Infants admitted to neonatal units – interventions to improve breastfeeding outcomes: a systematic review 1990–2007

Infants admitted to neonatal units – interventions toimprove breastfeeding outcomes: a systematic review1990–2007

Rhona J. McInnes* and Julie Chambers†

*NMAHP Research Unit, and †Department of Psychology, University of Stirling, Stirling, UK

Abstract

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

The medical electronic databases were searched for papers listed between 1990 and June 2005which had breastfeeding or breast milk as an outcome and which targeted infants who had beenadmitted to a neonatal unit, thus including the infant and/or their parents and/or neonatal unitstaff. 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 toinclude publications up to this date.

We assessed 86 papers in full, of which 27 ultimately fulfilled the inclusion criteria.The studiesemployed a range of methods and targeted different aspects of breastfeeding in the neonatalunit.Variations in study type and outcomes meant that there was no clear message of what worksbest but skin-to-skin contact and additional postnatal support seemed to offer greater advantagefor the infant in terms of breastfeeding outcome. Galactogogues for mothers who are unable tomeet their infants’ needs may also help to increase milk supply. Evidence of an effect from otherpractices, such as cup-feeding on breastfeeding was limited; mainly because of a lack of researchbut 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 popu-lation and to identify appropriate interventions to improve breastfeeding outcomes.

Keywords: breastfeeding, breast milk, premature infant, low-birthweight infant, systematicreview.

Corresponding: Dr Rhona J. McInnes, NMAHP Research Unit, Iris Murdoch Building, University of Stirling, Stirling FK9 4LA, UK.

E-mail: [email protected]

Review Article

235© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd. Maternal and Child Nutrition (2008), 4, pp. 235–263

mailto:[email protected]

Introduction

Infants born prematurely and those of low-birthweight (LBW), who form the bulk of admissionsto neonatal units (NU), are at greater risk of pooreroutcomes than term or normal birthweight infantsand 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 healthdisadvantage (Spencer et al. 1999; Moser et al. 2003).Health professionals caring for preterm/LBW infantsshould, therefore, aim to provide opportunities to givethese infants a better start in life. Breastfeeding isrecognized as the optimal method of feeding suchnewborns by providing protection from infection,enabling appropriate digestion and absorption ofnutrients, and optimizing neurological development(Schanler et al. 1999). However, infant feedingchoices continue to reflect socio-economic disadvan-tage with younger less affluent women tending to optto bottle-feed their babies (Bolling et al. 2007). In theNU, mothers are frequently encouraged to providebreast milk, which is often recognized as being crucialto their infant’s survival and well-being. The evidencethat many mothers will provide breast milk for theirinfant following admission to the NU (Jaeger et al.

1997; Miracle et al. 2004) suggests a unique opportu-nity to promote breastfeeding. However, there issome evidence that few infants are breastfed (i.e. fedat the breast rather than fed breast milk) at the timeof discharge from the unit (Buckley & Charles 2006).Furthermore mothers often feel excluded from theunit and from providing care for their infant (Lupton& Fenwick 2001; Flacking et al. 2006) and speakof distress at being separated from their babies(Hedberg Nyqvist et al. 1994). Mothers who expressbreast milk or breastfeed their infant speak of theimportant bond that this creates with their infant, theincreased opportunities for them to interact with theirinfant and the importance for them of this maternalrole (Lupton & Fenwick 2001; Miracle et al. 2004).Breastfeeding success is affected by the clinical well-being of the infant, the support the mother receivesand 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 decisionswhich affect the ability of the mother to maintain hersupply of breast milk and to establish breastfeeding.Some practices have been identified as beneficial forhealthy, term infants (Renfrew et al. 2005), such asavoiding supplements and/or artificial teats. However,as preterm infants and infants admitted to the NUexperience different feeding challenges (such asdelayed oral feeding) and have different needs (suchas supplemental feeding and/or the need to be fedduring the mothers absence from the unit), it may notbe helpful to extrapolate those findings to this group.

Given the importance of breast milk for thepreterm/LBW or sick infant and the mother, it iscrucial that we identify the processes that can supportthe mother to provide breast milk for her infant andto enable breastfeeding. This systematic review aimsto identify interventions that affect breastfeedingand/or breast milk feeding in NU.

Methods

Search strategy

A search of the electronic databases CDSR, DARE,AMED, BNI, CINAHL, EMBASE, MEDLINE,PsycINFO and the reference lists of published articlesfor papers published between 1990 and 2005 was con-ducted. This search was updated in December 2007 toinclude any further publications since 2005 (Fig. 1).

Inclusion

Studies were included if they were experimental, pub-lished in English, had breastfeeding or breast milk asan outcome and targeted infants admitted to NU, thusincluding infants and/or their parents and/or NU staff.To identify papers, we searched for studies which tar-geted preterm (<37 weeks) or LBW infants (<2.5 kg)and for interventions within NU. In our originalsearch we included studies from developing coun-tries; however, these studies are not included in thispaper as it was unclear whether their outcomesreflected an impact of the intervention or were a con-sequence of poorly resourced care often provided to

R.J. McInnes and J. Chambers236

© 2008 The Authors. Journal compilation © 2008 Blackwell Publishing Ltd. Maternal and Child Nutrition (2008), 4, pp. 235–263

Search date: December 2003 (updated 21 June 2005 and again in December 2007)Databases: CDSR, DARE, AMED, BNI, CINAHL, EMBASE, MEDLINE, PsycINFO Search terms included: lactation or lactating; milk, human; breastfeed$; breastfed; (breast-feed$; breast-fed; breastmilk or breast-milk; babymilk or baby-milk; nursing mother$; nursing bab$; infant food or feeding; infant formula; bottlefeed$ or bottle feed$ or bottle-feed$; breast milk substitute$ or breast-milk substitute$ or breastmilk substitute PLUS neonat$ or neonat$ unit or neonat$ intensive care unit; premature or preterm or low birth weight; paediatric unit or paediatric intensive care unit; neonat$ nursing; developmental care or kangaroo care or breast milk fortifiers Inclusion criteria: experimental studies published in English between 1990–2007, breastfeeding or breastmilk as an outcome, targeted low birthweight or premature infants, the parents of these infantsor were based in neonatal intensive care units.

Excluded: PhD theses, books and book chapters

1000+ articles Screening of article titles and removal of duplicates and those which did not immediately fulfil criteria

440 abstracts obtained by first twosearches plus another 157 in December 2007

Abstracts reviewed by two members of the BEG group (two researchers) independently using an agreed proforma. Excluded those that did not fulfil criteria. Full publication was obtained for all those fulfilling criteria or where it was not possible to tell from the abstract.

