Preterm Infants & Breastfeeding MCH Nutrition, Spring 2014

Late Preterm Birth & Breastfeeding

Author’s Note This fact sheet contains information primarily from three review articles:

“Preterm birth: Strategies for establishing adequate milk

production and successful lactation” (Geddes, D. et al), “The

Relationship of Brain Development and Breastfeeding in Late-Preterm

Infants” (Hallowell, S.G. et al), and “The Paradox of Breastfeeding-

Associated Morbidity among Late Preterm Infants” (Radtke, J.V. et

al). When these three articles were in agreement, there is no citation

and the reader should assume that the information is represented in all of them. Otherwise, please refer to the citation and reference list found

at the end of this fact sheet for further research.

Background & Problem Definition

Margot Zipperstein, MPHc University of California, Berkeley, School of Public Health

The purpose of this fact sheet is to explore the relationship between late preterm infants and breastfeeding. The fact sheet will discuss the difficulties and complications of

breastfeeding late preterm infants from both the infant’s and the mother’s perspectives. Finally, the fact sheet will consider areas for future research and potential intervention

strategies, considering both family- and hospital-based strategies.

Preterm infants are babies born before 37 weeks gestation. Late preterm (LP) infants, a subset of this population, are babies born between 34 and 36 weeks gestation. Often, physicians and providers consider these infants to be healthier than younger preterm babies because LP infants more closely resemble full term infants.

Researchers have demonstrated protective benefits of breastfeeding for infants – physiological and mental – as well as the long-term positive impact of early bonding between mother and child, especially for preterm infants who may need to be hospitalized following birth.

Preterm infants have not developed the brain function or nervous system maturity required for feeding, and so have difficulty latching onto nipples for breastfeeding and coordinating the suckling action. Further, new moms may struggle to produce enough breast milk to provide for their preterm babies since much of their milk storage is created in the last few weeks of pregnancy.

Because of developmental barriers experienced by both babies and new mothers, breastfeeding preterm infants can be very difficult. Late preterm infants are especially vulnerable to health problems because they appear healthy and so get less medical attention, but are still quite underdeveloped.

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“The specific needs [of late preterm infants] at birth are related to physiologic and developmental immaturity and are largely dependent

on their ability to successfully feed to avoid short-term outcomes resulting in hospital readmission.”1

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“They may resemble full term babies, but late preterm infants are physiologically, metabolically, and neurologically

immature with limited compensatory mechanisms for adjusting to extrauterine life.”4

Late Preterm Infants & Morbidity • LP infants have only 65% of their full brain

volume, demonstrating the importance of those last few weeks of gestation on brain development

• LP infants have a higher mortality rate (arguably somewhere between 3 times1 and 4.6 times higher2) than full-term infants

• The leading causes of death for LP infants are congenital malformations, low birth weight, and Sudden Infant Death Syndrome1

• LP infants are four times more likely than full-term infants to have jaundice, respiratory distress, poor feeding habits, temperature instability, or hypoglycemia2

• 54% of LP infants have jaundice, 37% have suspected sepsis, and 32% exhibit feeding difficulties2

Hospital Treatment While in the hospital, preterm babies often have extended stays or receive extra care through the NICU that can prevent initiation of breastfeeding.3 LP infants are likely to get discharged earlier than other preterm babies because they can appear as healthy as full-term babies. Often times, though, these younger infants need medical attention despite seeming developmentally on-track. Breastfed LP babies are 1.8 times more likely than breastfed full-term infants to need hospital care. Further, LP infants are susceptible to infection and health problems caused by inadequate nutritional intake likely due to difficulty with breastfeeding; indeed, 80% of hospital readmissions for LP infants are due to jaundice.

Prevalence of LP Infants in the United States Premature infants in the United States account for 12.8% of all births.4 Late preterm births account for 72% of all preterm births.4 In 2005, this translated into 375,000 late preterm births.2 They are the fastest growing cohort amongst all preterm births,2 yet there is not a lot of research and clinical focus on this age.

