The importance of breastfeeding for pre-term infants is discussed in this information sheet. Three recent studies by experts and an announcement have been reviewed in this context. Main data has been gathered from a retrospective audit (Trajanovska’s study of 2007), an original article of a study (Tanaka’s study of 2008), a phenomenological study (Sweet’s study of 2007) and the Elsevier announcement of 12th May 2008. Current Statistics 80% of pre-term infants were intended to be breastfed by Australian mothers while 87% of their term babies were breastfed 1.
Only 31% of American mothers wished to breastfeed pre-term babies while 13% wished to partially breastfeed 10 and 87% of the mothers wished to breastfeed term babies 1. The intention to breastfeed failed for 5% of term babies 2 and 30% of pre-term and sick babies in Australia. Pre-term infants are breastfed less than the general population 3. In the UK, 70% of mothers indicated the intention to feed 4. Background The best source of nutrition for babies is the mother’s milk. Pre-term babies reap even more benefits. Their immune system is underdeveloped; they are also susceptible to infections or nutritional deficiencies.
These drawbacks are nullified by the breastfeeding. A new mother is being very positive if she decides to feed her sick baby at a time of distress and giving it the best outcome 5. Breast feeding is of utmost necessity and the nutritional, gastrointestinal, immunological, neuro-developmental and psychosocial benefits of breastfeeding have been shown for term and pre-term infants 6. The pre-term infant in the neonatal ICU has associated medical and surgical problems and a difficulty arises in adhering to WHO standards of breastfeeding.
In Trajanovska’s study of 1163 babies, babies which were exclusively breastfed were of greater gestational age and had a shorter stay in the NICU than those who were fed on a combination of milk and formula. Breast feeding is believed to reduce the risks of gastrointestinal infections and otitis media. It is mainly instrumental in the bonding between the mother and baby 7. Breastfeeding depends on beliefs of mothers that it is natural, best for the baby and the partner’s preference. Contemporary Australia believes in the norm of breastfeeding the newborn for at least the first few weeks of pregnancy 8.
Most women decide the method of feeding her child before pregnancy or in the first trimester of pregnancy 9. Usually older, white, married, educated, lower parity, higher social class women and breastfed when young are the ones who opt for breastfeeding 10. Some studies have investigated whether the women adhere to their original decision if their baby turned out to be pre-term. Breastfeeding is a biological process and a culturally determined behavior 11. Parents of pre-term infants must be investigated to find out what they are experiencing in order to help them in opting for, achieving and sustaining breastfeeding 12.
Tanaka says that several studies have shown a relationship between infant nutrition and cognitive development in children. The meta-analysis by Anderson et al showed that breast feeding rather than formula feeding was associated with better cognitive functions 13. Anderson’s study showed that Polyunsaturated fatty acids (PUFAs) along with other nutrients are required for the development of the brain. Other studies say that giving docosahexaenoic acid to pregnant women influenced their children’s development. WHO Recommendation The WHO recommends breast milk up to six months.
The World Health Organization (WHO) recommended that breastfeeding should be continued until 6 months of age and complementary foods introduced thereafter 14. Objectives To determine the usefulness of breastfeeding in pre-term infants and to educate mothers of pre-term infants on the benefits of breastfeeding. Composition of Human Breast milk 22 Water (90%), nutrient proteins, non-protein nitrogen compounds, lipids, oligosaccharides, vitamins, minerals, hormones, enzymes, growth factors and protective agents are found in breast milk. It is rich in brain building omega 3s like DHA and amino acids.
The levels of DHA decline as infant grows. Fat digesting enzyme is present. Proteins are in the form of soft easily digestible whey which is higher in pre-term infants. Lactoferrin is for intestinal health. Lyzozyme is an antimicrobial. Brain and body building proteins and growth factors are present. Sleep inducing proteins are also found. Breast milk is rich in lactose and oligosaccharides which are good for intestinal health. The immune boosters are the immunoglobulins and the leucocytes. Vitamins and minerals like iron, zinc and calcium are better absorbed. Selenium, an antioxidant is also found.
