Establishment Of Breastfeeding Research Articles

The effectiveness and maternal satisfaction of breast-feeding support for women from disadvantaged groups: a comprehensive systematic review

Background Breast-feeding is considered the optimum method of infant nutrition conveying health and psychological benefits for mother and baby. Women from disadvantaged groups are less likely to initiate or successfully establish breast-feeding and with the current emphasis on addressing health inequalities there is an identified need to tailor breast-feeding strategies towards this population. Objectives To appraise and synthesize the best available evidence on effectiveness and maternal satisfaction of interventions supporting the establishment of breast-feeding in the early postnatal period, up to seven days following delivery, for women from disadvantaged groups. Inclusion criteria Types of participants Women from disadvantaged groups, defined as those from socio-economically deprived areas; low income; under 20 years or substance dependent. Types of intervention(s)/phenomena of interest Any study exploring practical, motivational, informative and/or educational interventions supporting disadvantaged women to establish breast-feeding. Types of studies Quantitative and qualitative studies. Types of outcomes The establishment of breast-feeding/lactation within the postnatal period; perceived usefulness and acceptability of the intervention to support breast-feeding establishment in the postnatal period. Search strategy Searches were conducted for any published or unpublished material, in the English language, between 1992 and March 2013. A three-step search of databases including ASSIA; Campbell Collaboration; CINAHL, Cochrane Database; EBSCO; EThOS; Journals @OVID; Medline and SAGE journals was conducted. Methodological quality Each paper was assessed by two independent reviewers for methodological quality using the appropriate critical appraisal instrument from Joanna Briggs Institute. Data collection Data was collected using standardized extraction tools developed by Joanna Briggs Institute. Data synthesis Data was synthesized according to their methodological approach using instruments from the Joanna Briggs Institute. Where this was not possible, findings are presented in a narrative form. Results A total of 10 studies were included in the review. Two were quantitative studies (prospective cohort studies) and eight were qualitative studies (qualitative components of a mixed methodology study and seven qualitative studies). Forty-five findings were extracted from the qualitative components of the studies. Findings were synthesized into 12 categories. Categories were synthesized into three findings. The quantitative review demonstrated that technical assistance and information provision resulted in greater awareness of breast-feeding physiology, increased rates and a longer duration of breast-feeding. The qualitative synthesized findings suggested that maternal satisfaction was enhanced when proactive practical assistance was given within the confines of a collaborative relationship. Professional support offering positive encouragement and delivering socio-culturally appropriate strategies were considered by mothers as helping to meet their breast-feeding objectives. Disempowering practices included inaccessible information, conflicting advice and judgmental attitudes from health care providers. Conclusions The review identified interventions aimed at enhancing technical skill and knowledge as clinically effective in establishing successful breast-feeding. Disadvantaged women considered support strategies offering culturally relevant advice and specific to their individualized needs as the most acceptable and effective in meeting their breast-feeding intentions.

Factors Associated with Exclusive Breastfeeding of Preterm Infants. Results from a Prospective National Cohort Study

Background and AimEvidence-based knowledge of how to guide the mothers of preterm infants in breastfeeding establishment is contradictive or sparse. The aim was to investigate the associations between pre-specified clinical practices for facilitating breastfeeding, and exclusive breastfeeding at discharge as well as adequate duration thereof.MethodsA prospective survey based on questionnaires was conducted with a Danish national cohort, comprised of 1,221 mothers and their 1,488 preterm infants with a gestational age of 24–36 weeks. Adjusted for covariates, the pre-specified clinical practices were analysed by multiple logistic regression analyses.ResultsAt discharge 68% of the preterm infants were exclusively breastfed and 17% partially. Test-weighing the infant, and minimizing the use of a pacifier, showed a protective effect to exclusive breastfeeding at discharge (OR 0.6 (95% CI 0.4–0.8) and 0.4 (95% CI 0.3–0.6), respectively). The use of nipple shields (OR 2.3 (95% CI 1.6–3.2)) and the initiation of breast milk expression later than 48 hours postpartum (OR 4.9 (95% CI 1.9–12.6)) were associated with failure of exclusive breastfeeding at discharge. The clinical practices associated with an inadequate breastfeeding duration were the initiation of breast milk expression at 12–24 hours (OR 1.6 (95% CI 1.0–2.4)) and 24–48 hours (OR 1.8 (95% CI 1.0–3.1)) vs. before six hours postpartum, and the use of nipple shields (OR 1.4 (95% CI 1.1–1.9)).ConclusionEarly initiation of breast milk pumping before 12 hours postpartum may increase breastfeeding rates, and it seems that the use of nipple shields should be restricted. The use of test-weighing and minimizing the use of a pacifier may promote the establishment of exclusive breastfeeding, but more research is needed regarding adequate support to the mother when test-weighing is ceased, as more of these mothers ceased exclusive breastfeeding at an early stage after discharge.

