfeeding as opposed to mothers who

decided to breastfeed because it was the best way to provide the needed nutrients for their infants (Demirci et al., 2012). Mothers also tended to have negative or positive management strategies that resulted in breastfeeding cessation (negative management) or continuation (positive management). Access to appropriate professional support increased positive breastfeeding management; however, support and knowledge of what to expect after discharge were lacking. Multiparas were more likely to know of available breastfeeding resources when needed. Primiparas were often unaware of these resources, and in this study the primipara mothers who had continued breastfeeding challenges were more likely to cease breastfeeding (Demirci et al., 2012). Of particular concern, mothers did not understand why their infants would act fussy and then fall asleep at the breast rather than eat (LPI fatigue). It is critical to identify this lack of understanding so that providers can educate mothers on the differences between term and LPI feeding development and issues related to fatigue versus satiation. Mothers with infants admitted to the NICU also expressed concern about NICU routines that seemed to focus more on volume consumption than the establishment of direct breastfeeds. Yet NICU nurses were perceived to be more supportive and knowledgeable about breastfeeding the LPI than the postpartum nurses (Demirci et al., 2012).

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took 4 months to transition to exclusive direct breastfeeding (Lucas, Gupton, Holditch-Davis, & Brandon, 2014). Throughout the transition, the mother used triple feeding (direct breast, pumping, and expressed breast milk by bottle) to build an appropriate supply and ensure the infant received adequate intake. The mother used an in-home test weighing scale to help determine infant milk transfer, which assisted her in knowing if she had to continue to express breast milk to build her supply. Community support was also sought by the mother and was essential for guidance and resources for the successful transition (Lucas et al., 2014).

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Policy statements, practice guidelines, and research provide essential information for health care providers who aim to deliver evidence-based and best practice care. Based on our review, we provide a table of recommendations that brings together the existing guidelines and the current research literature that could be the basis for a practice bundle for provision of breastfeeding support for LPI in the NICU (see Table 1).

Conclusions Management of breastfeeding in the LPI is challenging for mothers and health care providers. LPIs are developmentally disadvantaged when compared to term infants, and this concept must be acknowledged during the management of breastfeeding. Policies, guidelines, and research are useful when considering care of these vulnerable infants who may appear to be more neurologically developed than they actually are. Breastfeeding the LPI requires health care providers to practice consistent care giving and maintain current knowledge of breastfeeding challenges in this population. A possible solution to provide consistent care giving is to use formalized methods to care for the LPI with tools such as those provided by AWHONN in the LPI Implementation Toolkit (AWHONN, 2014b). A physiological assessment of breastfeeding readiness should be conducted by the NICU team, and breastfeeding should be initiated as soon as clinically appropriate. Direct breastfeeding should be the first oral feeding offered to the LPI. Mothers may need to initiate breast milk expression to supplement the nutritional needs of a LPI who is unable to physiologically transfer a sufficient milk volume to maintain growth and to maintain their breast milk supply. Throughout hospitalization, the NICU should provide education and support for mothers consistent with the known challenges of breastfeeding the LPI. Once discharged to home, prolonged breastfeeding support and medical management are needed at least until the infant reaches her or his due date.

Standard care must include monitoring of breastfeeding strategies and providing targeted interventions to support ongoing management of challenges as they arise.

appropriate and supportive of breastfeeding. Although bottle feeding is common in the NICU, other supplementation methods should be considered. Research in full-term literature suggests a negative impact on breastfeeding when bottles are used; outcomes are unknown for the LPI. Mother’s own milk is the preferred choice for supplementation, but the use and benefits of donor human milk must be established when mother’s own milk is unavailable. Due to hospital qualifications for donor human milk use, the LPI is often ineligible for receipt, but careful consideration should be given for high- risk LPIs such as those with congenital heart disease and gastrointestinal abnormalities. Breastfeeding the LPI can be challenging, yet this population could have a high yield from the benefits of breastfeeding. Standard care for these infants must include assessment with continued monitoring of breastfeeding strategies as well as providing targeted interventions to support ongoing management of breastfeeding challenges as they arise in this potentially high-risk population.

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Although we discuss breastfeeding the LPI in the NICU, these findings and recommendations are also relevant in other care areas such as special care and transitional nurseries. Additional research is still needed to understand the best interventions to support breastfeeding the LPI and suggestions are presented in Table 2. Important questions to explore include the best method of supplementation in the LPI and duration of breastfeeding at each feeding that is developmentally

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