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Keywords:

  • breastfeeding;
  • breast milk;
  • premature infant;
  • low-birthweight infant;
  • systematic review

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

This review aimed to identify interventions to promote breastfeeding or breast milk feeding for infants admitted to the neonatal unit.

The medical electronic databases were searched for papers listed between 1990 and June 2005 which had breastfeeding or breast milk as an outcome and which targeted infants who had been admitted to a neonatal unit, thus including the infant and/or their parents and/or neonatal unit staff. Only papers culturally relevant to the UK were included resulting in studies from the USA, Canada, Europe, Australia and New Zealand. This search was updated in December 2007 to include publications up to this date.

We assessed 86 papers in full, of which 27 ultimately fulfilled the inclusion criteria. The studies employed a range of methods and targeted different aspects of breastfeeding in the neonatal unit. Variations in study type and outcomes meant that there was no clear message of what works best but skin-to-skin contact and additional postnatal support seemed to offer greater advantage for the infant in terms of breastfeeding outcome. Galactogogues for mothers who are unable to meet their infants’ needs may also help to increase milk supply. Evidence of an effect from other practices, such as cup-feeding on breastfeeding was limited; mainly because of a lack of research but also because few studies followed up the population beyond discharge from the unit.

Further research is required to explore the barriers to breastfeeding in this vulnerable population and to identify appropriate interventions to improve breastfeeding outcomes.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

Infants born prematurely and those of low-birthweight (LBW), who form the bulk of admissions to neonatal units (NU), are at greater risk of poorer outcomes than term or normal birthweight infants and continue to be disadvantaged into adult life (Bhutta et al. 2002; Anderson et al. 2003; Klassen et al. 2004; Stein et al. 2006). These infants are also over-represented by those from less affluent backgrounds, thus increasing the likelihood of social and health disadvantage (Spencer et al. 1999; Moser et al. 2003). Health professionals caring for preterm/LBW infants should, therefore, aim to provide opportunities to give these infants a better start in life. Breastfeeding is recognized as the optimal method of feeding such newborns by providing protection from infection, enabling appropriate digestion and absorption of nutrients, and optimizing neurological development (Schanler et al. 1999). However, infant feeding choices continue to reflect socio-economic disadvantage with younger less affluent women tending to opt to bottle-feed their babies (Bolling et al. 2007). In the NU, mothers are frequently encouraged to provide breast milk, which is often recognized as being crucial to their infant's survival and well-being. The evidence that many mothers will provide breast milk for their infant following admission to the NU (Jaeger et al. 1997; Miracle et al. 2004) suggests a unique opportunity to promote breastfeeding. However, there is some evidence that few infants are breastfed (i.e. fed at the breast rather than fed breast milk) at the time of discharge from the unit (Buckley & Charles 2006). Furthermore mothers often feel excluded from the unit and from providing care for their infant (Lupton & Fenwick 2001; Flacking et al. 2006) and speak of distress at being separated from their babies (Hedberg Nyqvist et al. 1994). Mothers who express breast milk or breastfeed their infant speak of the important bond that this creates with their infant, the increased opportunities for them to interact with their infant and the importance for them of this maternal role (Lupton & Fenwick 2001; Miracle et al. 2004). Breastfeeding success is affected by the clinical well-being of the infant, the support the mother receives and by the separation of the mother from her infant, which in itself can act as a barrier to breastfeeding. There are a number of clinical practices and decisions which affect the ability of the mother to maintain her supply of breast milk and to establish breastfeeding. Some practices have been identified as beneficial for healthy, term infants (Renfrew et al. 2005), such as avoiding supplements and/or artificial teats. However, as preterm infants and infants admitted to the NU experience different feeding challenges (such as delayed oral feeding) and have different needs (such as supplemental feeding and/or the need to be fed during the mothers absence from the unit), it may not be helpful to extrapolate those findings to this group.

Given the importance of breast milk for the preterm/LBW or sick infant and the mother, it is crucial that we identify the processes that can support the mother to provide breast milk for her infant and to enable breastfeeding. This systematic review aims to identify interventions that affect breastfeeding and/or breast milk feeding in NU.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

Search strategy

A search of the electronic databases CDSR, DARE, AMED, BNI, CINAHL, EMBASE, MEDLINE, PsycINFO and the reference lists of published articles for papers published between 1990 and 2005 was conducted. This search was updated in December 2007 to include any further publications since 2005 (Fig. 1).

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Figure 1. Literature search. BEG, Breastfeeding Expert Group.

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Inclusion

Studies were included if they were experimental, published in English, had breastfeeding or breast milk as an outcome and targeted infants admitted to NU, thus including infants and/or their parents and/or NU staff. To identify papers, we searched for studies which targeted preterm (<37 weeks) or LBW infants (<2.5 kg) and for interventions within NU. In our original search we included studies from developing countries; however, these studies are not included in this paper as it was unclear whether their outcomes reflected an impact of the intervention or were a consequence of poorly resourced care often provided to control group infants in these countries. Furthermore the breastfeeding and parenting culture apparent in many developing countries may affect the generalizability of such studies to high technology NU in countries with generally lower rates of breastfeeding. A fuller report, which includes papers (from 1990 to 2005) from developing countries, is available from the authors on request. Excluded papers are listed in Appendix 1.

Screening and data extraction

Abstracts were independently screened for inclusion by the reviewers (RM and JC) who also independently appraised each of the included papers using a tool developed from critical appraisal publications (Centre for Reviews and Dissemination 2001; SIGN 2004; Higgins et al. 2006) and from previous work by the researchers. In the updated search for papers published between 2005 and 2007, papers were screened by the first author (RM) and reviewed for agreement by the second (JC).

Quality assessment

All papers were scored according to methodological rigour (see Appendix 2 for more details on how this was calculated). The quality rating for each paper is given in column 1 of Table 3. Papers scoring ≥70% were defined as good, those scoring 50–69% as intermediate and those <50% as poor quality. Authors were contacted to discuss ‘gaps’ in reporting that may impact upon the quality rating. Agreement between the reviewers was high and minor disagreements were resolved through discussion.

Table 3.  Interventions with accumulated evidence for outcomes (18 studies)
Citation Country Quality ratingAspect of BFParticipants Sample size n = xStudy type LocationIntervention detailsStudy outcome/sIntervention effect on outcomeComment
  1. Papers are arranged first by topic and then by decreasing order of quality rating. Citation = publication reference; score reflects our grading of study methods (lower scores, including negative ones, are indicative of poorer quality); participants = details of participants as provided by author [G = mean gestation at birth, BW = mean birthweight, CA = mean corrected age at initiation of intervention (where more than one figure is given for G, BW or CA this is for the intervention and control group if these have been given separately by authors)]; intervention details and outcomes are those identified by the author; comment = our comments on the study. RCT, randomized controlled trial; RT, subjects randomized to different treatment groups but no control; NICU, neonatal intensive care unit; SCN – special care nursery, NS, non-significant; BF, breastfeeding; EBM, expressed breast milk, OMM, own mothers milk; NG, nasogastric. Quality rating is given as a percentage for each study; we have graded studies scoring ≥70% as good, 50–69% as intermediate and <50% as poor, Appendix 2. *Funded by Canon Avent (Glemsford, Suffolk, UK) who also supplied the ISIS Manual pumps and Egnell pumps (Ameda, Taunton, UK). †Creamatocrit is a measure used to determine fat content. ‡Supported in part by a grant from Medela Inc, McHenry, IL, USA. §Part funded by Pharmacia AB, Stockholm, Sweden. ¶IBCLC = International Board Certified Lactation Consultant: these are either health professionals or others with background in health or social sciences who have completed comprehensive continuing education in lactation (a minimum of 45 hours) and have extensive experience of lactation counselling (900–6000 hours depending on existing qualifications).

