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Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 95-102

Family-centered lactation counseling and breastfeeding in preterm infants upon neonatal intensive care discharge

Department of Neonatology, Istinye University Medical Park Hospital, Antalya, Turkey

Date of Submission12-Oct-2020
Date of Decision10-Dec-2020
Date of Acceptance16-Dec-2020
Date of Web Publication15-May-2021

Correspondence Address:
Hakan Ongun
Department of Neonatology, Istinye University Medical Park Hospital, Antalya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.jcn_167_20

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Background: There is great variability in breastfeeding implications upon neonatal intensive care unit discharge for preterm infants. Aims and Objectives: To examine the breastfeeding rates and the impact of lactation-counseling on the nutrition following hospital discharge in preterm infants. Materials and Methods: A three-page survey was applied to the families of infants of gestational age ≤34 weeks who were hospitalized between 2016-2018. Exclusion criteria were family reluctance to consent, foster-care placement, acquiring enteral feeding by orogastric tube/gastrostomy. The group categorization was based on lactation-counselling that involved both parents and elderly relatives who would assist the mother at neonatal care. Statistics were performed using SPSS-22 for covariates of neonatal intensive care interventions and post-discharge nutrition. Results: Exclusive breastfeeding was 49.2% at hospital-discharge and declined to 31.3% at six months. Early introduction of complementary foods was 51.1%. Total duration of breastfeeding was 7.38±3.98 months. Lactation-counseling prolonged breastfeeding duration to 8.47±3.87 months. The program presented the highest odds of extending breastfeeding interventions beyond six months (OR: 2.183, 95% CI: 1.354–3.520). It favored the outcomes by reducing the introduction of formulas and complementary foods before six months (P = 0.044, P = 0.018). The physical contribution of the father towards nutrition was the most significant benefit claimed by the participants. (71.6 versus 51.8%). Conclusion: Family-centered peer lactation-counseling by the medical staff and increasing awareness for infant nutrition are promising local strategies in reaching the goals of national nutrition policies guided by the international recommendations in preterm infants.

Keywords: Breastfeeding, lactation counseling, neonatal intensive care unit, nutrition, prematurity

How to cite this article:
Ongun H, Demir M. Family-centered lactation counseling and breastfeeding in preterm infants upon neonatal intensive care discharge. J Clin Neonatol 2021;10:95-102

How to cite this URL:
Ongun H, Demir M. Family-centered lactation counseling and breastfeeding in preterm infants upon neonatal intensive care discharge. J Clin Neonatol [serial online] 2021 [cited 2023 Mar 24];10:95-102. Available from: https://www.jcnonweb.com/text.asp?2021/10/2/95/316178

  Introduction Top

Breast milk feeding (BMF) is the recommended source of nutrition providing short- and long-term beneficiary effects.[1],[2] It ensures optimal growth and food security in the neonate and improves survival of 820.000 lives per year.[3] Health benefits are also applicable to preterm infants.[4] Improved feeding tolerance, enhanced intestinal maturation, and reduced intestinal complications are some of the profits specific to prematurity.[1] Attenuated incidence of late-onset sepsis, chronic lung disease, and childhood development are the dose dependent, positive impacts in a more specific population of infants weighing <1500 g.[5]

Despite the evidence, BMF utilization in preterm neonates is lower at hospital discharge and breastfeeding continuity is shorter compared to their term counterparts.[6],[7] Complicated preterm delivery, comorbid maternal health problems, stress of having a newborn receiving intensive care, and pumping milk instead of breastfeeding are unique barriers specific to the mother of the preterm. The absence of environmental conditions, limited support of the health-care provider, and inadequate acquaint of the mother with the benefits of BMF increase the challenges.[1],[8] Even so, there is evidence that virtually all women can breastfeed if the mothers of these infants are provided accurate knowledge and support.[9]