Satiety Responsiveness and the Relationship Between Breastfeeding and Weight Status of Toddlers of Overweight and Obese Women

Numerous studies indicate an association between breastfeeding and decreased toddler adiposity. The mechanism behind this association is still unknown. One possibility is that children who are breastfed may have increased responsiveness to internal satiety cues. This study assessed the effect of satiety responsiveness on the association between breastfeeding and weight status among toddlers. We conducted a secondary analysis of data from 428 toddlers aged 2 years. Mothers' body mass index (BMI) and children's BMI z score were calculated from measured height and weight. Mothers completed a detailed breastfeeding survey and the satiety responsiveness subscale of the Child Eating Behaviour Questionnaire. Multiple linear regression and logistic regression were used to determine if satiety responsiveness mediated the effect of breastfeeding on BMI z score or overweight/obesity (BMI ≥ 85th percentile). Establishment of breastfeeding was associated with decreased BMI z score (0.40 vs. 0.60; p = 0.04), and increased breastfeeding intensity was associated with lower odds of overweight/obesity (OR 0.97, p = 0.04). Satiety responsiveness was not associated with either breastfeeding measures, suggesting it does not play a meditational role in the relationship between breastfeeding and toddler weight status. Furthermore, a relationship between satiety responsiveness and obesity does not exist after controlling for well-known confounders. This study did not find a mediation effect of satiety responsiveness on the association between breastfeeding and weight status in toddlers. More research is needed to characterize satiety responsiveness and its influence on the relationship between breastfeeding and childhood obesity.

Managing slow growth in preterm infants fed on human milk

The benefits of human milk for the preterm infant are well documented. However, after the first 2–3 weeks following delivery, the nutrient content in human milk may be insufficient to promote growth in the rapidly growing preterm infant. The challenge for the neonatal team is to develop clinical strategies that support the use of human milk and the establishment of breastfeeding, while supporting infant weight gain and growth. A range of clinical strategies are required to monitor growth and manage sub-optimal growth. Over 50% of the energy babies receive from mature breast milk is from lipids. Hence it is very important to minimise fat loss during milk collection, handling and storage while giving expressed breast milk to maximise growth. Once breastfeeding has been established an assessment should be performed to ensure that attachment and positioning is optimal and that feeding care plans are in place, to ensure infant growth does not falter following discharge from hospital.

The impact of maternal stress on initiation and establishment of breastfeeding

ObjectiveThe aim of this study was to explore the impact of maternal stress on initiation, and establishment of breastfeeding. MethodsNinety five women were included in the study. Maternal stress was assessed: (1) objectively, with plasma cortisol levels taken from participants' as well as the umbilical cord blood, 10 min after delivery; (2) subjectively, with self-reported questionnaires administered 1 h and 4 days after delivery. Detailed records of breastfeeding parameters were obtained. ResultsMultivariate analyses indicated that controlling for age, and use of epidural during labor, post-delivery stress score was significantly associated with delayed initiation of lactation, lower milk volume, less frequent feedings and shorter duration of first feeding. Mothers' positive emotions were positively associated with feed frequency. Cortisol levels were not significantly related to initiation and establishment of breastfeeding. ConclusionMaternal stress after delivery can hinder the establishment of successful breastfeeding practices.

