Breastfeeding
a Preterm Infant after NICU Discharge: Reflections on Ryan's Story
Paula P. Meier, RN, DNSC,
FAAN,
Associate Director for Clinical Research: Section of Neonatology,
and NICU Lactation Program,
Director: Rush-Presbyterian St. Luke's Medical Center,
Professor: Rush College of Nursing, Chicago, IL
Linda P. Brown, RN, PHD,
FAAN, Professor and Chair: Division of Health Care of Women and Childbearing Families,
University of Pennsylvania, Philadelphia, PA
from Breastfeeding Abstracts,
August 1997, Volume 17, Number 1, pp. 3-4.
"Ryan
Can Nurse Today," published in La Leche League International's publication
for mothers, NEW BEGINNINGS,1 captures the essence of studies that
address breastfeeding a preterm infant during the early postdischarge
period. In this article, Ryan's mother described the support and assistance
she received from health professionals during her preterm infant's stay
in the neonatal intensive care unit (NICU), and detailed the challenges
to persevering with breastfeeding after Ryan's discharge. The words
of Ryan's mother "personalize" the results from studies that focus on
breastfeeding for mothers and their preterm infants during this brief,
but physically and emotionally intense, period of time. These study
results show that mothers are concerned about their preterm infants
"getting enough" milk from exclusive breastfeeding2-6 and that these
concerns are real, in that preterm infants are at risk for underconsumption
of milk by exclusive breastfeeding until they reach approximately term,
corrected age.2, 7-12
The purpose of this review
is to highlight the differences between term and preterm infants with
respect to breastfeeding management and to describe research-based interventions
to facilitate breastfeeding for preterm infants and mothers during the
early post-discharge period. Preterm infants are not small term babies.
In the United States preterm infants are usually discharged from the
NICU before their expected birth dates, so they are still "immature"
during the early weeks at home.14 Typically, these babies weigh between
four and five pounds, which is approximately half to two-thirds the
body weight of a healthy, term newborn. In comparison to term infants,
preterm infants have a large body-surface-area-to-weight ratio and higher
metabolic demands to support temperature regulation and rapid growth.
In combination, these factors mean that preterm infants have greater
fluid and caloric requirements per pound of body weight than do healthy,
term infants.15 As such, a preterm infant is more susceptible to the
effects of even temporary underconsumption of milk and can become dehydrated
much more quickly than a healthy, term infant. Feeding behaviors also
differ for preterm infants, especially with respect to the regulation
of sleep and eating. Preterm infants may not have developed sufficient
state control to respond predictably to hunger until they reach approximately
term, corrected age.2 Ryan's mother provided an excellent example
of this when she wrote; "He was not able to 'demand' a feeding until
he was about seven weeks old, and would sleep eight hours, and still
not be interested in nursing when he awoke." Similarly, preterm infants
can demonstrate signs of satiation post-feed (e.g., falling asleep,
refusing the breast) when little or no milk has been consumed.7,8
These immature behaviors cannot be corrected by waking the preterm infant
to feed more frequently (>8 times daily), because sustained sleep
periods are necessary for the secretion of growth hormone, which is
crucial for adequate growth.
These physiologic and behavioral
differences mean that breastfeeding strategies commonly used for term,
healthy infants will often be ineffective (and possibly unsafe) for
preterm infants.12, 16, 17 In particular, unmonitored "demand" feedings
and/or frequent sleep interruption are not appropriate for preterm infants,
because of the risk for dehydration and slow weight gain.
Getting enough: Term and
preterm infant differences
The international literature
suggests that preterm infants are at risk for underconsumption of milk
with exclusive breastfeeding until they reach approximately term, corrected
age.2, 7-12 In contrast to mothers of healthy term infants, mothers
of preterm infants seldom cite insufficient milk as a reason for their
babies’ not taking an adequate volume of milk at breast.6 Mothers
of preterm infants often produce two to three times as much milk as
their babies need, which they can express effectively with a breast
pump, but they report that their babies do not take all the milk that
is available to them. Typically, mothers describe immature feeding behaviors,
such as not waking to feed, falling asleep early in the feeding, and
slipping off the nipple before a steady milk flow can be sustained.
These suggest to them that their infants are not getting enough.2,
4, 14 Studies suggest that these behaviors are the norm for preterm
infants, and they are gradually replaced with more mature behaviors
as the infants approach their expected due dates.2, 9, 14 Although
these maturationally dependent feeding behaviors cannot be corrected,
several breastfeeding strategies can be used to compensate for them.
Milk transfer is dependent upon infant suckling, maternal milk supply,
and milk ejection, so a preterm infant with an immature suck can still
“get enough” if the mother has extra milk and it flows easily.14
Research-based interventions for getting enough include: maintaining
an abundant maternal milk supply, breastfeeding in positions that support
and direct the infant’s head, and the temporary use of breastfeeding
aids, such as infant scales for measurement of milk intake.12, 13
Although strategies for increasing the milk supply may facilitate milk
transfer, they do not correct infant feeding behaviors that are maturationally
dependent. Thus, extra pumping and galactogogues may increase milk volume,
but do not correct the underlying problem of infants’ immaturity
in extracting milk from the breast.