The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) have advocated national policies to support breastfeeding practices of the infant and young child and launched baby-friendly hospitals initiatives (BFHI) three decades ago.[3],[10],[11] As more and more birth centers are becoming baby-friendly, it is imperative to promote BMF for the critically-ill neonate who require advanced neonatal care. Unfortunately, the concept of BFHI remains to be unsuited for many neonatal intensive care units (NICU).[12] Recent studies have emphasized great variability in breastfeeding practices and lactation counseling at NICU discharge for preterm infants.[5],[13] Neonatal intensive care nurse plays a critical role in supporting the provision of maternal milk and breastfeeding during the initial hospital stay. Shortage of nurse staffing and concentrating on the medical needs of the critically ill neonate may underrate the provision of BMF in the NICU context. In a 2014 report analyzing 6060 nurses who took care of 15233 infants, only 14%–15% of parents have received breastfeeding support in the NICU.[14] Sharing similar problems and concerns for breastfeeding utility upon discharge, the study center (Baby-Friendly initiative since 2012) has launched a contemporary family-centered lactation counseling program (LCP) that involved the participation of both parents and elderly relatives of all neonates requiring intensive care in 2017. The present study was conducted to examine breastfeeding utility and LCP efficiency on 1-year breastfeeding outcomes on hospital discharge.

  Methods Top

This retrospective study was approved by local ethics committee (no: 2019/6, date: 08.19.2019). The consent of each study participant was attained in accordance with the ethical principles for human investigations and outlined in the Second Declaration of Helsinki.

Study center

The university-affiliated facility has a 34-bed, tertiary, heavily populated NICU located in the south coast of Turkey. Nurse staffing is to work 12 h shifts in a week and nurse-to-patient ratio is 1:4–1:5 in the NICU. The employed nurses have baccalaureate degree for neonatal care. Approximately 1/6-1/7 of the nurses are national board-certified for lactation counseling; however, all nurses deliver regular training for lactation counseling in respect to institutional policy.

Baby-friendly initiative and peer lactation counseling

The facility is a baby-friendly hospital since 2012 and fulfills UNICEF's BFHI criteria and Turkish Ministry of Health's BFHI Program Further Recommendations for NICU.[11],[15] These include: (i) initiate breastfeeding and oropharyngeal colostrum once the health status of the newborn is stable for breastfeeding as soon as possible (stable preterm refers to the absence of desaturation, apnea, and bradycardia), (ii) if breastfeeding is not possible, apply maternal milk by cup, injector or orogastric route, (iii) provide rooms for the mothers and support milk sucking within 6 h of birth and every 2–3 h afterward, (iv) kangaroo mother care, and (v) providing rooms to enable mother-baby relationship once the preterm neonate is mature enough to achieve oral feeding and maintain normothermia at room temperature before hospital discharge.

By the beginning of 2017, a contemporary LCP has also been launched for the mothers of all neonates requiring intensive care in addition to BFHI requirements. This program has consisted of several upgrades such as: (i) selection of nurses specific for peer-to-peer lactation counseling, (ii) organizing the nursery shifts accordingly to enable their presence on day-time shifts for daily peer-counseling, (iii) the organization of 45 min of private counseling sessions initiated 5 days before hospital discharge in a lactation-equipped meeting room outside NICU, (iv) participation of family members including both parents and elderly care-taker/relatives who will assist the mother at neonatal-care, (v) recruiting the staff neonatologist or the pediatricians in the session for professional assistance on breastfeeding and infant nutrition after discharge.

Study population

The design of the study has consisted of two steps: to identify all preterm (gestational age ≤34 weeks) NICU admissions between February 2016 and January 2018 and then to contact their families for face-to-face interviews. Exclusion criteria were infant death after NICU discharge, family reluctance to consent for the study, foster-care placement and acquiring enteral feeding by orogastric/nasogastric tube or gastrostomy upon discharge. The participants were asked to fill in the three-page survey (23 questions) to collect 1-year nutrition and breastfeeding practices upon hospital discharge (see [Supplemental Table 1] for the survey).