Co-Sleeping and Bed Sharing in Postnatal Maternity Units

BACKGROUND: This 2-part article reviews the primary research on co-sleeping and bed sharing in maternity units and critiques clinical practice guidelines on co-sleeping and bed sharing in maternity units.METHODS: Electronic search strategies were used to identify primary research and to access clinical practice guidelines about co-sleeping and bed sharing on maternity units. Primary research was reviewed and compared. Clinical practice guidelines were critiqued against the United Nations Children’s Fund (UNICEF; 2004) document, Babies sharing their mothers’ bed while in hospital: A sample policy.FINDINGS: There is little published primary research about co-sleeping and bed sharing in maternity units but that which is available is of high standard. Clinical practice guidelines are more plentiful but vary in quality and scope. The primary research and clinical practice guidelines recognize the positive correlates between co-sleeping and bed sharing and the establishment of breastfeeding and the potential for risks to infant safety. There are differences in the acceptance of co-sleeping and bed sharing between geographic regions. The role of health care providers in educating about the benefits and risks of co-sleeping and bed sharing in maternity units is acknowledged but not well explored.CONCLUSION: Further research on co-sleeping and bed sharing in maternity units is needed to provide evidence to inform clinical practice guidelines.KEYWORDS: infant sleep location; policy development and dissemination; risk assessment; maternal education and behavior modeling; co-sleeping; bed sharing

Alimentação nos primeiros três meses de vida

Breastfeeding duration and the factors that make it a successful practice are extreme relevant topics. Based on the evidence of the benefits of exclusive breastfeeding and because of the intensive campaign in favor of this practice in Brazil by means of different policies and programs that have been implemented over the last three decades, promoting periodical updates of the knowledge about the epidemiology of early weaning is crucial (1-3) . One of the highlights of the March issue of Revista Paulista de Pediatria is the article by Cristina Kaufmann, Elaine Albernaz, Regina Silveira, and Maria Mascarenhas on infant feeding (4) . The objectives of this study were: to assess the dietary profile in the first three months of life, to identify factors related to the weaning/early introduction of complementary foods, and to evaluate the adequacy of the use of utensils during this period. The authors used a cohort study design with two compo- nents: perinatal stage (screening at hospital) and follow-up stage (home visits at one and three months of age). Data were collected by means of interviews with the mothers of babies born between September 2002 and May 2003. Home visits covered 30% of randomly selected infants. The final sample included 2,741 mothers. Of these, 973 were selected for home follow-up. The study suggests only 60% of prevalence of exclu- sive breastfeeding in the first month, and 39% in the third month. Such data demonstrate that infants from the city of Pelotas are inadequately fed. In the first month of life, 10% of infants had already been weaned, and in the third month, this figure had tripled. In spite of such low breastfeeding rate, when compared with previous decades, such data show an increase in the duration of breastfeed- ing in Pelotas, which is in agreement with what has been found in other regions of the country. Therefore, these data demonstrate that breastfeeding protection initiatives have led to decreased early weaning. This finding is essential to ensure that the existing programs and policies are main- tained and broaden in Brazil. Paternal educational level, intention to breastfeed, smoking during pregnancy, and use of pacifier were found to be risk factors for weaning in the first month of life. The risk factors for weaning in the third month of life were: paternal educational level, Caucasian mother, the fact that the mother lived with a partner, intention to breastfeed, smoking during pregnancy, use of pacifier, and bottle- feeding. Both models contribute to a better understanding of the determinants of breastfeeding. Since breastfeeding consists of a complex process involving the mother-child pair and their insertion into the family and society, its causal behavior has a different influence on breastfeeding establishment during the neonatal period and its mainte- nance in the subsequent months.