Like Ryan’s mother
in the story, mothers of preterm infants are acutely vulnerable with
respect to their infants’ getting enough–not because they
have become accustomed to “numbers” in the NICU, but because
their concerns are real. Mothers of preterm infants usually elect to
complement at-breast feedings with expressed milk “just to be sure”
the babies consume an adequate volume.2 Routine complementation establishes
an undesirable feeding pattern for the infant, because it is seldom
individualized to the amount just consumed at the breast. Additionally,
it involves so much extra work for mothers that they become exhausted;
each feeding involves at-breast feeding, pumping, and a bottle (or some
alternative) complement.2-6
Measuring milk intake in
the home
Studies have demonstrated
that mothers of preterm infants cannot use clinical indices of intake,
such as audible swallowing and changes in breast fullness pre-and post-feed,
accurately until infants are home for at least two to three weeks.2,
7 Thus, these women don’t know whether their babies consumed an
adequate amount of milk from the breast at a particular feeding. The
difference in the use of these clinical indices by mothers of term and
preterm infants is beyond the scope of this review, but has been detailed
in published research.7, 8
In-home measurement of at-breast
intake by test-weighing can prevent the sequelae of low milk consumption
while promoting and sustaining the breastfeeding relationship. Test-weighing
involves weighing the clothed infant before and after the feeding under
exactly the same conditions; the weight gain (in grams) is equal to
the volume of milk consumed (in cc’s).18 In one study, mothers
demonstrated the ability to perform test weights very accurately when
using an electronic scale available for short term in-home rental.7
The scale is portable, operates on household current or with batteries,
and automatically calculates milk intake from the pre-and post-feed
weights. A large study is currently underway to examine the effect of
in-home test-weighing on several breastfeeding outcomes including: infant
weight gain, transition to complete breastfeeding, and maternal concerns
about infant intake.19
However, in the interim,
it is important to acknowledge that no clinical trials have suggested
that in-home test weights are burdensome or anxiety- provoking for mothers.
In contrast, the preliminary results from a separate study suggest that
mothers find the information from test weights to be reassuring, in
that they know whether a complement is needed.20 Ryan’s mother
echoed the words of many mothers from published studies when she wrote;
“If I had known at the time that Ryan was still gaining weight,
I would not have been so quick to supplement.”
Individualized complementation
schedules
Use of in-home test-weighing
gives mothers the technology and information that they need in order
to make informed choices about complementation, while preventing dehydration
and slow weight gain in their preterm infants. Guidelines for in-home
test-weighing have been published, 13, 14 and are summarized briefly
as follows. At NICU discharge, the baby’s doctor discusses with
the mother the minimum amount of milk her baby should consume each day
(not every 3-4 hours); this volume can be further divided into 6-hour
or 12-hour volumes to ensure adequate hydration. Then mothers can measure
intake at each feeding, and maintain a milk intake record, such as the
one that was developed for use with the electronic scale.21 With advice
and guidance from professionals and/or another experienced mother, these
women can decide how they would like to complement breastfeeding.
For example, a mother might
decide with her baby’s doctor that she will measure intake at each
breastfeeding and will complement breastfeedings after a 6-hour or 8-hour
period of demand feeding. If her baby needed 100 cc’s of milk over
this period, but consumed only 80, the mother could provide the extra
20 cc’s as a complement. This approach meets everyone’s needs:
the mother will not feel so vulnerable with respect to infant intake;
the infant is given the opportunity to "demand;"
and the health care provider can feel comfortable knowing that a minimum
volume of milk will be consumed. The mother should implement the plan
while the infant is still in the hospital, so she becomes comfortable
with test-weights, recognizing hunger cues, and deciding when and how
to provide complements.
In most instances, mothers
will need the scales for two to three weeks at home. At first, they
will perform test-weights at every feeding, then occasional test-weights,
and finally a nude daily weight to measure weight gain patterns, rather
than milk intake. Many pediatricians defer a first return visit until
one week post-NICU discharge, if they know daily in-home nude weights
are being measured by the parents.13, 14
Giving mothers a choice
Lactation consultants and
health care providers who work primarily with healthy, term infants
may feel that the use of special breastfeeding positions, and technology
such as test-weights, is unnecessary and interferes with the naturalness
of breastfeeding. However, it is important to maintain a perspective
that includes information from the research literature and the preferences
of mothers of preterm infants. These women are accustomed to the highly
complex environment of the NICU, so that the use of equipment to facilitate
breastfeeding is not instinctively “unnatural”—it is
simply how breastfeeding will work for them. It has been argued that
if inadequate infant intake is confirmed by test-weighing, the mother
will be disappointed and discouraged.7, 8 Similarly, some breastfeeding
proponents feel that in lieu of in-home test-weighing, a mother can
take her preterm infant to the doctor or lactation consultant for a
“weight check” several times during the first week at home,
so that she is not burdened with an unnatural breastfeeding accessory.