The definitions of terms commonly used in the manuscript are BMF: Total sum of breastmilk including “breastfeeding only,”breastmilk+milk fortifier” and “breastmilk+formulary” by any method (breastfeeding, orogastric/nasogastric tube, feeding cup, bottle, or syringe), exclusive breastfeeding (EBF): Infant's nutrition of 100% of mother's milk, continued BMF: Any volume of maternal milk (with or without a fortifier) and contemporary foods, contemporary foods: Semi-solid or solid foods other than breastmilk and formula and milk other than human milk: Cow or goat milk. We have to mention Turkish laws do not govern national donor milk bank; however, common practice is to use breastmilk of a family relative/local trusted neighbor when the mother's milk is not available.

The group categorization was based on delivery of peer LCP. Descriptive analysis was performed for covariates of obstetric characteristics and NICU interventions (birthweight, gestational age, discharge weight, parity, multiple birth, mode of delivery, smoking at postnatal period, family sociodemographic data (including single parent, siblings, education, occupational status, and family's economic status) and 1-year nutritional outcome. Chi-square or Fisher's exact test was used for categorical and Mann–Whitney U-test or Student's t-test for numeric variables (following normality assumption). Variables were express as mean ± standard deviation and median (interquartile range [IQR]) and percentage (%). Spearman's rank correlation and logistic regression using SPSS version 22 software (IBM Corp., Armonk, NY, USA) statistical package have analyzed factors related to the length of BMF.

  Results Top

Three hundred and fifty-eight families have filled in the survey out of 435 preterm NICU admissions (77 exclusions; due to contact failure in 46, reluctance to consent in 19; infant death upon NICU discharge in five, foster care in four and gastrostomy in three infants). Of them, 190 (53.1%) families have received LCP before hospital discharge. The study population's demographics have shown male predominance (52.8%) with gestational age of 32 weeks (IQR: 30–33 weeks), birth weight of 1620 g (IQR: 1266.5–1840 g), and hospital discharge weight of 2240 g (IQR: 2140–360 g). NICU nutritional data have verified 77.1% of the infants received maternal milk within the 1st day by breastfeeding or orogastric route once the cardiorespiratory dynamics were achieved. The general demographics of the infants and the families can be observed at [Table 1] and [Table 2].
Table 1: The demographics of the study population

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Table 2: Sociocultural outcome of families

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Nutrition after hospital discharge

Approximately 90.2% of the infants have delivered BMF at discharge. Of the study group, 49.2% of the infants have received EBF at hospital discharge. Total duration of breastfeeding was 7.38 ± 3.98 months. Birth weight and length of NICU stay has shown the strongest correlation with BMF duration (r = 0.366 and r = −0.290). [Table 3] and [Table 4] present the correlations with breastfeeding duration and postdischarge nutrition outcome. Introduction of complementary foods before 6 months was 51.1%; cessation of breast milk has appeared to be the main reason beneath (69.6%).
Table 3: Correlation with breastfeeding length

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Table 4: Nutritional outcome after hospital dicharge

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Lactation counseling program

One hundred and ninety families have delivered lactation counseling. Despite the similar prevalence of EBF at hospital discharge, 4th and 6th months, the total length of BMF was longer in families delivering LCP [8.47 ± 3.87 months vs. 6.15 ± 3.75 months, P < 0.001, [Table 4]]. The peer counseling has favored the outcomes in terms of reduced use of formulas in addition to maternal milk and lesser introduction of complementary foods before 6 months (P = 0.044, P = 0.018). The most significant benefit of the program has appeared to be the “physical contribution of the father” on infant's nutrition (71.6% vs. 51.8%, P < 0.001). In the multivariable logistic regression [Table 5], peer lactation counseling has shown the highest odds of extending breastfeeding implementations beyond 6 months by 2.183 times in preterm infants [odds ratio: 2.183, 95% confidence interval (CI): 1.354–3.520, P = 0.001; [Table 5]].
Table 5: Logistic regression for breastfeeding interventions