El comienzo de la lactancia: experiencias de madres primerizas

Breastfeeding is important for promoting the healthy development of the newborn. Despite its benefits, the abandonment of breastfeeding is massive in the first three months of life. The aim of this research was to explore how first-time mothers perceived and experienced breastfeeding in order to identify issues affecting its establishment. A qualitative study with a descriptive phenomenological approach was used. Twelve first-time mothers were interviewed in-depth on two occasions: once a few days after childbirth, and another time one month from giving birth. The data were recorded and transcribed verbatim. Giorgi's method was used for the analysis. The essential meaning of the experience undergone by the mothers who took part in this study can be described by the following five themes: an idealization of breastfeeding; uncertainty over the difficulties; a desire for privacy during breastfeeding; shared responsibility with the child for breastfeeding to succeed; and, finally, disruption to the women's lives and changes in their role. This study allowed access to the experiences of first-time mothers during the establishment of breastfeeding. This information will facilitate the design of tailored interventions taking into account the mothers' reports. Health professionals should: consider women's expectations and how they face their new role, provide practical and emotional support, be consistent and avoid giving conflicting advice, and acknowledge the importance of the fathers' support.

Las Dos Cosas: An Analysis of Attitudes of Latina Women on Non-Exclusive Breastfeeding

Non-exclusive breastfeeding among Latina women is commonly seen in the newborn period. The reasons behind las dos cosas ("both things") are not well understood but have included the beliefs that formula has vitamins and that adding formula will result in a chubbier baby, which is desirable. Many previous studies involved Mexican and Puerto Rican women living in the mainland United States. We performed detailed semistructured interviews with 17 Latina mothers in late pregnancy or the newborn period at a community hospital and an affiliated clinic in Massachusetts, serving a large Dominican population. Women were asked about their beliefs about breastfeeding, colostrum, and infant formula. Transcripts were analyzed using Nvivo 9 software (QSR International Pty. Ltd., Melbourne, Australia) to identify the frequencies of common trends. The most common reasons for introducing formula were treatment for insufficient milk, to keep the baby fuller longer, and planning for return to work. None of the women understood the potential risks of introducing formula on the establishment of breastfeeding, particularly on milk supply. Many thought that even limited amounts of breastfeeding were sufficient to produce a healthier child, failing to understand a negative dose-response effect of formula on health and milk production. While every woman saw breastfeeding as healthier, only one saw formula as unhealthy, an important distinction. None of the women expressed familiarity with medical recommendations around breastfeeding duration or exclusivity, with many believing that breastmilk alone would be insufficient to satisfy the hunger or nutritional needs of a growing child after as little as 3 months. Women consistently demonstrated a willingness to learn from health professionals. In counseling Latina women, it may be important to discuss the risks of formula to infant health, breastfeeding, and milk supply and to include the medical recommendations for breastfeeding exclusivity. Educational opportunities exist in the prenatal setting and when postpartum women request formula.

Breastfeeding initiation in immigrant and non-immigrant women in Spain

Research about inequities between native and immigrant women regarding the quality of health care is still scarce. Initiation of breastfeeding in hospital is considered a quality care indicator. In this study, we explore the association between the geographical origin of the women and the establishment of breastfeeding in Spanish hospitals. Prevalence of breastfeeding initiation is higher for women from Latin America, Eastern Europe, Maghreb or sub-Saharan Africa than for Spanish women, and lower for Chinese women. Compared with Spanish women the odds of not breastfeeding in hospital were lower in all these immigrant groups but more than five times higher for Chinese immigrants. Culturally adapted health services are necessary to maintain breastfeeding rates in most immigrant groups. Moreover, it seems urgent to identify the factors influencing patterns of breastfeeding in Chinese immigrants and to develop innovative strategies to encourage breastfeeding initiation in hospital.

Validation of Nipple Diameter and Tongue Movement Measurements with B-Mode Ultrasound During Breastfeeding

Infant feeding problems are extremely common during breastfeeding establishment. To objectively assess infant sucking, consistent methods to analyze ultrasound images of the infant’s oral cavity are required. We developed and assessed the reliability of an extensive ultrasound measurement protocol by measuring nipple diameter and placement. Midline submental ultrasound scans of 30 term breastfed infants were analyzed by two raters. Nipple diameter, nipple hard-soft palate junction distance and tongue hard-soft palate junction distance were measured on two frames: tongue-up and tongue-down. No evidence of measurement bias was found between raters and inter-rater agreement and consistency scores were high. The changes in nipple diameter and placement were consistent with previous descriptions; however, the diameter of the nipple was not consistent in either position. This method provides objective measurements representative of tongue movement, and further investigation is required to ensure usefulness when examining sucking difficulties. (E-mail: holly.mcclellan@uwa.edu.au)