FACT: One-third of brain occurs develops during the

last six to eight weeks of gestation, leaving preterm infants with underdeveloped brains.

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Risk Factors for Baby • Preterm morbidities like chronic lung disease and intracranial hemorrhage can make it

difficult for babies to breastfeed6

• Undeveloped neurological function and developmental delays from early delivery can be very problematic:

o Limited coordination for the suck-swallow-breathe function required for breastfeeding o Diminished ability to suck on nipple o If tube feeding is introduced in order to help preterm infants feed, the baby may

develop poorer sucking habits later6 o Lack of required stamina or strength to initiate and continue breastfeeding

• Early discharge from the hospital for LP infants who appear healthy but are neurologically or physically immature have an increased risk of being readmitted to the hospital due to feeding difficulties and associated morbidities, like jaundice

o LP infants who are not admitted to the NICU are more likely than all other babies to be readmitted to the hospital within two weeks of discharge6

Risk Factors for Mom • The components of breast milk differ when

the milk is expressed before 37 weeks gestation, which may have an effect on mom or baby6 • Because preterm births are often delivered

via caesarean section and NICU trips that separate mom from baby,7 skin-to-skin contact is often delayed or does not occur at all, which inhibits the triggering of the milk production reflex and delays lactogenesis à Infection, multiple births, or complications

during labor may also prevent skin-to-skin contact2

à Type I diabetes, obesity, caesarean section, and hyptertension may also delay lactogenesis2

• Because the infants have weakened sucking abilities, the breasts do not produce as much milk • Lack of breastfeeding support, work or

school obligations, or disease may also inhibit a mother’s ability to breastfeed2

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FACT: In 2005, the National Institute of Child Health and Human Development

decided to rename “near term” infants as “late preterm” in order to specify that this age is, in fact, preterm.5

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Intervention Strategies Baby-Focused Interventions:

• Oral and non-oral stimulation • Supplement with donor-expressed milk8 or

formula • Monitor baby’s feeding to

ensure that baby is actually consuming breast milk, although this can be very difficult to measure

Mom-Focused Interventions:

• Use of nipple shields • Advocate for and initiate skin-to-skin contact,

which can help moms lactate up to four times longer than moms who did not experience skin-to-skin contact after birth6

• Hand expression of breast milk, especially early after delivery to ensure collection of colostrum

• Early and frequent breastfeeding, with the possible addition of double pumping to collect as much milk as possible

Hospital-Focused Interventions:

• Neonatal staff should encourage breastfeeding initiation and continuation after discharge9

• Breastfeeding education during pregnancy • Lactation Consultants (LCs) available for new

parents • Nurse or LC follow-up within 48 hours after

discharge to check-in on mom and baby • Broad multi-disciplinary approach focusing on

overall hospital care10 like the Association of Women’s Health, Obstetric, and Neonatal Nurses (AHWONN) Late Preterm Infant Initiative11 or CPQCC-organized interventions12

• Follow the 2008 Academy of Breastfeeding Medicine directives13 and focus on providers to coordinate and promote breastfeeding

Opportunities for Future Research There are many areas for research to improve the health and care of LP infants and the ability to breastfeed. In general,

more research needs to focus specifically on LP infants rather than grouping them together with all preterm infants. Directed research like this can provide more information on feeding behaviors and oral intake.

Researchers can develop more accurate clinical measurements and

assessments for the volume of breast milk that infants are actually ingesting. Weighing before and after feedings can be helpful in providing a rough estimate of the amount of milk consumed, but a more specific measurement tool would be helpful for understanding the differences between

preterm and full-term infants. Researchers could also study different approaches to increasing breast milk production, especially for mothers of preterm infants who might experience difficulty with adequate milk supply. A recent study found that relaxing sounds and imagery led to a 63% increase in milk yield, so more studies like this could lead to improved techniques for moms of preterm babies.2 On a broader scale, health researchers and practitioners would benefit from improved understanding of how LPT infants fit into the larger system of hospitals, timing of discharge, quality of bonding, and provider attitudes.2

“Physiological, psychological, process, and system factors

affecting breastfeeding outcomes within the late preterm population

warrant further investigation.”2

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1. *Hallowell SG, Spatz DL. The Relationship of Brain Development and Breastfeeding in the Late-Preterm Infant. Journal of Pediatric Nursing. 2012; 27: 154-162. doi:10.1016/j.pedn.2010.12.018

2. *Radtke, J.V. The Paradox of Breastfeeding-Associated Morbidity among Late Preterm Infants. J Obstet Gynecol Neonatal Nurs. 2011; 40 (1), 9-24. doi: 10.1111/j.1552-6909.2010.01211.x.