60 papers obtained in full from first twosearches plus another nine in December update Exclude studies which did not use an experimental or quasi-

experimental design

32 articles for inclusion from first twosearches + five from December update

Review of reference lists identified a further 17 articles

49 articles from firstsearch and five from December update

Subject to full review by two independent researchers

During this process 13 articles from first two searches and two from the December update were excluded as they did not conform to the inclusion criteria on in-depth scrutiny. Reasons for exclusion included insufficient information on methods or outcome; randomising to a study group but reporting on other aspects of the study; papers on the transition from tube to oral feeding where all babies were bottle fed.

Total number of papers reviewed in this paper = 27

Total number of publications in the review = 39

Excluded: 12 papers from the first two searches which were conducted in developing countries where high tech neonatal facilities were not available or limited. Excluded papers had been conducted in Ecuador, Brazil, Ethiopia, Mexico and India.

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

Infant feeding in the neonatal unit 237


control group infants in these countries. Furthermorethe breastfeeding and parenting culture apparent inmany developing countries may affect the generaliz-ability of such studies to high technology NU in coun-tries with generally lower rates of breastfeeding. Afuller report, which includes papers (from 1990 to2005) from developing countries, is available from theauthors on request. Excluded papers are listed inAppendix 1.

Screening and data extraction

Abstracts were independently screened for inclusionby the reviewers (RM and JC) who also indepen-dently appraised each of the included papers using atool developed from critical appraisal publications(Centre for Reviews and Dissemination 2001; SIGN2004; Higgins et al. 2006) and from previous work bythe researchers. In the updated search for papers pub-lished between 2005 and 2007, papers were screenedby the first author (RM) and reviewed for agreementby the second (JC).

Quality assessment

All papers were scored according to methodologicalrigour (see Appendix 2 for more details on how thiswas calculated). The quality rating for each paper isgiven in column 1 of Table 3. Papers scoring �70%were defined as good, those scoring 50–69% as inter-mediate and those <50% as poor quality. Authorswere contacted to discuss ‘gaps’ in reporting that mayimpact upon the quality rating. Agreement betweenthe reviewers was high and minor disagreements wereresolved through discussion.

Evidence statements

Grouping papers with similar interventions enabledidentification of a number of statements about theevidence. The strength of these statements could beassessed using a process of comparative judgement(SIGN 2004).Assessments were based on the numberand quality of studies, consistency of evidencebetween studies and clinical usefulness of the findings.Statements were graded as: A: more than one good

quality study; B: one good quality study plus morethan one lesser quality; C: one good quality study plusone of lesser quality OR more than one lesser qualitystudy; and D: insufficient evidence to form a judge-ment. Evidence statements are given in the resultssection where possible. Because of the heterogeneityof the interventions conducting a meta-analysis wasnot thought appropriate.

Results

Overall 27 studies fullfiled the inclusion criteria.Twenty-four studies included breastfeeding as anoutcome, of which seven also included a measure-ment of milk volume/supply. In the remaining threestudies, breast milk volume/supply but not breast-feeding was an outcome. It should be noted that manyof the studies used ‘breastfeeding’ to indicate that thebaby was fed breast milk but often did not differen-tiate how this was given (i.e. breast, bottle or cup).Where information is available this has been noted inthe relevant tables. Twenty-one studies recruited pre-mature infants, three recruited LBW infants and threerecruited all infants admitted to the NU during thestudy period.

Study characteristics

Tables 1 and 2 sumarize the general characteristics ofthe 27 studies grouped by outcome measured, i.e.breastfeeding or breast milk volume. The studiesvaried widely in terms of the structure of the inter-vention and there were seven topics where only onepaper was identified; thus, a consistent impact onbreastfeeding/breast milk volume could not bedetermined. 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 & Glenn2003), the Baby Friendly Hospital Initiative (Mere-wood et al. 2003) and a series of interventions, aimingto promote breastfeeding (Dall’Oglio et al. 2007).Planned early discharge with good home support wasevaluated in two studies and was not shown to signifi-cantly affect breastfeeding outcomes, but furtherresearch is recommended particularly in countrieswith lower rates of breastfeeding (Örtenstrand et al.



Tabl

e1.

Sum

mar

yof

stud

ies

whe

rebr

east

feed

ing

orbr

east

milk

feed

ing

was

anou

tcom

e(2

4st

udie

s)

Con

tine

ntSt

udy

type

Stud

yqu

alit

y*Im

pact

onbr

east

feed

ing

orbr

east

milk

feed

ing

Topi

c(n

)

Eur

ope

(n)

Nor

thA

mer

ica

(n)

Aus

tral

asia

(n)

Ran

dom

ized

cont

rolle

dtr

ial(

n)

Oth

erco

ntro

lled

(n)

Goo

d(n

)In

term

edia

te(n

)Po

or(n

)Po

siti

ve(n

)N

egat

ive

(n)

No

sign

ifica

ntdi

ffer

ence

(n)

Skin

-to-

skin

(5)

13

12

32

12

20

3C

up-f

eedi

ngvs

.bot

tle

(3)

20

13

02

01

1†0

2E

xpre

ssin

g(2

)2

00

20

11

00

02

Gal

acto

gogu

es(2

)0

20

20

20

00

02

Ear

lydi

scha

rge

(2)

10

11

12

00

00

2A

ddit

iona

lpos

tnat

alsu

ppor

t(3

)0

30

21

21

02†

01

Bab

yfr

iend

lyin

itia

tive

(1)

01

00

11

00

10

0P

rogr

amm

eof

inte

rven

tion

s(1

)1

00

01

01

01

1‡0

Nas

ogas

tric

feed

ing

vs.b

ottl

e(1

)0

10

10

01

01

00

Nip

ple

shie

lds

(1)

01

00

10

01

00

1Te

stw

eigh

ing

(1)

01

01

00

10

00

1L

iqui

dvs

.pow

der

fort

ifier

(1)

01

01

00

01

01§

0Fi

nger

feed

ing

(1)

00

10

10

01

00

1To

tal

713

415

912

66

82

15

*Stu

dies

grad

edas

good

qual

ity

had

scor

ed�

70%

,int

erm

edia

test

udie

ssc

ored

50–6

9%an

dpo

orqu

alit

yst

udie

ssc

ored

<50%

;see

App

endi

x2

for

mor

ede

tails

.† Inbo

thth

ese

stud

ies,

brea

stfe

edin

gm

eant

,mot

her’

sm

ilkgi

ven

bydi

rect

brea

stfe

edin

gor

any

othe

rfe

edin

gde

vice

(bot

tle,

cup

ortu

be).