Cochrane Review: Avoidance of bottles during the establishment of breast feeds in preterm infants

AbstractBackgroundPreterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed their preterm infant are not always available and an alternative approach to feeding is needed. Most commonly, milk (expressed breast milk or formula) is given by bottle. There is some controversy about whether using bottles during the establishment of breast feeds is detrimental to breastfeeding success.ObjectivesTo determine the effect of avoidance of bottle feeds during the establishment of breastfeeding on the likelihood of successful breastfeeding and to determine if alternatives to bottle feeds are safe.Search strategyWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL and EMBASE in any language. The search was updated in July 2008.Selection criteriaRandomised or quasi randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.Data collection and analysisTwo review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Standard methods of the Cochrane Collaboration and the Cochrane Neonatal Review Group were used.Main resultsFive trials of 543 infants were included. Four trials used a cup feeding strategy and one trial used a tube feeding strategy when supplements to breast feeds were needed. The single study of tube feeding had a high risk of bias. In the analysis of all five trials, significant heterogeneity was evident in two of the primary outcomes. This was reduced when the tube feeding trial was removed from analyses.Cup feeding significantly decreased 'no breastfeeding or only partial breast feeding' on discharge home (summary RR 0.75, 95% CI 0.61 to 0.91). However, cup feeding significantly increased length of hospital stay by 10 days (95% CI 3.87 to 16.29). There was a high degree of noncompliance in the largest study of cup feeding indicating dissatisfaction with this method by staff and/or parents.The one trial of a tube alone approach significantly reduced 'no breastfeeding or only partial breastfeeding' and 'no breastfeeding at all' at all time periods but the results need to be interpreted with caution due to the high risk of bias.Authors' conclusionsSupplementing breast feeds by cup confers no breastfeeding benefit beyond discharge home and delays discharge considerably. There is currently insufficient evidence on which to base recommendations for a tube alone approach to supplementing breast feeds. Further research is needed to evaluate a tube alone approach.Plain Language SummaryAvoidance of bottles during the establishment of breast feeds in preterm infantsPreterm infants start milk feeds by tube and as they mature they are able to manage sucking feeds. The number of sucking feeds each day are gradually increased as the baby matures. For women who choose to breast feed their preterm infant it is not always possible for them to be there every time the baby needs a sucking feed. Conventionally, bottles with mother's milk or formula are used. It has been suggested that using bottles may interfere with breast feeding success. Five trials have investigated alternatives to bottles in the establishment of breast feeds; four trials used cup feeds and one trial used tube feeds. The one study that used tube feeds was of poor quality and the results of this study need to be interpreted cautiously. When cup feeds were used, more women were discharged home fully breastfeeding, but there was no effect on any (fully and partially combined) breastfeeding. Using cup feeds also increased the length of hospital stay by 10 days. In the one study of tube feeds, breastfeeding (both fully and partially) was increased at discharge and at three and six months after discharge with no effect on length of hospital stay. However, because of the poor quality of this one study, we cannot recommend a tube feeding strategy until further studies of high quality are undertaken.

PICO Summary: Does bottle feeding during the establishment of breast feeding reduce the likelihood of successful breastfeeding in preterm infants?

PICO Summary: Does bottle feeding during the establishment of breast feeding reduce the likelihood of successful breastfeeding in preterm infants?

Influence of Test Weighing Before/After Nursing on Breastfeeding in Preterm Infants