Skin-to-Skin Contact (SSC) (5)
Rojas et al. (2003) USA 94%SSC vs. traditional holding (TH)G = 27.2/26.6 weeks BW = 939/906 g. CA at entry = 29.8/29.4. Weight at entry = 1002/1021. ’Mainly white or African American’ n = 60RCT NICUSSC: infant held in semi-upright position in direct contact with parents’ chest. Infants wore a nappy and their backs were covered with a blanket. TH: held in parents’ arms in supine position. Infants wore nappy and T-shirt and were wrapped in a blanket. All care offered up to total of 8 h per day in 2 × 4-h sessionsSuccessful BF (as judged by lactation specialist) Anthropometric measures Adverse events60% vs. 35% successfully BF (odds ratio = 2.8 (1.0 to 8.3, P = 0.06) [UPWARDS ARROW]head circumference (P = 0.03) No difference in weight or linear growth Fewer in SSC – only O2 desaturation significantSuccessful BF meant objective evidence of consistent BF using appropriate techniques and confirmed by retrospective analysis of medical records. Sample was small, parental refusal high (reasons not recorded) and compliance low (may be due to parents having returned to work, distance from hospital or psychosocial restraints)
Blaymore-Bier et al. (1996) USA 72%SSC vs. standard care (SC)G = 28/27 weeks BW = 993/942 g Age at entry to study = 29/30 days. CA = 32/31 weeks Mothers planned to BF. 17% primiparous. 34% previous BF experience n = 41 mothers (50 infants)RCT SCNSSC: infant wearing a nappy, held upright between mother's breasts. Both wrapped in blanket. SC: fully clothed infant wrapped in blanket, held cradled in mother's arms. One daily session for each baby for a maximum of 10 days. Contact was observed for 10 minBF Milk volumes (mL) Infant physiology[UPWARDS ARROW]BF at discharge 90% vs. 61% (P < 0.05) [UPWARDS ARROW]BF 1 month > discharge 50% vs. 11% (P < 0.01) No difference at 3 or 6 months No difference Less O2 desaturation (P < 0.001)More research needed as intervention limited to one 10-min session per day
Wahlberg et al. (1992) Sweden 57%SSCG = 31.1/31.3 weeks BW = 1482/1497 64% primiparous n = 66Quasi-experimental (pre-/post-intervention) Care unit for premature babies (equiv to USA level II)SSC: not sufficiently described: infant skin-to-skin with mother Control: dressed baby wrapped in blanket with heat pad. Both groups encouraged to hold baby as much as they wantedBF at discharge Weight gain/week Incubator stay (days) Hospital stay (days) Age at first time out of incubator[UPWARDS ARROW]82% vs. 45% (P = 0.005) [UPWARDS ARROW]237.5g vs. 195.5 g (P < 0.05) [DOWNWARDS ARROW]20.9 vs. 30.5 (P < 0.05) [DOWNWARDS ARROW]41.6 vs. 49.4 (P < 0.05) Younger (P < 0.01)The control group was selected from a time period prior to SSC, thus other unreported factors may have affected outcomes
Hurst et al. (1997) USA 47%SSCG = 27.7/27.5 weeks BW = 1129/1055 g Age at start of study = 15 days (8–26 days) All mothers in NICU in certain time periods n = 23Quasi-experimental (pre-/post-intervention) NICUSSC: all mothers participating in skin-to-skin holding in a specific time period. Excluded if SSC delayed > 4 weeks after birth. SSC = mothers instructed to hold infant once a day for at least 30 min inside clothing next to skin. Mean frequency of sessions = 4/week of a mean of 60 min Control: all mothers admitted in 12 months prior to initiation of SSC. No description of control conditions. Mothers excluded from the study if SSC had not begun in within the first 4 weeks after delivery. Control mothers who began BF within first 4 weeks were also excludedMilk volume (mL) increase over a 2 week period Mean milk volumes (mL) BFStrong linear increase in SSC vs. no change in control (P = 0.01). Higher at all time points in SSC group No differenceLimited statistical comparison because of very small sample (eight mothers in SSC group). Limited relevance because of unequivalent groups and conditions. Excluding control group mothers who began BF within four weeks after delivery could have biased outcomes
Roberts et al. (2000) Australia 21%SCC vs. conventional cuddling care (CCC)G = 31.5 weeks BW = 1524 g n = 30RT NICU and nurserySSC: baby wearing nappy ± hat held skin-to-skin with mother. Average of 1.6 h per day CCC: baby dressed and wrapped in light blanket held by mother. Average of 1.8 h per day Both groups were ‘permitted to breastfeed as desired’BF at discharge, 6 weeks, 3 months and 6 months Infant weight gain Infant temperature control Parental stress Hospital stayNo difference in any outcomes measuredThe authors state that the study lacked a control group which suggests that CCC was different to routine parental contact. Study size was inadequate and it was not clear if whole sample was followed up.
Cup-feeding vs. bottle feeding (3)
Collins et al. (2004) Australia 86%Cup-feeding vs. bottle-feeding Dummy vs. no dummyG = 29.2–30.3 weeks BW = 1325–1508 g Mother planed to BF. 48% primiparous, 40% previously BF, range of social groups, 78% in full time employment n = 303RCT Two large tertiary hospitals and 54 peripheral hospitalsInfants randomized to one of four groups i.e. cup/no dummy, cup/dummy, bottle/no dummy, bottle/dummy. Cup- or bottle-feeding commenced at discretion of clinical staff when mother not there for feeds or top-ups required. Dummies used from trial entry and encouraged during tube feeds or if infant restless. For babies not randomized to use a dummy alternative soothing measures were used.Proportion of infants fully BF at discharge Proportion of infants receiving any BF at discharge[UPWARDS ARROW]for cup-fed infants (odds ratios = 1.73, 1.04 to 2.88; P = 0.03) No significant effect from dummy No significant effect from cups or dummiesCompliance in study was low (bottle introduced to 53% of cup-fed infants and 31% of ‘no dummy’ group were given a dummy) which is likely to have affected outcomes. No adverse events noted
BF at 3 and 6 months Length of hospital stayNo difference [UPWARDS ARROW]for cup-fed infants (P = 0.01)
Mosley et al. (2001) UK 75%Cup-feeding vs. bottle-feeding Dummy vs. no dummyG = 35.5/35.2 weeks BW not given. Mothers planned to breastfeed. 50% primiparous. n = 14RCT Special Care Baby UnitInfants randomized to receive supplementary feeds of breast milk either by cup (six babies) or bottle (eight babies). No information given on dummy use. All mothers advised to express at least six times per dayExclusive BF at dischargeCup vs. bottle: no difference Dummy use: no difference (although use unclear)Very small sample, no information on expressing. Demographic differences but statistical significance not tested. Designed as feasibility study for larger trial
Mothers perception of BF support receivedHigh level of support reported
Gilks & Watkinson (2004) UK 25%Cup-feeding vs. bottle-feedingG = 31/32 BW = 1560/1750 g Mothers intended to BF n = 54RCT Neonatal UnitOral feeds of EBM when mother not present either given by bottle or cup as means of ‘assisting progression from tube to breast’BF at discharge BF at term and 6 weeks post-termNo difference in any BF NS [UPWARDS ARROW] exclusive BF (37 vs. 15%) in cup-fed group No differenceSmall number who BF therefore lack of statistical analysis. High refusal to participate and high withdrawal rate among cup-fed group
Expressing breast milk (n = 3)
*Fewtrell et al. (2001) UK 82%The efficacy of a standard electric pump compared with a hand pumpG = 29.4/29.1 weeks BW = 1357/1305 g. Mothers intended to express. Relatively advantaged social group. Mean n of expressions /day = 3.8. 60% primiparous n = 145RCT NICUMothers used ether a novel manual breast pump (Avent Isis) or an electric pump (Egnell). Mothers using the electric pump were able to double pump. Both groups were advised to express at least six times a day and were given information and supportTotal milk volume (mL)No significant differentComparing both pumps sequentially greater milk flow was achieved with the manual breast pump. 37 mothers (23 manual breast pump and 14 electric pump) attempted to BF. Breast milk at discharge does not differentiate between BF or breast milk given by bottle, etc.
Time (mean) Creamatocrit Maternal satisfaction Breast milk at discharge (from study)Manual breast pump vs. electric pump: 65 vs. 51 min/day (P < 0.001) No significant difference Manual breast pump preferred No significant difference
Jones et al. (2001) UK 66%Sequential vs. simultaneous breast milk expressing with or without massageG = 29.7 weeks BW = 1535 g Age at start of study = 5–7 days postpartum. 33% primiparous. n = 36RT NICUMothers allocated to express either simultaneously or sequentially. All participants also randomized to 2 days of breast massage i.e. days 1–2 or days 3–4. Mothers instructed to express at least eight times a day and express until milk no longer entered the collecting set. The Egnell Ameda Electric Elite pump was used ± silastic inserts. Study period = 4 days.Milk volume (g) Fat content BF duration (term)[UPWARDS ARROW]Milk weight Simultaneous + massage: 125 g Simultaneous + no massage: 88 g Sequential + massage: 79 g Sequential + no massage: 51 g (P < 0.01) Fat concentration similar but total fat volume was significantly higher for simultaneous pumping (P < 0.01). Massage NS No differenceBF: 15 of 17 sequential group mothers and 15 of 16 simultaneous group mothers were fully BF or expressing at term. 13% of study population either failed to lactate or suppressed lactation. Women felt strongly that expressing without massage was more difficult.
Groh-Wargo et al. (1995) USA 53%Sequential vs. simultaneous breast milk expressingMothers of premature infants weighing ≤1500 g and ≤7 days old. No infant data given. 56% primiparous n = 32RCT NICUIntervention – mothers used the Medela bilateral pump system. Instructed to pump the breasts simultaneously for 20 min every 3 h but not at night i.e. ≥4 times per day. Control – mothers used the Medela single pump and were instructed to pump each breast for 10 min every 3 h but not at night i.e. ≥4 times per dayMilk production (mL/week) Serum prolactin Number of pumping session/week Hours spent pumpingNo difference No difference No difference (28.6 ± 5 session per week) [UPWARDS ARROW]in single pump group (11.1 ± 3.1 vs. 7.6 ± 3 h per week, P < 0.01)Rather than pumping for the prescribed time, mothers would pump until milk stopped flowing which may be >20 or <10 min
Galactogogues (n = 4)
da Silva et al. (2001) Canada 100%Effect of domperidone on milk productionG = 29.1 Age at start of study = 31.9/33.1 Mothers of premature infants who were expressing breast milk but had low milk production. 38% primigravid, 12% previous BF experience n = 20RCT Double blind trial NICUIntervention: 10 mg domperidone 3× a day for 7 days Control: placebo for 7 days. Mothers were double pumping with electric pump and had received extensive counselling and teaching (which explains delay between birth and start of study).Increase in milk volume (mL) from baseline Serum prolactin increase from baseline Serum and breast milk levels of domperidone BF at discharge home Adverse effects[UPWARDS ARROW]to 44.5% in intervention group and 16.6% control (P < 0.05) [UPWARDS ARROW]119.3 µg/L vs. 18.1 µg/L (P < 0.01) Detected at low levels in serum and breast milk No differences NoneDomperidone may be effective in the short term; however long-term impact needs to be assessed. Small study, further research needed
Hansen et al. (2005) USA 87%Effect of metoclopramide on milk productionG = 28.1/28.0 Mothers of premature infants who planned to BF. 87% white, 77% married, 42% partners in white collar occupation n = 57RCTIntervention: 10 mg metoclopramide 3× a day for 10 days. Control: same volume of a placebo 3× a day for 10 days. All mothers given support by trained lactation consultant and supplied with an electric pumpMilk volumes (mL) Duration of BFNot significant No differences (median of 8.8 weeks)Study was under-powered to detect any significant differences at final analysis. Milk levels of metoclopramide suggest compliance was low
Fewtrell et al. (2006) UK 86%Effect of oxytocin spray on milk productionG = 29.9/29.0 BW = 1380/1315 Mothers of premature infants who planned to BF. Mothers older (average age = 31 years) and well educated. 67% white or Asian. 20% with previous BF experience n = 51RCT Double blind trial Neonatal unitIntervention: 5 mL oxytocin sprays containing 40IU synthetic oxytocin per mL. Control: placebo spray containing normal saline and benzalkonium chloride. All mothers advised to administer one spray (100 µL) 2–5 min before expressing milk. All mothers also given standard advice about expressing and advised to express milk at least every 3 h.Daily milk volumes (g) Pumping sessions (n) Milk volume and fat content over fixed 20-min period of expressing Mothers' opinion of sprayOnly significantly higher on day 2 (27 g vs. 13.2 g, P = 0.045) No difference No difference No significant differenceThe pattern of milk production differed significantly between the two groups but overall this did not seem to affect the volume of milk expressed. Several placebo mothers were convinced they had the oxytocin spray and seemed to perceive an affect on their milk supply.
§Gunn et al. (1996) NZ 65%Effect of growth hormone on milk productionG = 30.6/30.1 (25–35 weeks) BW = 1398/1239 Age at entry: 39.7/31.3 days Mothers expressing insufficient milk to meet infant's needs. 83% primigravidae, mean age 34 ± 4 years n = 20RCT Special Care Baby UnitIntervention: Subcutaneous injection of 0.2IU/kg/day recombinant human growth hormone (hGH), to a maximum of 16IU/day, for 7 days. Control: same volume of a placebo All mothers received standard management to promote and maintain lactation and were encouraged to express 5–6 times a dayIncrease in milk volume (mL or by test weight) from baseline to 7 days Plasma insulin like growth factor Plasma hGH Adverse effects[UPWARDS ARROW]in intervention group by 31% (P < 0.01) but not significant in control (7.6%) [UPWARDS ARROW]in intervention group (P < 0.001) Not significant NoneModest increase in milk production in women with lactational insufficiency. Unable to persuade mothers to express more than 5–6 times per day Small study and mothers were older
Support for BF (n = 3)
Merewood et al. (2006) USA 88%Peer supportG = 32.6 (26.3–37) BW = 682–3320 g (mean = 1914/1840 g Mothers of premature infants who planned to BF. >66% African American, >50% in receipt of Medicaid, >67% non-US born n = 108RCT Level III NICU of a baby-friendly hospitalIntervention: face-to-face contact with peer counsellor (PC) initiated before hospital discharge (≤72 h of birth). PCs = women with BF experience from the local community who were trained about BF and about NICU procedures. Contact maintained weekly up to 6 weeks. After the infants discharge contact was maintained by telephone unless mother choose to attend hospital to meet PC Control: SC, including referral to lactation consultant if required.Receiving any breast milk at 12 weeksIncreased odds ratio = 2.81 (95% confidence intervals, 1.11 to 7.14) P = 0.03Relatively disadvantaged population. Final outcome measured in terms of receiving breast milk which could be by bottle, tube or at the breast. Authors acknowledge that the BFHI status of the hospital may have influenced outcomes and that BF rates were higher in this hospital than the national average.
Receiving mostly breast milk at 12 weeks Receiving only breast milkNot significant Not significant
Gonzalez et al. (2003) USA 83%A lactation counselling service63.5% infants were <37 weeks and 36.5% ≥37 weeks 60% were low-birthweight (<2.5 kg) and 40% normal BW (≥2.5 kg). Stay in NICU ranged from 1–148 days. 82% of mothers were ≥21 years and 43% were white non-Hispanic n = 350Case-control NICUIntervention: lactation counselling service provided by IBCLC. This gave education and clinical support to mothers while infants hospitalized. Individual feeding/expressing plan developed. Preparation for BF after discharge. Telephone help-line. Private rooms with breast pumps were available and pumps could also be provided at the infant's bedside Control: period of 6 months before IBCLC support became available.Infants given OMM either by breast, bottle or NG tube Factors significantly associated with OMM feeding [UPWARDS ARROW]OMM during hospitalization (47% vs. 31%, P = 0.002) [UPWARDS ARROW]OMM at discharge (37% vs. 23% P = 0.004)The authors suggested that the sickest infants benefited least from this intervention. The use of a pre-/post-intervention design may affect outcomes. The study measured OMM and impact on actual BF not measured
Being in intervention group; Apgar > 7, white ethnicity, male infant, stay in NICU > 7 days
Pinelli et al. (2001) Canada 61%BF counselling for both parentsG = 29 weeks BW = 1083/1103 g Parents of very low-birthweight infants who chose to feed breast milk to their infant. Relatively advantaged social group. 60% primiparous, mothers planned to BF for 8 months n = 128RCT Tertiary level NICU and at the Growth and Development ClinicInterventions: video, one to one counselling by a research lactation consultant, weekly in-hospital contacts, frequent post-discharge contact for both parents for one year or until stopped BF Control: standard support during hospitalization i.e. contact with regular hospital staff, few of whom had received any formal training in BF support and lactation.BF duration Volume of feeds (test weight)Not significant Not significantPopulation relatively advantaged and highly motivated to breastfeed
BF exclusivityNot significant