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  Discussion Top

The present study has evaluated the postdischarge nutritional practices and the influence of family-based peer lactation counseling in preterm NICU admissions. The outcomes were; (i) 77.1% of the infants received maternal milk within the 1st day of NICU admission by breastfeeding or orogastric route, (ii) 49.2% of the infants were exclusively breastfed at hospital discharge, (iii) total duration of BMF was 7.38 ± 3.98 months, (iv) family-based peer lactation counseling has prolonged BMF interventions (8.47 ± 3.87 months), reduced the prevalence of formulary nutrition and the initiation of complementary foods before 6 months, (v) lactation counseling has extended breastfeeding beyond 6 months by 2.183 times (95% CI: 1.354–3.520).

Breast milk is the universally accepted source of nutrition for all infants.[16] Specific benefits for lower gestational infants include enhanced feeding tolerance and intestinal maturation, improved childhood growth, reduced necrotizing enterocolitis, and late-onset sepsis.[5] However, many preterm newborns fail to achieve their human milk feeding goals.[16],[17] Prematurity-related health conditions, maternal disease or stress resulting in reduced milk expression, insufficient encouragement due to work-overload of the health-care staff are some of the confronting challenges.[16],[17] Numerous research have demonstrated variable outcomes in breastfeeding prevalence of preterm infants of GA 32–34 weeks ranging between 27% and 87% (mean 59%).[6],[18] Our observations were confirming the fact that Turkish people appraise breastfeeding as a natural nutrition source for infants.[9] It is very common in Turkey and the widespread use of maternal milk has ranked the country no. 7 with an average of 80/100 points among 98 countries.[9] However, EBF is not as widely practiced as recommended and is far from optimum in Turkey. The similar outcome was also evident in the current study; the practice of maternal milk at discharge (regardless of milk volume administered) was 90.2%. However, the incidence of exclusively-breastfed preterm infants has remained at 49.2% at NICU discharge and declined to 43% and 31.3% at 4 and 6 months. Only 17% of the preterm infants have continued BMF after 1 year. Global standards in breastfeeding is to achieve at least 80% of preterm and term infants to deliver exclusive breast milk throughout their hospital stay, continue EBF by at least 50% at 6 months and keep breastfeeding at 2 years or beyond.[3] Despite the society's positive attitude toward breast milk, bottle feeding, early introduction of other milks, and complementary foods are the common practices in Turkey.[9],[19] Turkish Demographic Health survey has shown 40.7% of EBF prevalence in infants <6 months.[20] Moreover, 12% of babies receive complementary foods before 6 months.[9] The early introduction of complementary foods was much higher than the nation's statistics; 51.1% of the preterm infants have received semisolid/solid foods before 6 months. Reaching the global standards of at least 80% of the infants to receive breastmilk,[3] has eventually declined in time. These findings have confirmed the necessity of ongoing support following discharge.[1]