‡ Thi

sst

udy

had

two

sets

ofin

terv

enti

ons

over

two

dist

inct

tim

epe

riod

s,br

east

feed

ing

was

mea

sure

dat

base

line

and

follo

win

gse

t1

and

set

2.C

ompa

red

wit

hth

eba

selin

e,in

terv

enti

onse

t1

and

set

2sh

owed

anin

crea

sein

brea

stfe

edin

gat

disc

harg

e;se

t1

also

show

edan

incr

ease

aton

em

onth

.Int

erve

ntio

nsse

t1to

set2

:no

diff

eren

cein

brea

stfe

edin

gat

disc

harg

ebu

tasi

gnifi

cant

redu

ctio

nin

brea

stfe

edin

gat

1m

onth

.§ Infa

nts

fed

liqui

dsu

pple

men

tsw

ere

brea

stfe

edin

gfo

rsh

orte

rco

mpa

red

wit

hth

eir

goal

.



1999; Gunn et al. 2000). Two of the single-paperstudies showed a positive impact on breastfeedingoutcome, i.e. use of nasogastric tube-feeding in pref-erence to bottle-feeding for supplements for preterminfants (Kliethermes et al. 1999) and implementationof the Baby Friendly Hospital Initiative policies(Merewood et al. 2003). We have given more detailsof the single papers and the two on early discharge inAppendix 3 as this may highlight knowledge gaps forfuture research and will also enable updating of theevidence base. We have not included these papers inthis review as they do not offer any consistent evi-dence for effective practice.

The five topics with the most accumulated evidencewere skin-to-skin contact (SSC) (five papers), cup-feeding (three papers), expressing breast milk (threepapers), galactogogues (four papers) and postnatalsupport (three papers). These 18 studies are reviewedhere 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 themothers breasts (skin-to-skin) for varying periods oftime. In this review, contact times ranged from 10-minsession to 4-h sessions per day. This process is oftendescribed as Kangaroo Mother Care (KMC), which isa relatively standard intervention developed inColumbia in response to the lack of incubators (Rey& Martinez 1983). In KMC, the baby has free accessto the breast and will be nursed like this continuously(up to 24 h). Because contact times were so restrictedin the reviewed studies, none of them could be con-sidered to have used KMC as originally described;therefore, we have used the term skin-to-skin contact(SSC) to cover these interventions. In industrializedcountries, the terms KMC and SSC appear to be usedinterchangeably, but KMC as originally described iseither not well implemented or not understood. SSCas described in this section is different from ‘earlySSC’ which is encouraged in the first 24 h after birthand 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; RobertsTa

ble

2.Su

mm

ary

ofst

udie

sw

here

brea

stm

ilkvo

lum

ew

asan

outc

ome

(10

stud

ies)

Con

tine

ntSt

udy

type

*Stu

dyqu

alit

yIm

pact

onbr

east

milk

volu

me

Topi

c(n

)

Eur

ope

(n)

Nor

thA

mer

ica

(n)

Aus

tral

asia

(n)

Ran

dom

ized

cont

rolle

dtr

ial(

n)

Oth

erco

ntro

lled

(n)

Goo

d(n

)In

ter-

med

iate

(n)

Poor

(n)

Posi

tive

(n)

Neg

ativ

e(n

)N

osi

gnifi

cant

diff

eren

ce(n

)

Skin

-to-

skin

cont

act

(2)

02

01

11

01

10

1E

xpre

ssin

g(3

)2

10

30

12

01

02

Gal

acto

gogu

es(4

)1

21

40

31

02

02

Add

itio

nalp

ostn

atal

supp

ort

(1)

01

01

00

10

00

1To

tal

36

19

15

41

40

6

*Stu

dies

grad

edas

good

qual

ity

had

scor

ed�

70%

,int

erm

edia

test

udie

ssc

ored

50–6

9%an

dpo

orqu

alit

yst

udie

ssc

ored

<50%

,see

App

endi

x2.

Stud

ies

incl

uded

inth

ista

ble

wer

eth

ose

that

mea

sure

dac

tual

brea

stm

ilkvo

lum

ew

hich

may

beth

eon

lyou

tcom

eor

may

bein

addi

tion

toot

her

feed

ing

outc

omes

such

asbr

east

feed

ing.

Bre

astm

ilkvo

lum

eco

uld

bem

easu

red

afte

rex

pres

sing

(gor

mL

)or

byte

stw

eigh

ing.



Tabl

e3.

Inte

rven

tions

with

accu

mul

ated

evid

ence

for

outc

omes

(18

stud

ies)

Cit

atio

nC

ount

ryQ

ualit

yra

ting

Asp

ect

ofB

FP

arti

cipa

nts

Sam

ple

size

n=

x

Stud

yty

peL

ocat

ion

Inte

rven

tion

deta

ilsSt

udy

outc

ome/

sIn

terv

enti

onef

fect

onou

tcom

eC

omm

ent

Skin

-to-

Skin

Con

tact

(SSC

)(5

)R

ojas

etal

.(2

003)

USA

94%

SSC

vs.t

radi

tion

alho

ldin

g(T

H)

G=

27.2

/26.

6w

eeks

BW

=93

9/90

6g.

CA

aten

try

=29

.8/2

9.4.

Wei

ght

aten

try

=10

02/

1021

.’M

ainl

yw

hite

orA

fric

anA

mer

ican

’n

=60

RC

T NIC

USS

C:i

nfan

the

ldin

sem

i-up

righ

tpo

siti

onin

dire

ctco

ntac

tw

ith

pare

nts’

ches

t.In

fant

sw

ore

ana

ppy

and

thei

rba

cks

wer

eco

vere

dw

ith

abl

anke

t.T

H:h

eld

inpa

rent

s’ar

ms

insu

pine

posi

tion

.Inf

ants

wor

ena

ppy

and

T-sh

irt

and

wer

ew

rapp

edin

abl

anke

t.A

llca

reof

fere

dup

toto

talo

f8

hpe

rda

yin

2¥

4-h

sess

ions

Succ

essf

ulB

F(a

sju

dged

byla

ctat

ion

spec

ialis

t)A

nthr

opom

etri

cm

easu

res

Adv

erse

even

ts

60%

vs.3

5%su

cces

sful

lyB

F(o

dds

rati

o=

2.8

(1.0

to8.

3,P

=0.

06)

↑hea

dci

rcum

fere

nce

(P=

0.03

)N

odi

ffer

ence

inw

eigh

tor

linea

rgr

owth

Few

erin

SSC

–on

lyO

2

desa

tura

tion

sign

ifica

nt

Succ

essf

ulB

Fm

eant

obje

ctiv

eev

iden

ceof

cons

iste

ntB

Fus

ing

appr

opri

ate

tech

niqu

esan

dco

nfirm

edby

retr

ospe

ctiv

ean

alys

isof

med

ical

reco

rds.

Sam

ple

was

smal

l,pa

rent

alre

fusa

lhig

h(r

easo

nsno

tre

cord

ed)

and

com

plia

nce

low

(may

bedu

eto

pare

nts

havi

ngre

turn

edto

wor

k,di

stan

cefr

omho

spit

alor

psyc

hoso

cial

rest

rain

ts)

Bla

ymor

e-B

ier

etal

.(19

96)

USA

72%

SSC

vs.s

tand

ard

care

(SC

)G

=28

/27

wee

ksB

W=

993/

942

gA

geat

entr

yto

stud

y=

29/3

0da

ys.