Breast milk also has many digestive enzymes and hormones. The composition breast milk allows easy absorption. Composition of formula 22 Formula do not have lipase, cholesterol, DHA, lyzozyme, lactoferrin, growth factors, as many sleep inducing proteins, lactose, oligosaccharides, leucocytes and a few useless immunoglobulins, Very little iron is absorbed and selenium is minimal. Processing would kill the enzymes and hormones present. Generally speaking formulas are difficult to be digested. Definitions 1. A pre-term infant is one born prior to 37 weeks of gestation. 2.
Colostrum is the first milk that comes from the breast after delivery. Studies. Tanaka’s study evaluated the relationship between breastfeeding, especially the resultant DHA level in the red blood cell (RBC) membranes of infants, and the cognitive function of very-low-birth-weight infants at 5 years of age. Tanaka’s study investigated 18 pre-term infants who were divided into groups of breast-fed, formula-fed and fed with both. At 4 weeks of age, the Docosahexaenoic acid (DHA) level in the RBC membranes was measured. Cognitive function was function was evaluated at the age of 5.
Five tests for this were the Kaufman Assessment Battery for Children, Day–Night Test, Kansas Reflection Impulsivity Scale for Preschoolers (KRISP), Motor Planning Test and Strengths and Difficulties Questionnaire. Tanaka found that the DHA concentration at 4 weeks of birth was found to be higher in the breast milk group than the formula fed group. The scores for Day–Night Test, Kansas Reflection Impulsivity Scale for Preschoolers (KRISP) and Motor Planning Test were obviously higher in the breastfed group. A relationship was noticed between the DHA levels and the findings for the Day-Night test and KRISP test.
17 Australian parents (10 mothers and 7 fathers) expressed their experiences of breastfeeding pre-term infants with very low birth weights from birth to 12 months 8. Interviews were held at 2-3 weeks, 8-12 weeks and 12 months after birth. The participants ‘lived experiences’ were evaluated. Spontaneous discussion was encouraged. Sweet’s interpretive phenomenological study found that all the participants had planned to breastfeed before the pre-term birth. In spite of having a very low birth weight infant, they did not change their decision.
They expected a normal, natural and satisfying breastfeeding experience, whatever complications their post partum had. A slight disparity was seen in the ‘natural’ expectations, reality of long term expression and outcomes. Infant feeding was a joint mutual decision between the parents. Single mothers made the decision themselves. Friends or family did not seem to have any influence. The participants would not specify duration for fear of not being able to stick to schedule 8. Ladies who had done breast expression late earlier were happy that they could do it immediately after delivery for the baby.
Cultural persuasion was not involved in the participants’ decision to breastfeed 8. Maternal intention to breast feed was a stronger predictor of the initiation of breastfeeding and duration than maternal age, education level or both together. 6. In a study of pre-term infants it was found that infants with higher birth weight, lesser requirement for respiratory and an absence of bottle-feeding were positive predictors of higher competence with breastfeeding 15. Pre-term infants exhibited only average breastfeeding rates 6.
Some studies show that pre-term babies are less breastfed at the age of one month. Current Beliefs 1. As per literature and Trajanovska’s study, 77% of ladies wished to breastfeed. 2. Some ladies believed that breastfeeding was a part of parenthood and opting for the best possible for their child 8. 3. The themes identified in Sweet’s study were the ‘intention to breastfeed naturally; breast milk as connection; the maternal role of breast milk producer; breast milk as the object of attention; breastfeeding and parenting the. hospitalised baby and the demise of breastfeeding’ 8. 4.
Younger women and those of lower socio-economic status were more likely to stop breastfeeding in the first month due to sore nipples, inadequate milk supply, the infant having problems to suckle or belief that the child is not satisfied 6. 5. ‘Breast is best’ and ‘good motherhood’ are the main considerations behind the decision to breastfeed 8. Usefulness of breast milk to pre-term infants Colostrum consists of a mixture of material present in the mammary gland and ducts with new milk secreted. It must be given to the baby as sufficient amount of antibodies are present to protect the infant from the bacteria and viruses in the birth canal.
It also has the function of moving the meconium which is the excretory product of the fetus. Babies which were exclusively breastfed had normal weight gains and gestational age while those fed on only formula had highest weight gains and the longest stay 6. 1163 babies came under Trajanowska’s study. All infants admitted to the Royal Children’s Hospital Neonatal Unit, Melbourne, between 2001 and 2003 were brought under the study. 77 % of mothers indicated a desire to breastfeed. 534 babies were discharged directly to their homes.