Evidence statements

Grouping papers with similar interventions enabled identification of a number of statements about the evidence. The strength of these statements could be assessed using a process of comparative judgement (SIGN 2004). Assessments were based on the number and quality of studies, consistency of evidence between studies and clinical usefulness of the findings. Statements were graded as: A: more than one good quality study; B: one good quality study plus more than one lesser quality; C: one good quality study plus one of lesser quality OR more than one lesser quality study; and D: insufficient evidence to form a judgement. Evidence statements are given in the results section where possible. Because of the heterogeneity of the interventions conducting a meta-analysis was not thought appropriate.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

Overall 27 studies fullfiled the inclusion criteria. Twenty-four studies included breastfeeding as an outcome, of which seven also included a measurement of milk volume/supply. In the remaining three studies, breast milk volume/supply but not breastfeeding was an outcome. It should be noted that many of the studies used ‘breastfeeding’ to indicate that the baby was fed breast milk but often did not differentiate how this was given (i.e. breast, bottle or cup). Where information is available this has been noted in the relevant tables. Twenty-one studies recruited premature infants, three recruited LBW infants and three recruited all infants admitted to the NU during the study period.

Study characteristics

Tables 1 and 2 sumarize the general characteristics of the 27 studies grouped by outcome measured, i.e. breastfeeding or breast milk volume. The studies varied widely in terms of the structure of the intervention and there were seven topics where only one paper was identified; thus, a consistent impact on breastfeeding/breast milk volume could not be determined. These were nasogastric tube feeding (Kliethermes et al. 1999), nipple shields (Meier et al. 2000), test weighing (Hurst et al. 2004), fortifiers (Fenton et al. 2000), finger feeding (Oddy & Glenn 2003), the Baby Friendly Hospital Initiative (Merewood et al. 2003) and a series of interventions, aiming to promote breastfeeding (Dall'Oglio et al. 2007). Planned early discharge with good home support was evaluated in two studies and was not shown to significantly affect breastfeeding outcomes, but further research is recommended particularly in countries with lower rates of breastfeeding (Örtenstrand et al. 1999; Gunn et al. 2000). Two of the single-paper studies showed a positive impact on breastfeeding outcome, i.e. use of nasogastric tube-feeding in preference to bottle-feeding for supplements for preterm infants (Kliethermes et al. 1999) and implementation of the Baby Friendly Hospital Initiative policies (Merewood et al. 2003). We have given more details of the single papers and the two on early discharge in Appendix 3 as this may highlight knowledge gaps for future research and will also enable updating of the evidence base. We have not included these papers in this review as they do not offer any consistent evidence for effective practice.

Table 1.  Summary of studies where breastfeeding or breast milk feeding was an outcome (24 studies)
Topic (n)ContinentStudy typeStudy quality*Impact on breastfeeding or breast milk feeding
Europe (n)North America (n)Australasia (n)Randomized controlled trial (n)Other controlled (n)Good (n)Intermediate (n)Poor (n)Positive (n)Negative (n)No significant difference (n)
  • *

    Studies graded as good quality had scored ≥70%, intermediate studies scored 50–69% and poor quality studies scored <50%; see Appendix 2 for more details.

  • In both these studies, breastfeeding meant, mother's milk given by direct breastfeeding or any other feeding device (bottle, cup or tube).

  • This study had two sets of interventions over two distinct time periods, breastfeeding was measured at baseline and following set 1 and set 2. Compared with the baseline, intervention set 1 and set 2 showed an increase in breastfeeding at discharge; set 1 also showed an increase at one month. Interventions set 1 to set 2: no difference in breastfeeding at discharge but a significant reduction in breastfeeding at 1 month.

  • §

    § Infants fed liquid supplements were breastfeeding for shorter compared with their goal.

Skin-to-skin (5)13123212203
Cup-feeding vs. bottle (3)20130201102
Expressing (2)20020110002
Galactogogues (2)02020200002
Early discharge (2)10111200002
Additional postnatal support (3)03021210201
Baby friendly initiative (1)01001100100
Programme of interventions (1)10001010110
Nasogastric feeding vs. bottle (1)01010010100
Nipple shields (1)01001001001
Test weighing (1)01010010001
Liquid vs. powder fortifier (1)0101000101§0
Finger feeding (1)00101001001
Total713415912668215
Table 2.  Summary of studies where breast milk volume was an outcome (10 studies)
Topic (n)ContinentStudy type*Study qualityImpact on breast milk volume
Europe (n)North America (n)Australasia (n)Randomized controlled trial (n)Other controlled (n)Good (n)Inter-mediate (n)Poor (n)Positive (n)Negative (n)No significant difference (n)
  • *

    Studies graded as good quality had scored ≥70%, intermediate studies scored 50–69% and poor quality studies scored <50%, see Appendix 2. Studies included in this table were those that measured actual breast milk volume which may be the only outcome or may be in addition to other feeding outcomes such as breastfeeding. Breast milk volume could be measured after expressing (g or mL) or by test weighing.

Skin-to-skin contact (2)02011101101
Expressing (3)21030120102
Galactogogues (4)12140310202
Additional postnatal support (1)01010010001
Total36191541406

The five topics with the most accumulated evidence were skin-to-skin contact (SSC) (five papers), cup-feeding (three papers), expressing breast milk (three papers), galactogogues (four papers) and postnatal support (three papers). These 18 studies are reviewed here and are summarized in Table 3.