CA

=32

/31

wee

ksM

othe

rspl

anne

dto

BF.

17%

prim

ipar

ous.

34%

prev

ious

BF

expe

rien

cen

=41

mot

hers

(50

infa

nts)

RC

T SCN

SSC

:inf

ant

wea

ring

ana

ppy,

held

upri

ght

betw

een

mot

her’

sbr

east

s.B

oth

wra

pped

inbl

anke

t.SC

:ful

lycl

othe

din

fant

wra

pped

inbl

anke

t,he

ldcr

adle

din

mot

her’

sar

ms.

One

daily

sess

ion

for

each

baby

for

am

axim

umof

10da

ys.C

onta

ctw

asob

serv

edfo

r10

min

BF M

ilkvo

lum

es(m

L)

Infa

ntph

ysio

logy

↑BF

atdi

scha

rge

90%

vs.

61%

(P<

0.05

)↑B

F1

mon

th>

disc

harg

e50

%vs

.11%

(P<

0.01

)N

odi

ffer

ence

at3

or6

mon

ths

No

diff

eren

ceL

ess

O2

desa

tura

tion

(P<

0.00

1)

Mor

ere

sear

chne

eded

asin

terv

enti

onlim

ited

toon

e10

-min

sess

ion

per

day

Wah

lber

get

al.

(199

2)Sw

eden

57%

SSC

G=

31.1

/31.

3w

eeks

BW

=14

82/1

497

64%

prim

ipar

ous

n=

66

Qua

si-e

xper

imen

tal

(pre

-/po

st-i

nter

vent

ion)

Car

eun

itfo

rpr

emat

ure

babi

es(e

quiv

toU

SAle

vel

II)

SSC

:not

suffi

cien

tly

desc

ribe

d:in

fant

skin

-to-

skin

wit

hm

othe

rC

ontr

ol:d

ress

edba

byw

rapp

edin

blan

ket

wit

hhe

atpa

d.B

oth

grou

psen

cour

aged

toho

ldba

byas

muc

has

they

wan

ted

BF

atdi

scha

rge

Wei

ght

gain

/wee

kIn

cuba

tor

stay

(day

s)H

ospi

tals

tay

(day

s)A

geat

first

tim

eou

tof

incu

bato

r

↑82%

vs.4

5%(P

=0.

005)

↑237

.5g

vs.1

95.5

g(P

<0.

05)

↓20.

9vs

.30.

5(P

<0.

05)

↓41.

6vs

.49.

4(P

<0.

05)

You

nger

(P<

0.01

)

The

cont

rolg

roup

was

sele

cted

from

ati

me

peri

odpr

ior

toSS

C,t

hus

othe

run

repo

rted

fact

ors

may

have

affe

cted

outc

omes

Hur

stet

al.

(199

7)U

SA47

%

SSC

G=

27.7

/27.

5w

eeks

BW

=11

29/1

055

gA

geat

star

tof

stud

y=

15da

ys(8

–26

days

)A

llm

othe

rsin

NIC

Uin

cert

ain

tim

epe

riod

sn

=23

Qua

si-e

xper

imen

tal

(pre

-/po

st-i

nter

vent

ion)

NIC

U

SSC

:all

mot

hers

part

icip

atin

gin

skin

-to-

skin

hold

ing

ina

spec

ific

tim

epe

riod

.Exc

lude

dif

SSC

dela

yed

>4

wee

ksaf

ter

birt

h.SS

C=

mot

hers

inst

ruct

edto

hold

infa

nton

cea

day

for

atle

ast

30m

inin

side

clot

hing

next

tosk

in.M

ean

freq

uenc

yof

sess

ions

=4/

wee

kof

am

ean

of60

min

Con

trol

:all

mot

hers

adm

itte

din

12m

onth

spr

ior

toin

itia

tion

ofSS

C.N

ode

scri

ptio

nof

cont

rol

cond

itio

ns.M

othe

rsex

clud

edfr

omth

est

udy

ifSS

Cha

dno

tbe

gun

inw

ithi

nth

efir

st4

wee

ksaf

ter

deliv

ery.

Con

trol

mot

hers

who

bega

nB

Fw

ithi

nfir

st4

wee

ksw

ere

also

excl

uded

Milk

volu

me

(mL

)in

crea

seov

era

2w

eek

peri

odM

ean

milk

volu

mes

(mL

)B

F

Stro

nglin

ear

incr

ease

inSS

Cvs

.no

chan

gein

cont

rol(

P=

0.01

).H

ighe

rat

allt

ime

poin

tsin

SSC

grou

pN

odi

ffer

ence

Lim

ited

stat

isti

calc

ompa

riso

nbe

caus

eof

very

smal

lsam

ple

(eig

htm

othe

rsin

SSC

grou

p).

Lim

ited

rele

vanc

ebe

caus

eof

uneq

uiva

lent

grou

psan

dco

ndit

ions

.Exc

ludi

ngco

ntro

lgr

oup

mot

hers

who

bega

nB

Fw

ithi

nfo

urw

eeks

afte

rde

liver

yco

uld

have

bias

edou

tcom

es



Tabl

e3.

Cont

.

Cit

atio

nC

ount

ryQ

ualit

yra

ting

Asp

ect

ofB

FP

arti

cipa

nts

Sam

ple

size

n=

x

Stud

yty

peL

ocat

ion

Inte

rven

tion

deta

ilsSt

udy

outc

ome/

sIn

terv

enti

onef

fect

onou

tcom

eC

omm

ent

Rob

erts

etal

.(2

000)

Aus

tral

ia21

%

SCC

vs.

conv

enti

onal

cudd

ling

care

(CC

C)

G=

31.5

wee

ksB

W=

1524

gn

=30

RT N

ICU

and

nurs

ery

SSC

:bab

yw

eari

ngna

ppy

�ha

the

ldsk

in-t

o-sk

inw

ith

mot

her.

Ave

rage

of1.

6h

per

day

CC

C:b

aby

dres

sed

and

wra

pped

inlig

htbl

anke

the

ldby

mot

her.

Ave

rage

of1.