3. Alves E, Rodrigues C, Fraga S, Barros H, Silva S. Parents’ views on factors that help or hinder breast milk supply in neonatal care units: systematic review. Arch Dis Child Fetal Neonatal Ed. 2013; 98: F511-F517. doi:10.1136/archdischild-2013-304029

4. Walker M. Breastfeeding the Late Preterm Infant. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2008; 37(6): 692-701. doi: 10.1111/j.1552-6909.2008.00293.x

5. McDonald SW, Benzies KM, Gallant JE, McNeil DA, Dolan SM, Tough SC. A Comparison Between Late Preterm and Term Infants on Breastfeeding and Maternal Mental Health. Matern Child Health J. 2013; 17: 1468-1477. doi:10.1007/s10995-012-1153-1

6. *Geddes D, Hartmann P, Jones E. Preterm birth: Strategies for establishing adequate milk production and successful lactation. Seminars in Fetal and Neonatal Medicine. 2013; 18(3): 155-159. doi: 10.1016/j.siny.2013.04.001

7. Donovan TJ, Buchanan K. Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants. Cochrane Database Syst Rev. 2012; 3. doi: 10.1002/14651858.CD005544.pub2.

8. Menon G, Williams TC. Human milk for preterm infants: why, what, when and how? Arch Dis Child Fetal Neonatal Ed. 2013; 98: F559-F562. doi:10.1136/archdischild-2012-303582

9. Meier P, Patel AL, Wright K, Engstrom JL. Management of Breastfeeding During and After the Maternity Hospitalization for Late Preterm Infants. Clinics in Perinatology. 2013; 40(4): 689-705. Doi: 10.1016/j.clp.2013.07.014

10. Phillips RM. Multidisciplinary Guidelines for the Care of Late Preterm Infants. Journal of Perinatology. 2013; 33: S3-S4. doi:10.1038/jp.2013.528. 11. Association of Women’s Health, Obstetric and Neonatal Nurses. Newborns and Neonates: AWHONN Late Preterm Infant Initiative. http://www.awhonn.org/awhonn/content.do?name=02_PracticeResources/2C3_Focus_NearTermInfant.htm. Accessed 1 April 2014.

References

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12. Lee HC, Kurtin PS, Wight NE, et al. A Quality Improvement Project to Increase Breast

Milk Use in Very Low Birth Weight Infants. Pediatrics. 2012; 150(6): e1679. doi: 10.1542/peds.2012-0547

13. Liebert MA. ABM Statements: Position on Breastfeeding. Breastfeeding Medicine. 2008; 3(4): 267-270. doi: 10.1089/bfm.2008.9988

Image References 1. http://www.lilaussieprems.com.au/breastfeeding-your-premature-baby/ 2. http://www.healthynewbornnetwork.org/press-release/africa-global-report-preterm-

birth-rates-highest-sub-saharan-africa 3. http://www.topnews.in/health/premature-births-leading-cause-infant-deaths-26193 4. http://www.healthynewbornnetwork.org/press-release/preterm-birth-emerging-threat-

newborn-survival 5. http://kellymom.com/ages/newborn/newborn-concerns/preemie-links/ 6. http://community.babycenter.com/post/a48308293/please_stop_telling_women_that_b

irth_before_38-40_weeks_will_result_in_nicu_stay 7. https://healthonline.washington.edu/document

/health_online/pdf/Breastfeeding_Your_Preterm_Baby_ENTIRE_8_09.pdf