Skin-to-skin contact

In studies using SSC, the baby, wearing only a nappy (and a hat if required), is held vertically against the mothers breasts (skin-to-skin) for varying periods of time. In this review, contact times ranged from 10-min session to 4-h sessions per day. This process is often described as Kangaroo Mother Care (KMC), which is a relatively standard intervention developed in Columbia in response to the lack of incubators (Rey & Martinez 1983). In KMC, the baby has free access to the breast and will be nursed like this continuously (up to 24 h). Because contact times were so restricted in the reviewed studies, none of them could be considered to have used KMC as originally described; therefore, we have used the term skin-to-skin contact (SSC) to cover these interventions. In industrialized countries, the terms KMC and SSC appear to be used interchangeably, but KMC as originally described is either not well implemented or not understood. SSC as described in this section is different from ‘early SSC’ which is encouraged in the first 24 h after birth and was the subject of a recent Cochrane Review (Moore et al. 2007).

Five studies evaluated SSC (Wahlberg et al. 1992; Blaymore Bier et al. 1996; Hurst et al. 1997; Roberts et al. 2000; Rojas et al. 2003). Three studies compared SSC during specified parental visits with traditional contact (fully clothed and wrapped infant held supine in parents’ arms) (Wahlberg et al. 1992; Blaymore Bier et al. 1996; Rojas et al. 2003); one other study compared SSC with control infants but did not describe the intervention (SSC) conditions (Hurst et al. 1997). In the remaining study (Roberts et al. 2000), a programme of SSC was implemented following a 12-month control period which was not described. The gestational ages of the infants included in the studies ranged from 26 to 31 weeks with birthweight ranging from just over 900 g to over 1500 g. All studies comprised very small samples; thus, the total number of infants included in this section is 220. No adverse outcomes were reported. Box 1 summarizes the evidence.

Box 1. Summary of evidence for use of SSC

Impact on breastfeeding and breast milk volume:

  • • 
    SSC was associated with increased breastfeeding at hospital discharge C

Other outcomes:

  • • 
    SSC was associated with fewer episodes of oxygen desaturation A

Two of the four studies measuring breastfeeding outcomes showed statistically significant increases in breastfeeding at discharge from the NU (Wahlberg et al. 1992; Blaymore Bier et al. 1996). One of these also showed an increase at 1-month following discharge (Blaymore Bier et al. 1996). One further study showed a borderline-significant increase in successful breastfeeding (odds ratios = 1.0 to 8.3, P = 0.06) as judged by a lactation specialist (Rojas et al. 2003). The two other studies which measured breastfeeding showed no difference between the SSC group and the control. Both of these were poor quality studies and in one (Roberts et al. 2000) the average daily contact between mother and baby was longer for comparison mothers than for SSC mothers. Breast milk volume was measured in two studies with one (Blaymore Bier et al. 1996) showing no difference and the other (Hurst et al. 1997) demonstrating a significant increase in milk volumes over 2 weeks.

In two studies, SSC was associated with significantly fewer episodes of oxygen desaturation (Blaymore Bier et al. 1996; Rojas et al. 2003). There was no consistent impact of SSC interventions on infant growth in terms of weight gain and/or head circumference.

Cup-feeding

Some preterm or sick infants are initially fed enterally via a naso-gastric (NG) or oro-gastric (OG) tube until they are mature or well enough to take oral feeds. During the transition from ‘tube’ feeds to breastfeeding, the infant may be given supplements ('top-ups’) by tube, bottle or cup in addition to breastfeeds. In deciding how to give supplements, or to feed the infant during the mother's absence from the unit, health professionals must consider what method will best support the successful establishment of breastfeeding.

For mothers planning to breastfeed or who were breastfeeding, supplements given by cups were compared with the use of bottles (Mosley et al. 2001; Collins et al. 2004; Gilks & Watkinson 2004). Cups were used with babies born at 29–35 weeks, although age at use of cups was not given. One of the studies (Collins et al. 2004) was large (303 infants); however, the other two were both very small, giving a total of 374 infants in this section. Box 2 summarizes the evidence.

Box 2. Summary of evidence for cup-feeding

Impact on breastfeeding:

The effects of cup use on breastfeeding/breast milk feeding D

The impact of cup-feeding on breastfeeding duration was inconclusive. The largest and best quality study (Collins et al. 2004) indicated higher breastfeeding rates in cup-fed infants at discharge; however, compliance with the study protocol was low with bottles introduced to over 50% of cup-fed infants. The reasons for introducing bottles included mothers not liking or having problems with the cup (e.g. spillage, infant not satisfied) or staff refusing to cup-feed. Although this study was large, participants were recruited over 3.5 years in two large tertiary hospitals and included infants (59% of the sample) who were transferred out to one of the 54 participating peripheral hospitals where potential variations in practice, staff training and unit ethos may have affected the results. The two other studies (Mosley et al. 2001; Gilks & Watkinson 2004) did not show any overall effect on breastfeeding. In most studies, few mothers made the transition to full breastfeeding; thus, numbers were small in later stages of data collection. One good quality study monitored adverse events and noted no significant physiological adverse events but did find that cup-fed infants had increased hospital stay (Collins et al. 2004).

Expressing breast milk

Three studies evaluated techniques and types of pump for expressing breast milk on a range of outcomes. The infants in this section were all premature (29–30 weeks, although one study did not supply demographic data). Two of the studies were small; thus, the total number of infants in this section was 213. Two studies (Groh-Wargo et al. 1995; Jones et al. 2001) compared sequential expressing with simultaneous expressing using an electric pump, while the third (Fewtrell et al. 2001) compared a hand pump with an electric pump. One study also compared the use of breast massage with not using massage (Jones et al. 2001). Breastfeeding was an outcome of one study (Jones et al. 2001) with no difference in numbers of mothers’ breastfeeding or fully expressing at term. Milk volume was measured in all three studies with only one, showing an increase in volume associated with simultaneous pumping and also with massage (Jones et al. 2001). Both studies comparing sequential vs. simultaneous pumping had small numbers (n = 32 and 36 respectively); however, one of these (Jones et al. 2001) was stopped early as interim data analysis clearly identified a significant effect in the simultaneous pumping group. Mothers also found that expressing without the use of breast massage was more difficult (Jones et al. 2001) (Box 3). A manual (hand) pump compared with an electric pump demonstrated no difference in total volume of milk expressed, despite the electric pump users being able to pump simultaneously (Fewtrell et al. 2001) and when compared in similar conditions, i.e. breasts expressed sequentially, the manual pump users expressed greater volumes of milk and expressed a given volume more quickly. Fat content was not affected by pump type. Mothers also scored the manual pump more highly in terms of ease of use, amount of suction, comfort, pleasant to use and ‘overall opinion’.

Box 3. Summary of evidence for expressing

Impact on milk volume:

  • • 
    Simultaneous pumping was associated with increased breast milk volume D
  • • 
    Breast massage was associated with increased breast milk volume D

Galactogogues

Four small intervention studies were identified, two of which measured both milk volume and breastfeeding (da Silva et al. 2001; Hansen et al. 2005), and two which measured milk volume only (Gunn et al. 1996; Fewtrell et al. 2006). The gestation at birth for infants in this section ranged from 25 to 35 weeks although the infants were older at the time of trial entry was older, e.g. 31.9/33.1 weeks (da Silva et al. 2001) or over 31 days (Gunn et al. 1996). All the studies in this section were very small with a total of 148 infants. Two studies recruited women who had inadequate milk supply, (Gunn et al. 1996; da Silva et al. 2001) while the other two included all women who had given birth to a premature infant (Hansen et al. 2005; Fewtrell et al. 2006). One well-designed trial explored the short-term use of domperidone for women with low milk production and showed increased milk volumes from baseline (da Silva et al. 2001). Growth hormone, used with mothers with poor milk supply, achieved a modest increase in milk volume from baseline to 7 days (Gunn et al. 1996); however, neither metoclopramide nor oxytocin used with mothers of preterm infants had an effect on milk volume and/or breastfeeding duration (Hansen et al. 2005; Fewtrell et al. 2006). It is possible that the lack of effect from both metoclopramide and oxytocin was due to the fact that both the studies were small; none of the women participating had identifiable milk inadequacy and the numbers who could potentially have developed clinically significant milk inadequacy would have been smaller still. Overall, none of the studies showed an increase in duration of breastfeeding; however, increasing milk volume may be a more important goal than duration for mothers who are unable to achieve satisfactory volumes of breast milk (Box 4).

Box 4. Summary of evidence for use of galactogogues

Impact on breastfeeding and breast milk volume:

  • • 
    Domperidone or growth hormone may increase milk volume in women who are expressing insufficient amounts C
  • • 
    Effect of galactagogues on breastfeeding D

Postnatal support for breastfeeding

The interventions in this section varied considerably from the provision of structured breastfeeding counselling programme delivered by a ‘research lactation consultant’ (Pinelli et al. 2001); support and assistance from an International Board Certified Lactation Consultant (Gonzalez et al. 2003) and peer support delivered by women with breastfeeding experience from the local community (Merewood et al. 2006). The studies also measured different outcomes including breastfeeding duration (Pinelli et al. 2001), breastfeeding at 12 weeks (Merewood et al. 2006), exclusivity of breastfeeding (Pinelli et al. 2001; Merewood et al. 2006), volume of breast milk feeds as measured by test-weighing (Pinelli et al. 2001) and whether the infant received breast milk feeds by any means (breast, bottle or tube) during hospitalisation and at discharge (Gonzalez et al. 2003). They targeted different audiences with support being provided to both parents (Pinelli et al. 2001) or to mothers only (Gonzalez et al. 2003; Merewood et al. 2006). Furthermore, the mothers in two studies planned to breastfeed (Pinelli et al. 2001; Merewood et al. 2006) compared with the other study where feeding intention was not solicited (Gonzalez et al. 2003). The population recruited by Pinelli et al. was relatively advantaged, highly motivated to breastfeed and had good community support. The populations in the other two studies (Gonzalez et al. 2003; Merewood et al. 2006) appeared more mixed and included a high percentage of African American women who tend to have lower rates of breastfeeding (Ryan et al. 1997). The age of the infants varied; 36% of infants in one trial were born after 37 weeks (Gonzalez et al. 2003) while the gestational range for the other studies was 26–37 weeks. The studies had larger numbers than in the other sections involving a total of 586 infants.

Because of differences in the type of intervention, population recruited and outcomes measured any conclusions in this section must be interpreted with caution; however, in the two higher quality studies (Gonzalez et al. 2003; Merewood et al. 2006) additional postnatal support was associated with increased provision of breast milk feeding (Box 5).