To ensure food security of the vulnerable infant, WHO and UNICEF have published ten steps to successful breastfeeding and launched BFHI worldwide to motivate nations to implement these steps in the early 1990s.[3] Since then, almost all countries in the world have implemented BFHI at some point. In respect, Turkish Ministry of Health complies with the regulations of international BFHI policies for over three decades.[9] As the number of BFHI centers increase, it is imperative to promote breastmilk for the critically-ill neonate who requires advanced neonatal care. Unfortunately, the concept of BFHI remains to be unsuited for many NICUs.[12] Several studies emphasize the great variability in breastfeeding practices and lactation counseling at NICU discharge for preterm infants.[4],[6],[7],[13] A 2014 study investigating 6060 NICU nurses and 15.233 infants has shown only 14%–15% of the parents have received breastfeeding support in the NICU.[14] This scenario reflects the lower breastfeeding implementations in the preterm population.[17],[21] Regarding this fact, BFHI has adapted the 10-step recommendations to NICU context to promote BMF in this population.[17] In respect to baby-friendly hospital requirements, each NICU are encouraged to establish their local protocols to support breastfeeding.[3] In 2017, the study center has adapted a contemporary peer-lactation counseling to all families of NICU admissions. The peer sessions have involved both parents and an accompanying elderly relative/caretaker who would assist the mother in neonatal care upon hospital discharge. The results of the present study have confirmed the positive impact on postdischarge nutrition outcomes. The odds of delivering LCP were 2.183 on extending breastfeeding beyond 6 months. The contribution of peer-counseling to infant feeding appears to be prolonging overall maternal milk administration to 8.47 ± 3.87 months, reducing the prevalence of formulary nutrition and initiation of complementary foods before 6 months. The topic of counseling is obscure due to opposing results in literature. Two studies have reported positive outcome in lactation counseling: Increased BMF both at hospital discharge and overall nutrition after discharge (from 23% to 37% and from 31% to 47%, respectively),[22] while Merewood et al. have shown the impact of peer counselors on postpartum 12 weeks as increased breastfeeding odds of 181%.[23] Conversely, in the randomized controlled study from Pinelli et al., no effect at breastfeeding duration in 1-year period.[24] Apparently, instead of increasing the EBF rates, the counseling sessions have their influence on overall breastfeeding interventions.

Three main categories have been identified in providing breastfeeding policies such as structural, settings, and individual factors.[13],[25],[26] The structural determinant is the sociocultural aspect that shapes the breastfeeding attitudes. Each community has its own interfamily dynamics and many individual and cultural factors are attributed to breastfeeding outcomes including maternal education, employment status, environmental conditions, and maternal psychological status.[21] Paternal involvement in NICU has a beneficiary effect in better breastfeeding exclusivity as well as improved cognitive functions and regular sleep patterns.[27] Participating the elderly relative to the counseling sessions might also influence the nutritional outcomes, because of their social influence, especially in the young, inexperienced mothers in our society. The lower practice of formulary feeding and complementary food before 6 months might reflect the higher maternal motivation by the other parent and the elderly relative. Family-centered approach involving both parents and the elderly relatives have also enabled enhanced maternal self-confidence for breastfeeding continuation.[19],[28] Approximately ¼ of all mothers experience breastfeeding problems during the postpartum period. The rates are even much higher in mothers of preterm deliveries.[13] Despite the obstacles, mothers of preterm deliveries have stronger will to breastfeed their infants.[5] We assume the higher motivation of these mothers by family-centered peer counseling, professional support of the NICU staff and unit policies can help to overcome individual and social factors, while they increase the likelihood of improved breastfeeding outcomes.[13],[29],[30]

There were several limitations in the present study. More than 1/5 of the admissions were excluded from the study due to the failure of contact or other exclusion criteria. The retrospective design has led to potential risk of bias. The absence of maternal data including maternal morbidities, neighborhood characteristics, and feeding intervals was the other limitations preventing to examine individual and social factors. The challenges in breastfeeding are multifactorial and the social structure of each community defines the expectations in infant nutrition. Considering this fact, this comprehensive family-based lactation counseling was launched in respect with fulfill the need of the mothers of fragile infants. Higher maternal motivation by family-centered peer counseling and unit policies can overcome the obstacles and improve breastfeeding outcomes in preterm infants. The study outcomes were promising to see whether helping the preterm infant is not limited to delivering neonatal care at NICU, but sparing a little more time and effort of the health-care provider can contribute to reaching the nutritional goals and achieve long-term health benefits in this fragile population. Future multicenter research would address the impact of family-based counseling programs individualized to each community on multinational basis.

  Conclusion Top

Appropriate nutrition with breastmilk in early childhood prevents future obesity and another noncommunicable disease that makes breastfeeding a public-health priority.[2] Despite the widespread efforts to implement the policies for more than three decades, many preterm infants fail to achieve their human milk feeding goals. Family-centered, peer counseling by NICU staff and increasing awareness for infant nutrition are promising local strategies in reaching the goals of national nutrition policies guided by the international recommendations in preterm infants.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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