This approach has led to some clinicians’ request that infant scales
be available to mothers only by prescription. Such an approach implies
that mothers are not capable of making appropriate choices about managing
breastfeeding for their preterm infants. In contrast, Ryan’s mother’s
story and the research literature suggest that mothers need only the
information, assistance, and support for their individual breastfeeding
situation in order to make informed choices for themselves and their
infants. Then breastfeeding can be the empowering experience for these
women that it is for mothers of healthy, term infants.
REFERENCES
1. Lucas, J. G. Ryan can
nurse today. NEW BEGINNINGS, 1997; 14(2):24-25.
2. Kavanaugh, K., L. Mead,
P. Meier, and H. H. Mangurten. Getting enough: Mother's concern about
breastfeeding a preterm infant after discharge. J Obstet Gynecol
Neonatal Nurs 1995; 24:23-32.
3. Meier, P. P., J. L. Engstrom,
H. H. Mangurten et al. Breastfeeding support services in the neonatal
intensive-care unit. J Obstet Gynecol Neonatal Nurs 1993; 22:338-47.
4. Hill, P. D., K. S. Hanson,
and A. L. Mefford. Mothers of low birthweight infants: breastfeeding
patterns and problems. J Hum Lact 1994; 10:169-75.
5. Hill, P. D., R. J. Ledbetter,
and K. L. Kavanaugh. Breastfeeding patterns of low birthweight infants
at hospital discharge and four weeks after birth. J Obstet Gynecol
Neonatal Nurs 1997; 26(2):189-97.
6. Kavanaugh, K. L., P.
P. Meier, B. Zimmerman, and L. P. Mead. The rewards outweigh the effort:
Breastfeeding outcomes for mothers of preterm infants. J Hum Lact
1996; 13:1.
7. Meier, P. P., J. L. Engstrom,
C. Crichton et al. A new scale for in-home weighing for mothers of preterm
and high risk infants. J Hum Lact 1994; 10:163-68.
8. Meier, P. P., J. L. Engstrom,
B. Fleming et al. Estimating milk intake of hospitalized preterm and
high risk infants. J Hum Lact 1996; 12:21-26.
9. Ramasethu, J., L. Jeyaseelan,
and C. P. Kirubakaran. Weight gain in exclusively breastfed preterm
infants. J Trop Pediatr 1993; 39:152-59.
10. Kaufman, K. J., and
L. A. Hall. Influences of the social network on choice and duration
of breastfeeding in mothers of preterm infants. Res Nurs Health
1989; 12:661-62.
11. Lefevre, F., and M.
Ducharme. Incidence and duration of lactation and lactational performance
among mothers of low-birthweight and term infants. Can Med Assoc
1989; 140:1159-64.
12. Meier, P. P., and L.
P. Brown. State of the science: Breastfeeding for mothers and low birthweight
infants. Nurs Clin North Am 1996; 31:351-65.
13. Meier, P. P., and L.
P. Brown. Strategies to assist breastfeeding preterm infants. Rec
Adv Pediatr 1997; 15:1137-50.
14. Meier, P. P. Professional
Guide to Breastfeeding Premature Infants. Columbus, OH:Ross Laboratories,
1997.
15. Van Aerde, J. Nutrition
and metabolism in the high-risk neonate. In Neonatal and Perinatal
Medicine: Diseases of the Fetus and Infant, ed. A.A. Fanaroff and
R.J. Martin. St. Louis:Mosby Year Book, 1992, pp 478-526.
16. Meier, P. P., and H.
H. Mangurten. Breastfeeding the preterm infant. In Breastfeeding
and Human Lactation, ed. J. Riordan and K.G. Auerbach. Boston: Jones
and Bartlettt, 1993, pp 253-78.
17. Meier, P. P., Caution
needed in extrapolating from term to preterm infants (reply to letter
to editor). J Hum Lact 1995; 11:91-92.
18. Meier, P. P., T. Y.
Lysakowski, J. L. Engstrom et al. The accuracy of test-weighing for
preterm infants. J Pediatr Gastroenterol Nutr 1990; 10:62-65.
19. Hurst, N. M. In-home
test-weighing for preterm infants. Research grant funded by Medela Inc,
August 1996-December 1997.
20. Brown, L. P., P. P.
Meier, A. Spitzer et al. Breastfeeding services for low birthweight
infants: Outcomes and cost. NINR Grant #R01NR03881, September 1995-June
2000.
21. Meier, P. P. The
BabyWeigh Scale from Medela: Parent’s Instructions. McHenry,
IL:Medela Inc.
Acknowledgment:
The Authors acknowledge
research support for this manuscript from the National Institute for
Nursing Research (Grants NR01935 and NR03881), National Institutes of
Health.
Page last edited Sun Oct 14 09:32:41 UTC 2007.