8h

per

day

Bot

hgr

oups

wer

e‘p

erm

itte

dto

brea

stfe

edas

desi

red’

BF

atdi

scha

rge,

6w

eeks

,3m

onth

san

d6

mon

ths

Infa

ntw

eigh

tga

inIn

fant

tem

pera

ture

cont

rol

Par

enta

lstr

ess

Hos

pita

lsta

y

No

diff

eren

cein

any

outc

omes

mea

sure

dT

heau

thor

sst

ate

that

the

stud

yla

cked

aco

ntro

lgro

upw

hich

sugg

ests

that

CC

Cw

asdi

ffer

ent

toro

utin

epa

rent

alco

ntac

t.St

udy

size

was

inad

equa

tean

dit

was

not

clea

rif

who

lesa

mpl

ew

asfo

llow

edup

.C

up-f

eedi

ngvs

.bot

tle

feed

ing

(3)

Col

lins

etal

.(2

004)

Aus

tral

ia86

%

Cup

-fee

ding

vs.

bott

le-f

eedi

ngD

umm

yvs

.no

dum

my

G=

29.2

–30.

3w

eeks

BW

=13

25–1

508

gM

othe

rpl

aned

toB

F.48

%pr

imip

arou

s,40

%pr

evio

usly

BF,

rang

eof

soci

algr

oups

,78%

infu

llti

me

empl

oym

ent

n=

303

RC

T Two

larg

ete

rtia

ryho

spit

als

and

54pe

riph

eral

hosp

ital

s

Infa

nts

rand

omiz

edto

one

offo

urgr

oups

i.e.c

up/n

odu

mm

y,cu

p/du

mm

y,bo

ttle

/no

dum

my,

bott

le/

dum

my.

Cup

-or

bott

le-f

eedi

ngco

mm

ence

dat

disc

reti

onof

clin

ical

staf

fw

hen

mot

her

not

ther

efo

rfe

eds

orto

p-up

sre

quir

ed.

Dum

mie

sus

edfr

omtr

iale

ntry

and

enco

urag

eddu

ring

tube

feed

sor

ifin

fant

rest

less

.For

babi

esno

tra

ndom

ized

tous

ea

dum

my

alte

rnat

ive

soot

hing

mea

sure

sw

ere

used

.

Pro

port

ion

ofin

fant

sfu

llyB

Fat

disc

harg

eP

ropo

rtio

nof

infa

nts

rece

ivin

gan

yB

Fat

disc

harg

e

↑for

cup-

fed

infa

nts

(odd

sra

tios

=1.

73,

1.04

to2.

88;

P=

0.03

)N

osi

gnifi

cant

effe

ctfr

omdu

mm

yN

osi

gnifi

cant

effe

ctfr

omcu

psor

dum

mie

s

Com

plia

nce

inst

udy

was

low

(bot

tle

intr

oduc

edto

53%

ofcu

p-fe

din

fant

san

d31

%of

‘no

dum

my’

grou

pw

ere

give

na

dum

my)

whi

chis

likel

yto

have

affe

cted

outc

omes

.N

oad

vers

eev

ents

note

d

BF

at3

and

6m

onth

sL

engt

hof

hosp

ital

stay

No

diff

eren

ce↑f

orcu

p-fe

din

fant

s(P

=0.

01)

Mos

ley

etal

.(2

001)

UK

75%

Cup

-fee

ding

vs.

bott

le-f

eedi

ngD

umm

yvs

.no

dum

my

G=

35.5

/35.

2w

eeks

BW

not

give

n.M

othe

rspl

anne

dto

brea

stfe

ed.5

0%pr

imip

arou

s.n

=14

RC

T Spec

ialC

are

Bab

yU

nit

Infa

nts

rand

omiz

edto

rece

ive

supp

lem

enta

ryfe

eds

ofbr

east

milk

eith

erby

cup

(six

babi

es)

orbo

ttle

(eig

htba

bies

).N

oin

form

atio

ngi

ven

ondu

mm

yus

e.A

llm

othe

rsad

vise

dto

expr

ess

atle

ast

six

tim

espe

rda

y

Exc

lusi

veB

Fat

disc

harg

eC

upvs

.bot

tle:

nodi

ffer

ence

Dum

my

use:

nodi

ffer

ence

(alt

houg

hus

eun

clea

r)

Ver

ysm

alls

ampl

e,no

info

rmat

ion

onex

pres

sing

.D

emog

raph

icdi

ffer

ence

sbu

tst

atis

tica

lsig

nific

ance

not

test

ed.D

esig

ned

asfe

asib

ility

stud

yfo

rla

rger

tria

lM

othe

rspe

rcep

tion

ofB

Fsu

ppor

tre

ceiv

edH

igh

leve

lof

supp

ort

repo

rted

Gilk

s&

Wat

kins

on(2

004)

UK

25%

Cup

-fee

ding

vs.

bott

le-f

eedi

ngG

=31

/32

BW

=15

60/1

750

gM

othe

rsin

tend

edto

BF

n=

54

RC

T Neo

nata

lUni

tO

ralf

eeds

ofE

BM

whe

nm

othe

rno

tpr

esen

tei

ther

give

nby

bott

leor

cup

asm

eans

of‘a

ssis

ting

prog

ress

ion

from

tube

tobr

east

’

BF

atdi

scha

rge

BF

atte

rman

d6

wee

kspo

st-t

erm

No

diff

eren

cein

any

BF

NS

↑ex

clus

ive

BF

(37

vs.1

5%)

incu

p-fe

dgr

oup

No

diff

eren

ce

Smal

lnum

ber

who

BF

ther

efor

ela

ckof

stat

isti

cala

naly

sis.

Hig

hre

fusa

lto

part

icip

ate

and

high

wit

hdra

wal

rate

amon

gcu

p-fe

dgr

oup

Exp

ress

ing

brea

stm

ilk(n

=3)

*Few

trel

leta

l.(2

001)

UK

82%

The

effic

acy

ofa

stan

dard

elec

tric

pum

pco

mpa

red

wit

ha

hand

pum

p

G=

29.4

/29.

1w

eeks

BW

=13

57/1

305

g.M

othe

rsin

tend

edto

expr

ess.

Rel

ativ

ely

adva

ntag

edso

cial

grou

p.M

ean

nof

expr

essi

ons

/day

=3.

8.60

%pr

imip

arou

sn

=14

5

RC

T NIC

UM

othe

rsus

edet

her

ano

velm

anua

lbr

east

pum

p(A

vent

Isis

)or

anel

ectr

icpu

mp

(Egn

ell)

.Mot

hers

usin

gth

eel

ectr

icpu

mp

wer

eab

leto

doub

lepu

mp.

Bot

hgr

oups

wer

ead

vise

dto

expr

ess

atle

ast

six

tim

esa

day

and

wer

egi

ven

info

rmat

ion

and

supp

ort

Tota

lmilk

volu

me

(mL

)N

osi

gnifi

cant

diff

eren

tC

ompa

ring

both

pum

psse

quen

tial

lygr

eate

rm

ilkflo

ww

asac

hiev

edw

ith

the

man

ual

brea

stpu

mp.

37m

othe

rs(2

3m

anua

lbre

ast

pum

pan

d14

elec

tric

pum

p)at

tem

pted

toB

F.B

reas

tm

ilkat

disc

harg

edo

esno

tdi

ffer

enti

ate

betw

een

BF

orbr

east

milk

give

nby

bott

le,e

tc.