Box 5. Summary of evidence for additional PN support

Impact on breast milk feeding:

  • • 
    Postnatal support is associated with increased likelihood of breast milk feeding A*

*This grading should be considered with caution as although two good quality studies showed an effect on breastfeeding the outcomes were measured at different times (discharge and 12 weeks) and the interventions differed greatly (International Board Certified Lactation Consultant support vs. peer support)

Discussion and recommendations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

Considering the value, i.e. placed on breast milk for the preterm or LBW infant, there is very little well-designed research into practices which might support or improve breastfeeding or breast milk feeding. Overall, the evidence for effective interventions was limited with only SSC and additional postnatal support showing an effect on breastfeeding or breast milk feeding at discharge [SSC and postnatal (PN) support], 1 month (SSC) or 12 weeks (PN support) (Box 6).

Box 6. Summary of results (consistent evidence of an effect).

Interventions which may help the mother with expressing breast milk:

  • • 
    None identified

Interventions which may increase breast milk supply:

  • • 
    Galactogogues where clinical insufficiency has been established C

Interventions which may increase breast milk feeding:

  • • 
    Additional postnatal support A
  • • 
    Skin-to-skin contact C

Interventions which may help establish successful breastfeeding:

  • • 
    Skin-to-skin contact C

The majority of papers in this review targeted the preterm or LBW infant. Our selection procedure aimed to identify interventions that evaluated feeding in other infant groups which might be admitted to the NU but we did not identify any such studies. Indeed, many of the studies included in this review excluded infants with congenital abnormalities or mothers who had a history of illicit drug use. Most of the studies reviewed in full (14) recruited only preterm infants. Three studies (Blaymore Bier et al. 1996; Hurst et al. 1997; Pinelli et al. 2001) recruited LBW infants but these infants also appeared to be preterm. One study (Gonzalez et al. 2003) included all infants in the unit during the study time period of which over 60% were either LBW or premature. This study, which showed a significant increase in breast milk feeding during hospital stay and at discharge, did not identify an association between gestational age and outcome by multivariate analysis. Premature infants and infants, who are LBW because of foetal growth restriction, are likely to respond differently to feeding interventions but any difference between these two groups was not adequately evaluated in the reviewed articles.

Skin-to-skin contact was associated with increased breastfeeding in two out of the four studies that measured this outcome, and a tendency towards more successful breastfeeding in a further study. However, there was no consistent effect on breastfeeding rates following discharge from the unit. A Cochrane Review of the use of KMC for LBW infants (Conde-Agudelo et al. 2003) also noted some improvement in breastfeeding but the authors expressed concerns about study methods and could not recommend routine use of KMC for LBW infants. The four papers in the Cochrane review were based in countries with non-westernized healthcare systems and were not eligible for inclusion here; however, neither the Cochrane Review nor the papers reviewed here reported any adverse effects. Following preterm birth, the separation of mother and infant can cause distress (Roller 2005) and despair for the mother (Nyström & Axelsson 2002) who wants to get to know her infant by seeing, holding and touching him (Roller 2005). Mothers have described KMC as calming and positive, providing comfort for themselves and their infant (Roller 2005). In a qualitative study, the implementation of KMC guidelines in Sweden was associated with improved parental and infant well-being (Wallin et al. 2005). However, resistance to implementing KMC has been noted in both developed (Wallin et al. 2005) and developing countries (Charpak & Ruiz-Paláez 2006) often because of KMC being considered as substandard care, improper or unusual and resulting in extra work for staff. Lack of privacy and space in some units can also be problematical and continuous KMC contact is not always encouraged (Charpak & Ruiz-Paláez 2006). The evidence reviewed here and elsewhere suggests that KMC or SSC is beneficial for both infant and mother and, given its recent systematic application in NU in Sweden, can be used successfully in high-tech NU. From the research already completed, it is not clear which components of KMC/SSC (i.e. is it SSC per se, or length of contact or stimulation of the breast) affect breastfeeding and/or breast milk volume and further research is, therefore, needed.

Additional postnatal support was associated with an increased likelihood of the infant receiving some breast milk by any means in two out of three studies. Postnatal support from a trained person (peer or professional) is associated with increased breastfeeding among mothers of healthy term infants who want support and/or who want to breastfeed, although outcomes differed according to population demographics and/or intentions (Renfrew et al. 2005). Additional support has received little attention for infants admitted to NU but it is possible that it might prove beneficial for a mother trying to feed her infant in this more difficult environment. The studies in this review varied considerably in their approach to providing support; thus, further research is needed to evaluate the impact of postnatal support and to determine the most effective and acceptable method of delivery. Peer support is one such method of delivering additional support and such initiatives have been increasing in number and popularity in the UK (Dykes 2005; Britten et al. 2006). The evidence for the effectiveness of peer support varies with some showing increases in some breastfeeding where offered proactively to women who want to breastfeed (Renfrew et al. 2005) or increases in exclusive breastfeeding but not in any breastfeeding (Britton et al. 2006). We identified only one eligible study using peer support in the NU (Merewood et al. 2006), which showed increased breast milk feeding by any means at 12 weeks following discharge. However, we identified one other study (Agrasada et al. 2005) based in the Philippines which used peer support for term LBW infants, some of whom were admitted to the NU for 12–24 h. Breastfeeding support was provided by village women who had had personal positive experience of breastfeeding and had received additional training. Compared with comparison and a control group mothers, those who had received peer breastfeeding counselling were significantly more like to be exclusively breastfeeding at 2 weeks and 6 months, to continue to breastfeed and to be breastfeeding at 6 months. The peer support study (Merewood et al. 2006) is one of only two studies which demonstrated an impact on feeding beyond discharge from the NU (the other being an increase in breastfeeding at 1 month associated with SSC) (Blaymore Bier et al. 1996). Thus, further research is recommended to identify how best peer support might be delivered in this environment in a manner that is both acceptable and accessible to parents and staff.

Neonatal staff frequently require to give supplemental feeds to infants within the NU or to provide feeds when the mother is absent. These feeds should be given in a manner which supports the transition to successful breastfeeding, if this is the mothers wish, but the choice of method is limited by what is currently available. The evidence that the skills used to feed from a bottle differ from those used at the breast, has led to concerns about ‘nipple confusion’ where a breastfed infant may become confused if given a bottle (Neifert et al. 1995). Therefore, there is now a tendency to offer breast milk either by cup or tube (NG/OG). However, it is likely that the skills used for cup-feeding also differ from breastfeeding as suggested by Dowling and colleagues in a study of eight preterm infants, in which the authors also had concerns about the small volumes of milk actually ingested by cup-feeding (Dowling et al. 2002). A Cochrane review of cupfeeding for infants unable to fully breastfeed (Flint et al. 2007) reviewed four studies and could not recommend cup-feeding over bottle-feeding as it conferred no significant benefits and was associated a longer hospital stay. In our review, which included three of the four studies in the Cochrane review, cup-feeding was associated with increased breastfeeding at discharge in one of the three studies reviewed but overall there was no accumulated evidence of an effect from cup-feeding. This may be due in part to few mothers making the transition to breastfeeding; however, protocol violations indicate a need for further exploration of the acceptability of cup-feeding. While the evidence for nipple confusion and cup-feeding is limited, there may be a risk in removing cups from this environment altogether as this may reinforce a culture of bottle-feeding. Neonatal staff have expressed concerns about the psychological impact supplementing by bottle may have on the mother especially if she is having difficulty with breastfeeding (McInnes, unpublished) and while this may be the case, it has not received any attention in the research literature. The possibility that cup-feeding unnecessarily complicates breastfeeding should also be considered. The evidence from this review suggests that it is essential to explore the use of cup-feeding in more detail from the perspective of both the mother and NU staff.

Dummy use is part of the ‘nipple confusion’ debate; however, none of the studies reviewed provided useful evidence on the impact of dummies on breastfeeding in the NU because of study design, protocol violations and very few mothers achieving full breastfeeding and/or maintaining breastfeeding once home (Mosley et al. 2001; Collins et al. 2004). Dummy use has not been consistently associated with breastfeeding duration in healthy term babies (Renfrew et al. 2005); however, comparison between dummy use in term healthy infants and their use for preterm or LBW babies may be unhelpful. In NU, dummies are often used to enable non-nutritive sucking (NNS), and a review of this practice (Pinelli & Symington 2005) demonstrated that NNS was associated with significantly reduced hospital stay and improved transition to bottle-feeding but did not include breastfeeding as an outcome. Further research is needed to identify potential effects on breastfeeding of preterm NNS devices for ill or ventilated babies.

Given that expressing breast milk may be the most important thing a mother can do for her pre-term infant, there has been very little research into this area. Mothers speak of frustration and lack of support when expressing (Jaeger et al. 1997) but those who succeed experience a sense of satisfaction or reward (Miracle et al. 2004; Bernaix et al. 2006). In the studies in this review, however, the authors reported that although mothers appeared motivated to express, they rarely did so at the level recommended in the study protocol, which warrants further investigation. The frequency of expressing recommended by health professionals in these studies varied from four to eight times per day. There also appears to be little consensus in the published literature regarding frequency of expressing, e.g. at least five times per day (Furman et al. 2002), at least eight times a day (Jones & Spencer 2007) or every 3 h (Meier et al. 2004). Possible variation in storage capacity of the breast suggests that frequency of expressing may not be absolute (Hartmann et al. 2003) and although 8–10 times per day may be required to initiate lactation once milk supply is established (a few days to 2 weeks), frequency may then depend on breast storage capacity (Spatz 2006). In addition, there was no consensus on whether individual pumping sessions should be for a set period of time or until milk stops flowing, or whether short-frequent pumping is preferable to longer less frequent sessions. Interventions, such as relaxation, visualization and back massage are thought to increase milk supply but were not identified in this literature search. Neither were any studies which evaluated the use of hand expression a method sometimes favoured by mothers especially when expressing very small amounts of milk in the early days.