50% of babies were being breastfed at the time of discharge or expressed milk or a combination of milk and formula. Breastfeeding is recognized as the optimum approach to provision of infant nutrition. Tanaka’s study revealed that breastfeeding in the neonatal period increases the levels of DHA in pre-term infants. This has a relationship to the cognitive development of pre-term infants in infancy and pre-school years. Executive function is the one most changed with breastfeeding. The DHA which was increased with the breastfeeding in pre-term infants has a positive effect on brain development.
There was a positive relationship between the breastfeeding in the neonatal period and head circumference at 5 years of age 13. The head circumference is an indicator of brain volume. Breast milk also improved maternal mood and interactive behaviors, indirectly influencing the infantile development. Most ladies spoke of breastfeeding as natural and the best for their baby. There was obviously an emotional component in the desire to breastfeed. The mothers wanted to hold their babies to their breast, caress them and share some ‘special’ time with them. However the emotional side came second to the baby reasons for the feeding 8.
Pre-term infants have a better chance of survival in recent years. Though development varies, many studies have shown that pre-term infants are prone to developmental problems, poor cognitive function and behavioral problems like Attention Deficit Hyperactivity Disorder 17. It is believed that prolonged breastfeeding in pre-term infants may be associated with improved developmental achievement 16. Agostoni also indicated that a balanced content of amino acids and LC-PUFAs (especially DHA) contributed positively to the growing brain of the pre-term infants.
Health Education New mothers of premature babies are likely to be going through a very traumatic and stressful time. These mothers should receive the advice and support they need. Lack of support would result in the premature infants not getting the necessary breast milk for their nutrition and survival. If mothers of sick or pre-term infants are not adequately informed in time and supported, their milk supply will dry up by the time they process our information into a favorable outcome. Hospital staff need to help these mothers for expressing milk with their hands 5.
The appeal for raising awareness for hand expression techniques is being advertised by BLISS by distributing knitted breasts for mothers to practice. They are also donating portable swing pumps to many neonatal units across the UK where 80000 babies are born sick or pre-term 5. Kaufman and Hall found that most women out of the 125 who had pre-term babies stayed with their first decision. Only very few changed the decision. In another study, 8 out of 44 mothers who had pre-term babies changed their decision 18.
Lucas et al 19 found that hospital staff have no influence on the changing of a mother’s decision related to infant feeding. Having a pre-term baby may alter a mother’s decision not to breastfeed. However there is no study evidence for the matter 8. Previously studies were nutritionally and statistically based on the biological approach 20. Recent research is emphasizing on the health education of mothers and encouraging to breastfeed more 21. 38% of mothers, who participated in a BLISS survey, did not breastfeed as they did not get support from the staff, even though they knew about the benefits of breast milk.
12% said no one showed them how to position and attach their baby to the breast. 36% however knew the problems they could encounter and how to face those 5. 5% ladies felt that due to pressure from the staff, they preferred to give up breastfeeding and start the babies on bottles. Recommendations for breastfeeding pre-term infants 1. Breast milk should be the sole method of feeding pre-term infants if possible. 2. Colostrum must be expressed to feed the baby initially. 3. Breast milk must be given compulsorily for the first six months after delivery to pre-term infants. 4.
Breastfeed and keep away nutritional deficiencies, immunological defects, gastrointestinal problems, neurodevelopmental problems and psychosocial problems in pre-term infants. 5. Expression of milk should start after delivery and colostrum should be given to pre-term infants. 6. Breastfeed and build the bonding between the mother and pre-term infant. 7. Breast milk is natural and the best infant nutrition. 8. Breast feeding should start immediately after delivery and not be delayed. 9. Breast feeding contributes to cognitive development in infancy and pre-school days, especially the executive function. 10.
Breast milk is essential to prevent developmental and behavioral complications like ADHD. 11. The decision to breast feed should not change if the infant turns out to be pre-term. 12. Mothers of pre-term babies should receive dedicated and specialized support and advice to help them to express their milk soon after birth, and to make the transition to breastfeeding. Advice on ‘how and when to express, access to the necessary equipment and facilities, help with having skin-to-skin contact with the baby, and advice on when and how to start breastfeeding’ should be given (Elsevier Announcement, 2008). References: 1. Chezem, J. , Friesen, C.