Swedish hospitals apply various regimens for preterm infants' nutrition in connection with their mothers' establishment of breastfeeding. Milk intake is assessed either by test weighing before and after breastfeeding or by observing the infant's suckling behavior (ie, clinical indices). These differing policies may lead to differences in infants' feeding progress. The purpose of this study was to compare effects on breastfeeding and weight gain of preterm infants, depending on whether the volume of breast milk intake when suckled in the hospital was estimated by "clinical indices" or determined by test weighing. Sixty-four infants treated at a unit applying test weighing were compared with 59 infants treated at a unit assessing milk intake by "clinical indices." A retrospective, descriptive, and comparative design was used to explore the consequences of different nutrition regimens. Data were obtained from a review of hospital medical records. The infants treated at the hospital where test weighing was practiced attained exclusive breastfeeding at an earlier postmenstrual age (PMA) and were also discharged at an earlier PMA. However, the 2 study units were alike regarding the proportion of infants attaining exclusive breastfeeding, the postnatal age when this occurred, and the weight pattern in hospital. To establish breastfeeding in preterm infants, test weighing before and after breastfeeding and gradual reduction of supplementation are both applicable regimens. Mothers can be encouraged to choose either of them, although test weighing may help infants attain exclusive breastfeeding at an earlier PMA.

Nipple confusion in neonates

Breastfeeding is influenced by social factors, some of which motivate women to seek additional feeding solutions, including feeding formula milk or expressed breastmilk (EBM) by bottle. Anecdotal evidence indicates that some women offer bottles of EBM during and after the establishment of breastfeeding and continue to breastfeed successfully. The World Health Organization (WHO) recommends that breastfed infants should not be offered artificial teats during the establishment of breastfeeding. This is due to concerns regarding nipple confusion. This article confirms that the evidence supporting nipple confusion is inconclusive and that other issues such as supplementation with formula milk can lead to problems labelled as nipple confusion. Breastfeeding advice advocated by WHO may not meet the needs of all breastfeeding women and prescriptive advice from health care professionals may lead to early cessation of breastfeeding which is avoidable. Midwives should be flexible in their approach to breastfeeding and take women's individual needs into account.

Factors related to unsuccessful lactogenesis - a literature review

The objective of this literature review was to investigate the factors that may interfere in the production of breast milk (lactogenesis), making difficult the establishment of lactation and having hypogalactia as a result. Since breast milk is widely known as the most natural and important food for newborns, it is necessary for nurses to understand and acknowledge the physiological mechanisms involved in lactation in order to help mothers to achieve a successful breastfeeding. Methodology: Two computerized databases were assessed in search for articles: Literature Latin American and Caribbean Health Sciences and Medical Literature and Retrieval System On Line, both covering a 10 years (1997-2007) period. Considering the objective of the study, 21 articles were selected; other academic text-books were also consulted for supporting the development of contents and concepts on lactation physiology. Results: Factors related to failure and/or delay in lactogenesis were: placental retention; deficiency and /or resistance to prolactine; presence of ovarian cysts; breast’s structural alterations; obesity; primiparity; prolonged labor and delivery; cesarean and hypotension. Conclusion: Lactogenesis is a subject that has not been properly acknowledged by nurses, although being essential for the proper establishment of breastfeeding, which is an important issue in nursing care and research. Relevance to clinical practice: When nurses take care of women who experience difficulties on breastfeeding, it is important to consider factors that may interfere in their lactogenesis; this issue seems to be rarely discussed in nursing literature. Therefore, in order to make women’s breastfeeding experience meaningful, enjoyable and effective, nurses should improve their knowledge to investigate factors related to those difficulties and plan interventions. This review is hoped to contribute in raising some aspects that should be addressed in client’s assessment and taken into consideration on planning nursing care.

Early attainment of breastfeeding competence in very preterm infants

To explore the development of breastfeeding capacity in very preterm infants, as an immature sucking behaviour is often mentioned as a barrier in the establishment of breastfeeding in these infants. A prospective descriptive design study in which mothers of 15 infants, born at gestational ages between 26 and 31 weeks, used the Preterm Infant Breastfeeding Behaviour Scale for daily assessments of their infants' oral motor behaviour in hospital. Semi-demand feeding with prescription of a total daily volume of milk was practiced during the transition from scheduled to demand feeding. Breastfeeding was initiated from a postmenstrual age (PMA) of 29 weeks. Obvious rooting, efficient areolar grasp, and repeated short sucking bursts were noted from 29 weeks, and occasional long sucking bursts and repeated swallowing from 31 weeks. The maximum number of consecutive sucks was limited to between 5 and 24 sucks, with a median of 17. Full breastfeeding was attained at a median of 35 weeks, between 32 and 38 weeks. The infants' weight gain when fully breastfed was adequate. Very preterm infants have the capacity for early development of oral motor competence that it sufficient for establishment of full breastfeeding at a low postmenstrual age.