The production of sufficient breast milk is important for all mothers expressing breast milk for their infant in the NU. However, the stressful environment of the NU, separation of the mother from her infant and the need to stimulate and maintain lactation solely by milk expression can cause milk supply problems. For mothers who are unable to meet their infant's needs, even small increases in expressed milk are important. For those mothers pharmacological intervention may be required and there is some evidence that short-term use of Domperidone or Growth Hormone may be beneficial. However, long-term use of these or their impact on breastfeeding was not evaluated. Milk supply is affected by the frequency and efficiency of milk removal (Knight et al. 1998; Wilde et al. 1998). In the studies reviewed here the advice on milk expression was at least every 3 hours (Fewtrell et al. 2006) or 5–6 times a day, (Gunn et al. 1996) although two studies did not give any information. A comparison of the effectiveness of galactogogues with other techniques to increase milk supply, such as increasing the frequency of expressing and/or additional support, is recommended.

Limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

This review is restricted to experimental studies that evaluated the impact of an intervention on breastfeeding or breast milk supply; thus, non-experimental studies and those which did not have breastfeeding or breast milk as an outcome were not included. Qualitative studies which explore the beliefs and experiences of parents and staff, were included in a qualitative synthesis published elsewhere (McInnes & Chambers 2006). This review was one of series of reviews conducted concurrently and in order to be consistent this dictated a number of limitations to our search strategy. Thus, we only included published literature, the search commenced from 1990, and we included only papers published in English. When we updated our search in December 2007, we did not identify any non-English publications (from 1990 to 2007) which fulfilled our inclusion criteria. The population group of mainly preterm infants may limit the generalizability to other infant groups in the NU.

The studies varied widely in intervention type, duration (of intervention and of data collection) and outcomes (type of outcome and time of collection), and many studies did not examine potential confounding variables, such as population demographics. All of this makes it difficult to draw any firm conclusions about effective practice. Of the papers reviewed in full the majority (13 out of 18) of the studies had small sample sizes (<100), making the results less generalizable. Finally, because of the specific nature of some of the interventions, the results may not be generalizable to other populations or cultures.

Fourteen of the 18 papers in this review reported ‘breastfeeding’ as an outcome although only two papers (Pinelli et al. 2001; Collins et al. 2004) used an internationally recognized definition for breastfeeding (Labbok & Krasovec 1990; World Health Organization 1991). Only six studies differentiated between exclusive and partial breastfeeding; however, it was also not clear in many of the studies whether breastfeeding meant feeding at the breast or being fed breast milk by other means. Future research requires more useful definitions of breastfeeding. Simply using the definitions applied to healthy term infants may not be helpful for the preterm/sick infant as it is important to differentiate between whether an infant was fed breast milk by bottle, tube or cup and at-breast breastfeeding. It is accepted that many preterm/sick infants will receive some breast milk during their hospitalization but it is also clear that few go on to breastfeed despite the known advantages of breastfeeding (at the breast) over breast milk feeding (by bottle, cup or tube) (Buckley & Charles 2006).

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

Current recommendations for increasing breastfeeding among term healthy infants suggest that effective interventions should be identified and that each area (geographical and clinical) should consider the best package of interventions for their population group and that this should be informed by the views of practitioners and users (Dyson et al. 2006). The ad hoc nature of the interventions identified in this review suggests a need to work with mothers and staff to identify the best approach to supporting mothers in feeding their infants. In the environment of the NU, it may be necessary to consider feeding alongside the other aspects of parenting a small, sick or preterm infant. Given the physical and emotional benefits of expressing and breastfeeding for both the infant and the mother, future interventions should work towards supporting mothers to express milk where required and should identify ways to maximize milk production in terms of both volume and duration. Once the infant is able to feed at the breast, effective strategies need to be developed to support the mother in this important step to ensure effective breastfeeding and the mother's confidence in her role.

Conflicts of interest

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

None declared.

Key messages

  • • 
    Human milk is the optimal form of nutrition for the preterm or LBW neonate and although many mothers will express breast milk for their infant few go on to breastfeed.
  • • 
    Interventions to promote breastfeeding in the NU appear to be task orientated and lack consistency.
  • • 
    There are substantial gaps in our knowledge of what aids breastfeeding in the NU and more research is needed to identify what practices are effective in supporting breastfeeding in the NU.
  • • 
    Currently skin-to-skin and/or postnatal support offers the most promise for increasing breastfeeding for the preterm/LBW infant.

References

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  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices
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Appendices

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and recommendations
  7. Limitations
  8. Conclusion
  9. Conflicts of interest
  10. References
  11. Appendices