, Boettcher, J. , 2003. Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices. Journal of Obstetric, Gynecologic and Neonatal Nursing 32 (1), 40e47. 2. Shaker, I. , Scott, J. A. , Reid, M. , 2004. Infant feeding attitudes of expectant parents: breastfeeding and formula feeding. Journal of Advanced Nursing 45 (3), 260e268. 3. Meier PP, Brown LP. Breastfeeding for mothers and low birth weight infants. Nursing Clinician North Am, 1996; 31(2):351—65. 4. Jaeger, M. C. , Lawson, M. , Filteau, S. , 1997. The impact of prematurity and neonatal illness on the decision to breast-feed.
Journal of Advanced Nursing 25 (4), 729e737. 5. Elsevier Announcement, “Lack of support means premature and sick babies are missing out on their mothers’ milk”, Journal of Neonatal Nursing (2008) 14, 136e137 Published by Elsevier. 6. Trajanovska, M. et al, (2007), “A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit”, Journal of Neonatal Nursing (2007) 13, 150e154. Published by Elsevier Ltd. 7. Arora, S. , McJunkin, C. , Wehrer, J. , Kuhn, P. , 2000. Major factors influencing breastfeeding rates: Mother’s perception of father’s attitude and milk supply. Pediatrics 106 (5), E67.
8. Sweet, Linda; (20070, “Birth of a very low birth weight preterm infant and the intention to breastfeed ‘naturally’”, Women and Birth (2008) 21, 13—20 9. Earle S. Why some women do not breast feed: bottle feeding and father’s role. Midwifery 2000; 16:323—30. 10. Sable MR, Patton CB. Prenatal lactation advice and intention to breastfeed: selected maternal characteristics. J Human Lactatation 1998;14(1):35—40. 11. Stuart-Macadam P. Biocultural perspectives on breastfeeding. In: Stuart-Macadam P, Dettwyler K, editors. Breastfeeding: biocultural perspectives. New York: Aldine De Gruyter; 1995. p. 1—37. 12. Golembeski SM.
Navigating through uncertainty: breastfeeding the high-risk infant. Miami: University of Miami; 2000. [Doctor of Philosophy]. 13. Tanaka, K. et al, (2008), “Does breastfeeding in the neonatal period influence the cognitive function of very-low-birth-weight infants at 5 years of age? ” Brain and Development may, 2008, Pg. 1-6 14. World Health Organisation, 2001. The Optimal Duration of Exclusive Breastfeeding. Report of an Expert Consultation. Geneva, Switzerland, 28e30 March 2001. 15. Nyqvist, K. , Ewald, U. , 1999. Infant and maternal factors in the development of breastfeeding behaviour and breastfeeding outcome in preterm infants.
Acta Paediatrica 88 (11), 1194e1 16. Agostoni C. Small-for-gestational-age infants need dietary quality more than quantity for their development: the role of human milk. Acta Paediatrics 2005; 94:827–9. 17. Reijneveld SA, de Kleine MJ, van Baar AL, Kolle? e LA, Verhaak CM, Verhulst FC, et al. Behavioural and emotional problems in very preterm and very low birth weight infants at age 5 years. Arch Dis Child Fetal Neonatal Ed 2006; 91:F423–8 18. Kaufman KJ, Hall LA. Influences of the social network on choice and duration of breast-feeding in mothers of preterm infants. Resident Nursing Health 1989; 12:149—59.
19. Lucas A, Cole TJ, Morley R, Lucas PJ, Davis JA, Bamford MF, et al. , Factors associated with maternal choice to provide breast milk for low birthweight infants. Arch Dis Child 1988; 63(1):48—52. 20. Maushart S. The Mask of Motherhood. How mothering changes everything and why we pretend it doesn’t. Milsons Point: Random House Australia Pty Ltd. ; 1997. 1999; 13(3):308—25. 21. Stearns C. Breastfeeding and the good maternal body. Gen Soc 1999; 13(3):308—25. 22. Sears, William and Sears, Martha; (2006), “Breastfeeding”, http://www. askdrsears. com/html/2/T021600. asp AskDr. Sears. com,