Stillen beim Frühgeborenen

Preterm infants have fewer nutrient reserves at birth than term infants. Additional physiological and metabolic stress factors, such as infection or respiratory distress, can affect their nutritional needs and metabolism. Hence, the provision of appropriate nutrition for growth and development is a cornerstone of care of preterm infants. Well infants of a gestational age > 34 weeks are usually able to suck effectively and coordinate swallowing and breathing. Therefore establishment of breast feeding seems reasonable for newborns of this gestational age. For less mature infants, national and international advisory boards also recommend enteral human milk feeding early postnatally. Challenges remain, particularly in establishing evidence-based standards of breastfeeding and the use of human milk for preterm infants in the intensive-care nursery. This article highlights the aspects of growth and nutritional needs, infection prophylaxis and neurological development with regard to the use of human milk versus formula for the preterm infant. Approaches to the initiation and maintenance of milk supply and the decision about when to replace gavage by breast feeding are illustrated.

Bed sharing on the postnatal ward: Breastfeeding and infant sleep safety

Many hospitals make a commitment to institute 'baby-friendly' initiatives on post-natal wards. Bed sharing (bedding-in) is one of these initiatives. By allowing mothers to comfort, feed and care for their babies in bed, bed sharing may assist the establishment of breastfeeding while helping mothers to get more rest. The effects of skin-to-skin contact and suckling within a short time of birth are well known, but research into the optimal method for reinforcement of these practices over the subsequent days has rarely included research on bed sharing. Currently, there is no published research on any negative effects for mothers and infants in the postnatal period. There are no data, for instance, on which to make judgements as to the safety of mothers and babies when bed sharing after exhausting deliveries. In the present article, the preliminary results of a randomized controlled study of bedsharing on a postnatal ward are reported. Nighttime infrared video recordings are used to examine mother and baby behaviour on the first and second postnatal nights for mothers experiencing vaginal deliveries without the use of opiate analgesics during labour. When completed, the current study will be able to address important, unanswered questions about bed sharing as a caregiving strategy on the postnatal ward.

The Impact of Intrapartum Analgesia on Infant Feeding

Most women in labor require analgesia, but strategies for providing analgesia are changing; today more women receive neuraxial analgesia, whereas the use of general anesthetics and reliance on inhalation or intramuscular analgesia have declined. To learn whether and how these changes have affected infant feeding practices after discharge from the hospital, the investigators undertook a retrospective case review of 425 primiparas who delivered a healthy singleton neonate at term. The mean gestational age was 39.6 weeks, and the mean birth weight was 3.4 kg. Nearly half of the women (45%) were exclusively bottle feeding their infants at discharge. Approximately one in 5 had attempted breast feeding. Approximately one third of all women did not attempt breast feeding at any time. At discharge from the hospital, 55% of women were successfully breast feeding their infants, partially or fully. Rates of bottle feeding were 32% for women given only nitrous oxide with oxygen, 42% for those given only intramuscular opioids plus nitrous oxide with oxygen, 44% for those given neuraxial analgesia containing only local anesthetic, and 54% for those given neuraxial analgesia containing an opioid. In particular, the lipophilic opioids fentanyl and diamorphine correlated with more frequent bottle feeding. The intrapartum use of antiemetics was associated with bottle feeding and also with operative delivery. There were no significant associations between feeding method and antenatal oxytocin, length of hospital stay, duration of labor, maternal body weight, or special infant care. Logistic regression analysis showed feeding at discharge to be predicted by maternal age, antenatal feeding plans, cesarean section, and the dose of fentanyl. Use of this agent correlated with bottle feeding in a dose-response manner. Fentanyl had little influence in women who planned to bottle feed, but for those considered least likely to bottle feed, it had a marked effect. The intrapartum use of fentanyl, especially in high doses, may act against the establishment of breast feeding. Replacing fentanyl-containing analgesic regimens with neuraxial analgesia containing only local anesthetic would be expected to promote breast feeding at the time of hospital discharge.