Appendix 1: Papers excluded from the review

Author & citationTitleReason not included
Agrasada, GV., Gustafsson, J., Kylberg, E., Ewald, U. (2005) Acta Paediatrica. 94(8): 1109–15Postnatal peer counselling on exclusive breastfeeding of low-birthweight infants: a randomized, controlled trial.Excluded by location (Philippines)
Bell EH. Geyer J. Jones L. (1995) MCN: The American Journal of Maternal/Child Nursing; 20(6): 309–14.A structured intervention improves breastfeeding success for ill or preterm infantsProtocol Not research
Bingham PM, Abassi S, Sivieri E (2003) Archives of Pediatrics & Adolescent Medicine; 157(1): 72–5.A pilot study of milk odor effect on nonnutritive sucking by premature newborns.Breastfeeding or breast milk not an outcome
Bosque EM. Brady JP. Affonso DD. Wahlberg V. (1995) JOGNN: Journal of Obstetric, Gynecologic, and Neonatal Nursing; 24(3): 219–26.Physiologic measures of kangaroo versus incubator care in a tertiary-level nursery.Breastfeeding or breast milk not an outcome
Caple J. Armentrout D. Huseby V. Halbardier B. Garcia J. Sparks JW. Moya FR. (2004) Pediatrics; 114(6): 1597–600.Randomized, controlled trial of slow versus rapid feeding volume advancement in preterm infants.Breastfeeding or breast milk not an outcome
Cattaneo A, Davanzo R. Worku B et al. (1998) Acta Paediatrica; 87: 976–985.Kangaroo Mother Care for LBW infants: an RCT in different settings.Excluded by locations
Charpak N, Ruiz-Pelaez JG, Charpak Y. (1994) Pediatrics; 94 (6 I): 804–810.Rey-Martinez Kangaroo mother program: An alternative way of caring for low birth weight infants? One year mortality in a two cohort study.Excluded by location (Colombia)
Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. (2001) Pediatrics; 108(5): 1072–9.A randomized, controlled trial of Kangaroo Mother Care: results of follow-up at 1 year of correctedExcluded by location (Colombia)
Charpak N, Ruiz-Pelaez JG. Figueroa de C Z. (1997). Pediatrics; 100: 682–688.Kangaroo mother vs traditional care for newborn infants <2000 g: an RCTExcluded by location (Colombia)
Chwo MJ. Anderson GC. Good M. Dowling DA. Shiau SH. Chu DM. Journal of Nursing Research: JNR. 10(2): 129–42, 2002 Jun.A randomized controlled trial of early kangaroo care for preterm infants: effects on temperature, weight, behavior, and acuity.Breastfeeding or breast milk not an outcome
Colson SD. de Rooy L. Hawdon JM. (2003) MIDIRS Midwifery Digest; 13(1): 92–7.Biological nurturing increases duration of breastfeeding for a vulnerable cohort.Not an intervention study
Cousins R (1999). Journal of Neonatal Nursing, 5(6):12–13.Breastfeeding the preterm infant in the special care baby unit: the first feedNot an intervention study
Cregan MD, De Mello TR, Kershaw D et al. (2002). Acta Obstetricia et Gynecologica Scandinavica, 81(9): 870–877.Initiation of lactation in women after preterm deliveryNot an intervention study
Dollberg S, Kuint J, Mazkereth R, Mimouni FB (2000) Journal of the American College of Nutrition; 19(6): 797–800.Feeding tolerance in preterm infants: Randomized trial of bolus and continuous feeding.Breastfeeding or breast milk not an outcome
Dombrowski MAS. Anderson GC. Santori C. Roller CG. Pagliotti F. Dowling DA. (2000) MCN: The American Journal of Maternal/Child Nursing; 25(2): 92–4.Kangaroo skin-to-skin care for premature twins and their adolescent parents.Breastfeeding or breast milk not an outcome
Elliott S. Reimer C. (1998) Neonatal Network – Journal of Neonatal Nursing. 17(6): 41–5.Post-discharge telephone follow-up program for breastfeeding preterm infants discharged from a special care nursery.Project description. Not an intervention study
Flacking R. Nyqvist KH. Ewald U. Wallin L. (2003) Journal of Human Lactation. 19(2):157–65.Long-term duration of breastfeeding in Swedish low birth weight infants.Not an intervention study Descriptive.
Freer Y (1999) Journal of Neonatal Nursing; 5(1): 16–21.A comparison of breast and cup feeding in preterm infants: effect on physiological parameters.Breastfeeding or breast milk not an outcome
Fucile S. Gisel EG. Lau C. (2005) Developmental Medicine & Child Neurology. 47(3): 158–62.Effect of an oral stimulation program on sucking skill maturation of preterm infants.Breastfeeding or breast milk not an outcome
Furman L. (2003) Italian Journal of Pediatrics; 29(2): 118–122.Supporting lactation in mothers of very low birth weight infants: What should we do?Not an intervention study Review/discussion
Gupta A. Khanna K. Chattree S. (1999) Journal of Tropical Pediatrics. 45(2): 108–10.Cup feeding: an alternative to bottle feeding in a neonatal intensive care unit.Not an intervention study
Hall WA, Shearer K, Mogan J, Berkowitz J. (2002) MCN, American Journal of Maternal Child Nursing. 27(6): 318–26.Weighing preterm infants before & after breastfeeding: does it increase maternal confidence and competence?Breastfeeding or breast milk not an outcome
Hill AS. Kurkowski TB. Garcia J. (2000) Nursing Research. 49(1): 2–10.Oral support measures used in feeding the preterm infant.Breastfeeding or breast milk not an outcome
Hill PD, Aldag JC, Chatterton RT (1999) Birth, 26(4): 233–238.Breastfeeding experience and milk weight in lactating mothers pumping for preterm infants.Not an intervention study
Hill PD, Aldag JC, Chatterton RT (2001) Journal of Human Lactation, 17(1): 9–13.Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants.Not an intervention study
Howard CR. Howard FM. Lanphear B. Eberly S. deBlieck EA. Oakes D. Lawrence RA. (2003) Pediatrics; 111(3): 511–8.Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding.Not in a neonatal unit
Jones E. (1995) Mod. Midwife. 5(3): 8–11.Strategies to promote preterm breastfeeding.Not an intervention study
Jones E. Spencer A. (2000) Professional Care of Mother and Child; 10(6): 145–7.Promoting successful breastfeeding for mothers of preterm infants – 1.Not an intervention study
Jones L. Spencer A. (2002) Practising Midwife; 5(4): 18–20.Promoting successful preterm breastfeeding: part 1.Not an intervention study
Jones L. Spencer A. (2002) Practising Midwife; 5(5): 22–4.Promoting successful preterm breastfeeding: part 2.Not an intervention study
Jones L. Spencer A. (2002) Practising Midwife; 5(6): 18–9.Establishing successful preterm breastfeeding: part 3.Not an intervention study
Kennedy TS. Oakland MJ. Shaw RD. Nutrition in Clinical Practice. 2000; 15(1): 30–5.A nutrition intervention with families of low-birth-weight infants.Breastfeeding or breast milk not an outcome
Marinelli KA, Burke GS, Dodd VL (2001). Journal of Perinatology; 21(6): 350–355.A comparison of the safety of cup-feedings and bottle-feedings in premature infants whose mothers intend to breastfeedBreastfeeding or breast milk not an outcome
McCain GC (1995) Journal of Pediatric Nursing, 10(1): 3–8.Promotion of preterm infant nipple feeding with non-nutritive sucking.Breastfeeding or breast milk not an outcome
McCain GC. Gartside PS. 2002 Newborn and Infant Nursing Reviews; 2(3): 187–93.Behavioral responses of preterm infants to a standard-care and semi-demand feeding protocol.Breastfeeding or breast milk not an outcome?
McCain GC. Gartside PS. Greenberg JM. Lott JW. (2001) Journal of Pediatrics; 139(3): 374–9.A feeding protocol for healthy preterm infants that shortens time to oral feeding.[see comment].Breastfeeding or breast milk not an outcome?
Meier PP. (2003) Pediatric Annals. Vol. 32(5): 317–325.Supporting lactation in mothers with very low birth weight infants.Not an intervention study
Meier PP. Engstrom JL. Mangurten HH. Estrada E. Zimmerman B. Kopparthi R. J (1993) Obstet Gynecol Neonatal Nurs. 22(4): 338–47.Breastfeeding support services in the neonatal intensive-care unit.Not an intervention study
Meier PP. Engstrom JL. Mingolelli SS. Miracle DJ. Kiesling S. (2004) JOGNN – Journal of Obstetric, Gynecologic, & Neonatal Nursing. 33(2): 164–74.The Rush Mothers’ Milk Club: breastfeeding interventions for mothers with very-low-birth-weight infants.Intervention evaluated by retrospective case note analysis with no comparison group
Meier PP. Lysakowski TY. Engstrom JL. Kavanaugh KL. Mangurten HH. (1990) J Pediatr Gastroenterol Nutr; 10(1): 62–5.The accuracy of test weighing for preterm infants.Breastfeeding or breast milk not an outcome
Meyer EC. Coll CT. Lester BM. Boukydis CF. McDonough SM. Oh W. (1994) Pediatrics; 93(2): 241–6.Family-based intervention improves maternal psychological well-being and feeding interaction of preterm infants.Breastfeeding or breast milk not an outcome
Meza CV, Powell NJ, Covington C (1998) Occupational Therapy Journal of Research, 18(3): 71–83.The influence of olfactory intervention on non-nutritive sucking skills in a premature infant.Breastfeeding or breast milk not an outcome
Miles R., Cowan F., Glover V., et al. (2006) Early Human Development; 82(7): 447–455.A controlled trial of skin-to-skin contact in extremely preterm infants.No infant feeding data presented (author contacted but no reply)
Minchin M. Minogue C. Meehan M. McDonnell G. Shaw S. Donohue L. Campbell N. Watkins A. (1996) Breastfeeding Review; 4(2): 87–8.Expanding the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI): eleven steps to optimal infant feeding in a paediatric unit.Not an intervention study
Morton JA. (2003) Pediatric Annals; 32(5): 308–316.The role of the pediatrician in extended breastfeeding of the preterm infant.Not an intervention study
Musoke RN. (1990) Int J Gynaecol Obstet; 31 Suppl 1: 57–9.Breastfeeding promotion: feeding the low birth weight infant.Not an intervention study
Nyqvist KH, Ewald U. Acta Paediatr 1999; 88 (11): 1194–1203.Infant & maternal factors in the development of BF behaviour & BF outcome in preterm infants.Not an intervention study
Nyqvist KH. (2002) Journal of Pediatric Nursing; 17(4): 246–56.Breastfeeding in preterm twins: Development of feeding behavior and milk intake during hospital stay and related caregiving practices.Not an intervention study
Nyqvist KH. Ewald U. Sjoden PO. J Hum Lact. 12(3): 221–8, 1996 Sep.Supporting a preterm infant's behaviour during breastfeeding: a case report.Not an intervention study
Nyqvist KH. Strandell E. Journal of Neonatal Nursing. 1999 Mar; 5(2): 31–6.A cup feeding protocol for neonates: evaluation of nurses’ and parents’ use of two cups.Not an intervention study
Paul VK, Singh M, Deorari AK, Pacheco J, Taneja U. (1996) Indian Journal of Pediatrics; 63(1): 87–92Manual and pump methods of expression of breastmilk.Excluded by location (India)
Pantazi M. Jaeger MC. Lawson M. (1998) Journal of Human Lactation; 14(4): 291–6Staff support for mothers to provide breast milk in pediatric hospitals and neonatal units.Not an intervention study
Ritchie JF. (1998) Journal of Neonatal Nursing. Mar; 4(2): 13–7.Immature sucking response in premature babies: cup feeding as a tool in increasing maintenance of breastfeeding.Not an intervention study
Rocha NMN, Martinez FE, Jorge SM. (2002) Journal of Human Lactation; 18 (2): 132–138.Cup or bottle for preterm infants: effects on oxygen saturation, weight gain and breastfeedingExcluded by location (Brazil)
Ross ES. Browne JV. 2002. Seminars in Neonatology. 7(6): 469–75.Developmental progression of feeding skills: an approach to supporting feeding in preterm infants.Not an intervention study
Sankaran K. Papageorgiou A. Ninan A. Sankaran R (1996). Journal of the American Dietetic Association. 96(11): 1145–9.A randomized, controlled evaluation of two commercially available human breast milk fortifiers in healthy preterm neonates.Breastfeeding or breast milk not an outcome
Saunders RB, Friedman CB, Stramoski PR (1991) Journal of Obstetric, Gynecologic, & Neonatal Nursing. 20(3): 212–8.Feeding preterm infants: schedule or demand?Breastfeeding or breast milk not an outcome
Schubiger G. Schwarz U. Tonz O (1997) European Journal of Pediatrics. 156(11): 874–7.UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Neonatal Study Group.Not based in a neonatal unit (term healthy infants in postnatal ward)
Siddell E, Marinelli K, Froman RD, et al. (2003) Journal of Human Lactation, 19(3): 293–302.Evaluation of an educational intervention on breastfeeding for NICU nurses.Breastfeeding or breast milk not an outcome
Sisk PM. Lovelady CA. Dillard RG. Advances in Experimental Medicine & Biology. 554: 307–11, 2004. USAEffect of education and lactation support on maternal decision to provide human milk for very-low-birth-weight infants.Comparison study
Sisk PM. Lovelady CA. Dillard RG, Gruber KJ. (2006). Pediatrics; 117(1): e67-e75Lactation counselling for mothers of very low birthweight infants: effect on maternal anxiety and infant intake of human milkFeeding outcome related to intention rather than intervention
Sloan NL, Camacho LWL, Rojas EP, Stern C. (1994) Lancet; 344: 782–785.Kangaroo mother method: an RCT of an alternative method of care for stabilised LBW Infants.Excluded by location (Eucador)
Spatz DL. (2004) Journal of Perinatal & Neonatal Nursing. 18(4): 385–96.Ten steps for promoting and protecting breastfeeding for vulnerable infants.Not an intervention study
Spatz DL. (2005) Journal of Perinatal Education; 14(1): 30–8.Report of a staff program to promote and support breastfeeding in the care of vulnerable infants at a children's hospital.Not an intervention study
Warren I. Tan GC. Dixon PD. Ghaus K. (2000) Journal of Neonatal Nursing. Mar; 6(2): 43–4, 46–8.Breastfeeding success and early discharge for preterm infants: the result of a dedicated breastfeeding programme.Not an intervention study
Wheeler JL. Johnson M. Collie L. Sutherland D. Chapman C. (1999) Breastfeeding Review. 7(2): 15–8.Promoting breastfeeding in the neonatal intensive care unit.Not an intervention study
White-Traut RC. Nelson MN. Silvestri JM. Vasan U. Littau S. Meleedy-Rey P. Gu G. Patel M. (2002) Developmental Medicine & Child Neurology; 44(2): 91–97.Effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants.Breastfeeding or breast milk not an outcome
Whitworth C M; Topping A. (1996) Journal of Neonatal Nursing; 2(2): 20–23.The interface between policy, quality and research: an action research approach to promote successful breastfeeding.Not an intervention study
Woldt EH. (1991) Neonatal Network. 9(5): 53–56.Breastfeeding support group in the NICU.Not an intervention study

Appendix 2: Quality assessment tool

Author:

Title:

Methods Quality Assessment CriteriaFully metPartially metNot metNot applicable
Clear aims/hypotheses and objectives     
Clear description of intervention    
Recruitment method given    
Sample size/power calculations given    
Population demographics given    
Explicit inclusion/exclusion criteria    
Baseline characteristics statistically equal    
Method of allocation described    
Blinding of researchers    
Blinding of participants    
Groups treated equally aside from intervention    
Data recorded and presented in detail    
Complete follow-up with drop-outs fully explained    
Attrition rate given for both control and experimental group    
Analysis by intention to treat (N/A for older studies)    
Analysis appropriate and details given    
Conclusions substantiated by data    
Limitations of study discussed    
Subject Quality Assessment Criteria    
Definition of breastfeeding    
Follow-up of authors required    
Author follow-up successful    

To assess the methodological quality of each study items were scored as follows:

‘fully met’ = +1
‘partially met’ = +0.5
‘not met’ = −1
‘not applicable’ = 0.