Tim

e(m

ean)

Cre

amat

ocri

t†

Mat

erna

lsat

isfa

ctio

nB

reas

tm

ilkat

disc

harg

e(f

rom

stud

y)

Man

ualb

reas

tpu

mp

vs.e

lect

ric

pum

p:65

vs.5

1m

in/d

ay(P

<0.

001)

No

sign

ifica

ntdi

ffer

ence

Man

ualb

reas

tpu

mp

pref

erre

dN

osi

gnifi

cant

diff

eren

ce



Tabl

e3.

Cont

.

Cit

atio

nC

ount

ryQ

ualit

yra

ting

Asp

ect

ofB

FP

arti

cipa

nts

Sam

ple

size

n=

x

Stud

yty

peL

ocat

ion

Inte

rven

tion

deta

ilsSt

udy

outc

ome/

sIn

terv

enti

onef

fect

onou

tcom

eC

omm

ent

Jone

set

al.

(200

1)U

K66

%

Sequ

enti

alvs

.si

mul

tane

ous

brea

stm

ilkex

pres

sing

wit

hor

wit

hout

mas

sage

G=

29.7

wee

ksB

W=

1535

gA

geat

star

tof

stud

y=

5–7

days

post

part

um.

33%

prim

ipar

ous.

n=

36

RT N

ICU

Mot

hers

allo

cate

dto

expr

ess

eith

ersi

mul

tane

ousl

yor

sequ

enti

ally

.All

part

icip

ants

also

rand

omiz

edto

2da

ysof

brea

stm

assa

gei.e

.day

s1–

2or

days

3–4.

Mot

hers

inst

ruct

edto

expr

ess

atle

ast

eigh

tti

mes

ada

yan

dex

pres

sun

tilm

ilkno

long

eren

tere

dth

eco

llect

ing

set.

The

Egn

ellA

med

aE

lect

ric

Elit

epu

mp

was

used

�si

last

icin

sert

s.St

udy

peri

od=

4da

ys.

Milk

volu

me

(g)

Fat

cont

ent

BF

dura

tion

(ter

m)

↑Milk

wei

ght

Sim

ulta

neou

s+

mas

sage

:12

5g

Sim

ulta

neou

s+

nom

assa

ge:8

8g

Sequ

enti

al+

mas

sage

:79

gSe

quen

tial

+no

mas

sage

:51

g(P

<0.

01)

Fat

conc

entr

atio

nsi

mila

rbu

tto

talf

atvo

lum

ew

assi

gnifi

cant

lyhi

gher

for

sim

ulta

neou

spu

mpi

ng(P

<0.

01).

Mas

sage

NS

No

diff

eren

ce

BF

:15

of17

sequ

enti

algr

oup

mot

hers

and

15of

16si

mul

tane

ous

grou

pm

othe

rsw

ere

fully

BF

orex

pres

sing

atte

rm.1

3%of

stud

ypo

pula

tion

eith

erfa

iled

tola

ctat

eor

supp

ress

edla

ctat

ion.

Wom

enfe

ltst

rong

lyth

atex

pres

sing

wit

hout

mas

sage

was

mor

edi

fficu

lt.

‡ Gro

h-W

argo

etal

.(1

995)

USA

53%

Sequ

enti

alvs

.si

mul

tane

ous

brea

stm

ilkex

pres

sing

Mot

hers

ofpr

emat

ure

infa

nts

wei

ghin

g�

1500

gan

d�

7da

ysol

d.N

oin

fant

data

give

n.56

%pr

imip

arou

sn

=32

RC

T NIC

UIn

terv

enti

on–

mot

hers

used

the

Med

ela

bila

tera

lpum

psy

stem

.In

stru

cted

topu

mp

the

brea

sts

sim

ulta

neou

sly

for

20m

inev

ery

3h

but

not

atni

ght

i.e.�

4ti

mes

per

day.

Con

trol

–m

othe

rsus

edth

eM

edel

asi

ngle

pum

pan

dw

ere

inst

ruct

edto

pum

pea

chbr

east

for

10m

inev

ery

3h

but

not

atni

ght

i.e.�

4ti

mes

per

day

Milk

prod

ucti

on(m

L/

wee

k)Se

rum

prol

acti

nN

umbe

rof

pum

ping

sess

ion/

wee

kH

ours

spen

tpu

mpi

ng

No

diff

eren

ceN

odi

ffer

ence

No

diff

eren

ce(2

8.6

�5

sess

ion

per

wee

k)↑i

nsi

ngle

pum

pgr

oup

(11.

1�

3.1

vs.

7.6

�3

hpe

rw

eek,

P<

0.01

)

Rat

her

than

pum

ping

for

the

pres

crib

edti

me,

mot

hers

wou

ldpu

mp

unti

lmilk

stop

ped

flow

ing

whi

chm

aybe

>20

or<1

0m

in

Gal

acto

gogu

es(n

=4)

daSi

lva

etal

.(2

001)

Can

ada

100%

Eff

ect

ofdo

mpe

rido

neon

milk

prod

ucti

onG

=29

.1A

geat

star

tof

stud

y=

31.9

/33.

1M

othe

rsof

prem

atur

ein

fant

sw

how

ere

expr

essi

ngbr

east

milk

but

had

low

milk

prod

ucti

on.

38%

prim

igra

vid,

12%

prev

ious

BF

expe

rien

cen

=20

RC

T Dou

ble

blin

dtr

ial

NIC

U

Inte

rven

tion

:10

mg

dom

peri

done

3¥a

day

for

7da

ysC

ontr

ol:p

lace

bofo

r7

days

.M

othe

rsw

ere

doub

lepu

mpi

ngw

ith

elec

tric

pum

pan

dha

dre

ceiv

edex

tens

ive

coun

selli

ngan

dte

achi

ng(w

hich

expl

ains

dela

ybe

twee

nbi

rth

and

star

tof

stud

y).

Incr

ease

inm

ilkvo

lum

e(m

L)

from

base

line

Seru

mpr

olac

tin

incr

ease

from

base

line

Seru

man

dbr

east

milk

leve

lsof

dom

peri

done

BF

atdi

scha

rge

hom

eA

dver

seef

fect

s

↑to

44.5

%in

inte

rven

tion

grou

pan

d16

.6%

cont

rol

(P<

0.05

)↑1

19.3

mg/L

vs.

18.1

mg/L

(P<

0.01

)D

etec

ted

atlo

wle

vels

inse

rum

and

brea

stm

ilkN

odi

ffer

ence

sN

one

Dom

peri

done

may

beef

fect

ive

inth

esh

ort

term

;how

ever

long

-ter

mim

pact

need

sto

beas

sess

ed.