The scores of all applicable items were then totalled, and the percentage score was derived by dividing the total by the number of applicable items. For example, if a study did not meet the criteria for sample size calculation, partially met the criteria for demographic data (e.g. some of the characteristics of interest may be missing such as ‘age’), and fully met the remaining criteria with the exception of the item ‘analysis by intention to treat’ which was not applicable (e.g. for older studies), then the Quality Assessment % would be:

16 (fully met) + 0.5 (1 partially met) −1 (not met) = 15.5 divided by 18 (19 − 1 item n/a) = 15.5/18 86%

(This means it is possible for studies of poor methodological quality to have a negative quality rating.)

We then grouped papers by quality as follows:

Studies were graded as good where they scored:≥70%
Studies were graded as intermediate where they scored:50–69%
Studies were graded as poor where they scored:<50%

Appendix 3: Other studies not included in the full article (9 papers)

Citation Country Study type Quality ratingAspect of breastfeedingParticipants Location Sample size n = xIntervention detailsStudy Outcome/sIntervention effect on outcome?Comment
  1. BFHI, Baby Friendly Hospital Initiative; IBCLC, International Board Certified Lactation Consultant: these are either health professionals or others with background in health or social sciences who have completed comprehensive continuing education in lactation (a minimum of 45 hours) and have extensive experience of lactation counselling (900–6000 h depending on existing qualifications). *Funded by Ross Laboratories.

Early Discharge
Gunn et al. (2000) New Zealand RCT 78%Early discharge with home supportPreterm (<37 weeks). 90% planned to BF. 66% of European origins, 17% Maori, 39% primigravid NICU/SCN n = 308Early discharge group: met criteria for discharge without need for weight gain. Visited daily for 1st 7–10 days and 24 h telephone support. Control group: discharged when meeting criteria and sustained pattern of weight gainBF duration BF exclusivity Weight of infantNo difference No difference No differenceYes. Early discharge with adequate support does not appear to affect BF rates. There was a high rate of refusal so may not be acceptable to all parents
No difference in re-admissions [UPWARDS ARROW] maternal satisfaction
Örtenstrand et al. (2001) Sweden Quasi-experimental 71%Early discharge (EDG) with home support and parental anxietyParents of preterm infants ( < 37 weeks). 65% primiparous, 53% educated to high school level, 33% beyond high school NSCU/home n = 75EDG: infants still in need of special care mainly NG feeding; care planning prior to discharge, domiciliary care and support by mobile phone. Control group: routine care, home for test period before discharge, clinically well, gaining weight, no NG feedsParental anxiety BFEDG Mothers less anxious (state) at discharge (P < 0.01) No significant differences in BF but tendency towards less BF in EDG at 6/12 (P = 0.06)Possibly, although very high BF rates and a culture of BF. BF outcome was only small part of the study
Other single topics
Merewood et al. (2003) USA Quasi-experimental 72%Baby Friendly Hospital Initiative (BFHI)All babies admitted to NICU during 1995 (pre-BFHI) or 1999 (post BFHI). 67% black, 17% Hispanic, 10% white. 28% uninsured NICU n = 227All 10 steps of the BFHI policies were implemented and the BFHI status was granted in 1999. Data collected from all infants admitted in 1995 prior to policy implementation and 1999 following BFHI status being awardedBF initiation Any BF at 2 weeks Exclusive BF at 2 weeks Any BF at 6 weeks[UPWARDS ARROW] (P < 0.001) [UPWARDS ARROW] (P < 0.001) [UPWARDS ARROW] (NS) [UPWARDS ARROW] (1/8 vs. 6/9)Increased BF associated with BFHI status. Mothers were supplied with electric pumps which might by themselves have improved BF. Very small numbers (17) for follow-up by 6 weeks. Culturally very different from UK populations
Hurst et al. (2004)1 USA RCT 64%Test weighingPreterm infants (31–36 weeks). Mother maintained lactation in NICU & planned to BF post discharge. 64% Caucasian, 32% African American or Hispanic. 71% primiparous. 20% previous BF experience NICU/home n = 46Intervention: mothers supplied with electronic scale & instructed to test-weigh before & after each feed. Supplements determined by prescribed volumes in discharge plan & consultation with primary care provider. Control: Supplementation determined on basis of clinical indices & consultation with primary care providerBF duration with respect to BF goal Weight gain BF concerns Perception of test weighNo difference (1/3 met or exceeded goal) No difference No difference Scale was helpful in transition to BFMaternal feedback suggested that this type of intervention should be individualized. Bottles & nipple shields were used during transition which may have affected results but no data given This was a small sample and combined with sample attrition rendered follow-up of continued breastfeeding inadequate.
Dall’Oglio et al. (2007) Italy Quasi-experiemental 60%A series of changes to promote BFNewborns admitted to the Neonatal Unit. Gestation range 25–41 weeks (mean 34 + weeks); birthweight range 700–4210 (mean 2250 + g). Data collected at three time points (1998, 2000, 2002) NICU n = 204Intervention: During 1998: room with pumps made available; information & support by an IBCLC; staff training. During 2000: pamphlet on BF a preterm infant for relatives; proposal for simultaneous milk collection; use of domperidone; weekly BF meetings with the mothers. Control: clinical data collected for infants hospitalized in the first 6 months of 1998 prior to the interventionFeeding on first day home Feeding at 1 month > discharge Feeding at 2 months > discharge[UPWARDS ARROW] BF (any) 1998 to 2000 (21.2 to 64%, P < 0.01) [UPWARDS ARROW] BF (any) 1998 to 2002(21.2 to 51.2%, P < 0.05) No difference 2000 to 2002 [UPWARDS ARROW] BF (any) 1998 to 2000 (19.7% to 46% P < 0.001) [DOWNWARDS ARROW] BF (any) 2000 to 2002 (46% to 35.9%, P < 0.04) NS 1998 vs. 2000 vs. 2002 (19.7% vs. 40% vs. 28.2%)The presentation of results in this paper was difficult to follow. At discharge from the unit there was an increase in any BF but little change over the longer period. It was not possible to state what elements of the programme of interventions were effective and it was also not clear if the interventions added between 2000 and 2002 were of benefit or indeed had a negative effect. The authors suggested that this intervention followed the BFHI but as it did not follow the clear steps outlined in the BFHI or receive a BFHI award it could not be considered with the above paper
Kliethermes et al. (1999) USA RCT 53%Nasogastric (NG) vs. bottle supplement-ationInfants weighing 1–2.5 kg whose mothers planned to BF. 41% previous BF experience Level III Intensive Care Nursery n = 84All participants received standard BF education, an electric pump & were contacted twice a week to offer support & encouragement & collect data. If the mother was not available for BF or if supplementation required 1 group received oral feeds by bottle & the other by NG tube. Non-nutritional sucking was facilitated by use of fingers or pacifier. NG feeding ceased when mother began rooming in thereafter supplements were given by cup or syringeBF practiceHigher BF rates in NG group at all times (Significant but no statistics supplied) Method of supplementation predictive of BF outcome at discharge (P < 0.0001), 3 days (P < 0.0001, 3/12 (P = 0.0006), 6/12 (P = 0.002)Elimination of bottles from preterm feeding regime recommended. Self reported data and lack of definition of full & partial BF. Effect of pacifier use not recorded Cup-feeding used to facilitate transition to full BF in NG group but no data on this
Infant weight Hospital stay Adverse eventsNo difference at discharge No difference Significantly [DOWNWARDS ARROW] episodes of apnoea or bradycardia but significantly more which required stimulation in NG group
Meier et al. (2000) USA Quasi-experimental 46%Use of nipple shields (NS)Preterm infants (25–37 weeks). All infants were being BF. 71% white non-Hispanic, 21% African American. 41% twins. NICU n = 34Retrospective analysis of data of infants participating in another study. Feed volumes measured in all feeds, data collected from feed immediately prior to use of NS and for 1st feed using NS. Use of NS was indicated by advanced practice nurse. Milk volume measured by test weighing infant. Infants self-controlledVolume of milk transferred[UPWARDS ARROW] when NS used (P = 0.0001)Infants had all been randomized to 2 different interventions, given small numbers this may have affected results. All mothers had adequate milk supply, no evidence that NS will correct milk transfer problems if inadequate supply
Indications for NS use Duration of NS use Duration of BF60% poor latch, 30% infant falling asleep, 9% other (eg pain) NS used for a mean of 33 days No statistical association between NS use & BF duration
*Fenton et al. (2000) Canada RCT 38%Breast milk enrichment as a powder vs. a liquidParents of VLBW infants (≤1.5 kg) whose mother chose to BF. 35% had BF previously n = 63 families (71 infants) NICUInfants were given supplements which were mixed with breast milk. Supplements were either powder or liquid. Liquid supplements were mixed with the same volume of milk, while powder supplements required to be mixed with more breast milkParental attitudes to enrichment BF duration vs. intended durationPowder preferred over liquid (P < 0.01) Infants fed liquid were BF for shorter duration relative to their goal (P < 0.05)Duration of BF may be maximized by considering parents’ attitudes to type of enrichment and the amount of breast milk required
Oddy & Glen (2003) Australia Quasi-experimental −7%Finger feedingAll preterm (<37 weeks) babies born in 1998 or in 2001 Special Care Nursery n = 35Finger feeding introduced as part of the implementation of the Baby Friendly Hospital Initiative (BFHI) as bottles & teats could no longer be used. Finger feeding with a feeding tube was used to feed the baby expressed breast milk if baby too tired to BF, refused to BF or if separated from mother. No further information on process givenBF at discharge[UPWARDS ARROW] (NS)Authors conclude that finger feeding increases BF rates however, implementation of the BFHI may have changed entire approach to infant feeding. Small sample, no information on dummy use