Smal

lstu

dy,f

urth

erre

sear

chne

eded



Tabl

e3.

Cont

.

Cit

atio

nC

ount

ryQ

ualit

yra

ting

Asp

ect

ofB

FP

arti

cipa

nts

Sam

ple

size

n=

x

Stud

yty

peL

ocat

ion

Inte

rven

tion

deta

ilsSt

udy

outc

ome/

sIn

terv

enti

onef

fect

onou

tcom

eC

omm

ent

Han

sen

etal

.(2

005)

USA

87%

Eff

ect

ofm

etoc

lopr

amid

eon

milk

prod

ucti

on

G=

28.1

/28.

0M

othe

rsof

prem

atur

ein

fant

sw

hopl

anne

dto

BF.

87%

whi

te,7

7%m

arri

ed,4

2%pa

rtne

rsin

whi

teco

llar

occu

pati

onn

=57

RC

TIn

terv

enti

on:1

0m

gm

etoc

lopr

amid

e3¥

ada

yfo

r10

days

.C

ontr

ol:s

ame

volu

me

ofa

plac

ebo

3¥a

day

for

10da

ys.

All

mot

hers

give

nsu

ppor

tby

trai

ned

lact

atio

nco

nsul

tant

and

supp

lied

wit

han

elec

tric

pum

p

Milk

volu

mes

(mL

)D

urat

ion

ofB

FN

otsi

gnifi

cant

No

diff

eren

ces

(med

ian

of8.

8w

eeks

)

Stud

yw

asun

der-

pow

ered

tode

tect

any

sign

ifica

ntdi

ffer

ence

sat

final

anal

ysis

.M

ilkle

vels

ofm

etoc

lopr

amid

esu

gges

tco

mpl

ianc

ew

aslo

w

Few

trel

leta

l.(2

006)

UK

86%

Eff

ect

ofox

ytoc

insp

ray

onm

ilkpr

oduc

tion

G=

29.9

/29.

0B

W=

1380

/131

5M

othe

rsof

prem

atur

ein

fant

sw

hopl

anne

dto

BF.

Mot

hers

olde

r(a

vera

geag

e=

31ye

ars)

and

wel

ledu

cate

d.67

%w

hite

orA

sian

.20%

wit

hpr

evio

usB

Fex

peri

ence

n=

51

RC

T Dou

ble

blin

dtr

ial

Neo

nata

luni

t

Inte

rven

tion

:5m

Lox

ytoc

insp

rays

cont

aini

ng40

IUsy

nthe

tic

oxyt

ocin

per

mL

.C

ontr

ol:p

lace

bosp

ray

cont

aini

ngno

rmal

salin

ean

dbe

nzal

koni

umch

lori

de.

All

mot

hers

advi

sed

toad

min

iste

ron

esp

ray

(100

mL)

2–5

min

befo

reex

pres

sing

milk

.All

mot

hers

also

give

nst

anda

rdad

vice

abou

tex

pres

sing

and

advi

sed

toex

pres

sm

ilkat

leas

tev

ery

3h.

Dai

lym

ilkvo

lum

es(g

)P

umpi

ngse

ssio

ns(n

)M

ilkvo

lum

ean

dfa

tco

nten

tov

erfix

ed20

-min

peri

odof

expr

essi

ngM

othe

rs’o

pini

onof

spra

y

Onl

ysi

gnifi

cant

lyhi

gher

onda

y2

(27

gvs

.13.

2g,

P=

0.04

5)N

odi

ffer

ence

No

diff

eren

ceN

osi

gnifi

cant

diff

eren

ce

The

patt

ern

ofm

ilkpr

oduc

tion

diff

ered

sign

ifica

ntly

betw

een

the

two

grou

psbu

tov

eral

lthi

sdi

dno

tse

emto

affe

ctth

evo

lum

eof

milk

expr

esse

d.Se

vera

lpla

cebo

mot

hers

wer

eco

nvin

ced

they

had

the

oxyt

ocin

spra

yan

dse

emed

tope

rcei

vean

affe

cton

thei

rm

ilksu

pply

.

§ Gun

net

al.

(199

6)N

Z65

%

Eff

ect

ofgr

owth

horm

one

onm

ilkpr

oduc

tion

G=

30.6

/30.

1(2

5–35

wee

ks)

BW

=13

98/1

239

Age

aten

try:

39.7

/31.

3da

ysM

othe

rsex

pres

sing

insu

ffici

ent

milk

tom

eet

infa

nt’s

need

s.83

%pr

imig

ravi

dae,

mea

nag

e34

�4

year

sn

=20

RC

T Spec

ialC

are

Bab

yU

nit

Inte

rven

tion

:Sub

cuta

neou

sin

ject

ion

of0.

2IU

/kg/

day

reco

mbi

nant

hum

angr

owth

horm

one

(hG

H),

toa

max

imum

of16

IU/d

ay,f

or7

days

.C

ontr

ol:s

ame

volu

me

ofa

plac

ebo

All

mot

hers

rece

ived

stan

dard

man

agem

ent

topr

omot

ean

dm

aint

ain

lact

atio

nan

dw

ere

enco

urag

edto

expr

ess

5–6

tim

esa

day

Incr

ease

inm

ilkvo

lum

e(m

Lor

byte

stw

eigh

t)fr

omba

selin

eto

7da

ysP

lasm

ain

sulin

like

grow

thfa

ctor

Pla

sma

hGH

Adv

erse

effe

cts

↑in

inte

rven

tion

grou

pby

31%

(P<

0.01

)bu

tno

tsi

gnifi

cant

inco

ntro

l(7

.6%

)↑i

nin

terv

enti

ongr

oup

(P<

0.00

1)N

otsi

gnifi

cant

Non

e

Mod

est

incr

ease

inm

ilkpr

oduc

tion

inw

omen

wit

hla

ctat

iona

lins

uffic

ienc

y.U

nabl

eto

pers

uade

mot

hers

toex

pres

sm

ore

than

5–6

tim

espe

rda

ySm

alls

tudy

and

mot

hers

wer

eol

der

Supp

ort

for

BF

(n=

3)M

erew

ood

etal

.(2

006)

USA

88%

Pee

rsu

ppor

tG

=32

.6(2

6.3–

37)

BW

=68

2–33

20g

(mea

n=

1914

/184

0g

Mot

hers

ofpr

emat

ure

infa

nts

who

plan

ned

toB

F.>6

6%A

fric

anA

mer

ican

,>50

%in

rece

ipt

ofM

edic

aid,

>67%

non-

US

born

n=

108

RC

T Lev

elII

IN

ICU

ofa

baby

-fr

iend

lyho

spit

al

Inte

rven

tion

:fac

e-to

-fac

eco

ntac

tw

ith

peer

coun

sello

r(P

C)

init

iate

dbe

fore

hosp

ital

disc

harg

e(�

72h

ofbi

rth)

.PC

s=

wom

enw

ith

BF

expe

rien

cefr

omth

elo

cal

com

mun

ity

who

wer

etr

aine

dab

out

BF

and

abou

tN

ICU

proc

edur

es.

Con

tact

mai

ntai

ned

wee

kly

upto

6w

eeks

.Aft

erth

ein

fant

sdi

scha

rge

cont

act

was

mai

ntai

ned

byte

leph

one

unle

ssm

othe

rch

oose

toat

tend

hosp

ital

tom

eet

PC

Con

trol

:SC

,inc

ludi

ngre

ferr

alto

lact

atio

nco

nsul

tant

ifre

quir

ed.

Rec

eivi

ngan

ybr

east

milk

at12

wee

ksIn

crea

sed

odds

rati

o=

2.81

(95%

confi

denc

ein

terv

als,

1.11

to7.

14)

P=

0.03

Rel

ativ

ely

disa

dvan

tage

dpo

pula

tion

.Fin

alou

tcom

em

easu

red

inte

rms

ofre

ceiv

ing

brea

stm

ilkw

hich

coul

dbe

bybo

ttle

,tub

eor

atth

ebr

east

.A

utho

rsac

know

ledg

eth

atth

eB

FH

Ist

atus

ofth

eho

spit

alm

ayha

vein

fluen

ced

outc

omes

and

that

BF

rate

sw

ere

high

erin

this

hosp

ital

than

the

nati

onal

aver

age.

Rec

eivi

ngm

ostl

ybr

east

milk

at12

wee

ksR

ecei

ving

only

brea

stm

ilk

Not

sign

ifica

ntN

otsi

gnifi

cant



Tabl

e3.

Cont

.

Cit

atio

nC

ount

ryQ

ualit

yra

ting

Asp

ect

ofB

FP

arti

cipa

nts

Sam

ple

size

n=

x

Stud

yty

peL

ocat

ion

Inte

rven

tion

deta

ilsSt

udy

outc

ome/

sIn

terv

enti

onef

fect

onou

tcom

eC

omm

ent

Gon

zale

zet

al.

(200

3)U

SA83

%

Ala

ctat

ion

coun

selli

ngse

rvic

e

63.5

%in

fant

sw

ere

<37

wee

ksan

d36

.5%

�37

wee

ks60

%w

ere

low

-bir

thw

eigh

t(<

2.5

kg)

and

40%

norm

alB

W(�

2.5

kg).

Stay

inN

ICU

rang

edfr

om1–

148

days

.82%

ofm

othe

rsw

ere

�21

year

san

d43

%w

ere

whi

teno

n-H

ispa

nic

n=

350

Cas

e-co

ntro

lN

ICU

Inte

rven

tion

:lac

tati

onco

unse

lling

serv

ice

prov

ided

byIB

CL

C¶.T

his

gave

educ

atio

nan

dcl

inic

alsu

ppor

tto

mot

hers

whi

lein

fant

sho

spit

aliz

ed.I

ndiv

idua

lfee

ding

/ex

pres

sing

plan

deve

lope

d.P

repa

rati

onfo

rB

Faf

ter

disc

harg

e.Te

leph

one

help

-lin

e.P

riva

tero

oms

wit

hbr

east

pum

psw

ere

avai

labl

ean

dpu

mps

coul

dal

sobe

prov

ided

atth

ein

fant

’sbe

dsid

eC

ontr

ol:p

erio

dof

6m

onth

sbe

fore

IBC

LC

supp

ort

beca

me

avai

labl

e.

Infa

nts

give

nO

MM

eith

erby

brea

st,

bott

leor

NG

tube

Fact

ors

sign

ifica

ntly

asso

ciat

edw

ith

OM

Mfe

edin

g

↑OM

Mdu

ring

hosp

ital

izat

ion

(47%

vs.3

1%,P

=0.

002)

↑OM

Mat

disc

harg

e(3

7%vs

.23

%P

=0.

004)

The

auth

ors

sugg

este

dth

atth

esi

ckes

tin

fant

sbe

nefit

edle

ast

from

this

inte

rven

tion

.The

use

ofa

pre-

/pos

t-in

terv

enti

onde

sign

may

affe

ctou

tcom

es.

The

stud

ym

easu

red

OM

Man

dim

pact

onac

tual

BF

not

mea

sure

dB

eing

inin

terv

enti

ongr

oup;

Apg

ar>

7,w

hite

ethn

icit

y,m

ale

infa

nt,s

tay

inN

ICU

>7

days

Pin

elli

etal

.(2

001)

Can

ada

61%

BF

coun

selli

ngfo

rbo

thpa

rent

s

G=

29w

eeks

BW

=10

83/1

103

gP

aren

tsof

very

low

-bir

thw

eigh

tin

fant

sw

hoch

ose

tofe

edbr

east

milk

toth

eir

infa

nt.

Rel

ativ

ely

adva

ntag

edso

cial

grou

p.60

%pr

imip

arou

s,m

othe

rspl

anne

dto

BF

for

8m

onth

sn

=12

8

RC

T Tert

iary

leve

lN

ICU

and

atth

eG

row

than

dD

evel

opm

ent

Clin

ic

Inte

rven

tion

s:vi

deo,

one

toon

eco

unse

lling

bya

rese

arch

lact

atio

nco

nsul

tant

,wee

kly

in-h

ospi

tal

cont

acts

,fre

quen

tpo

st-d

isch

arge

cont

act

for

both

pare

nts

for

one

year

orun

tils

topp

edB

FC

ontr

ol:s

tand

ard

supp

ort

duri

ngho

spit

aliz

atio

ni.e

.con

tact

wit

hre

gula

rho

spit

alst

aff,

few

ofw

hom

had

rece

ived

any

form

altr

aini

ngin

BF

supp

ort

and

lact

atio

n.

BF

dura

tion

Vol

ume

offe

eds

(tes

tw

eigh

t)

Not

sign

ifica

ntN

otsi

gnifi

cant

Popu

lati

onre

lati

vely

adva

ntag

edan

dhi

ghly

mot

ivat

edto

brea

stfe

ed

BF

excl

usiv

ity

Not

sign

ifica

nt

Pap

ers

are

arra

nged

first

byto

pic

and

then

byde

crea

sing

orde

rof

qual

ity

rati

ng.C

itat

ion

=pu

blic

atio

nre

fere

nce;

scor

ere

flect

sou

rgr

adin

gof

stud

ym

etho

ds(l

ower

scor

es,i

nclu

ding

nega

tive

ones

,are

indi

cati

veof

poor

erqu

alit

y);

part

icip

ants

=de

tails

ofpa

rtic

ipan

tsas

prov

ided

byau

thor

[G=

mea

nge

stat

ion

atbi

rth,

BW

=m

ean

birt

hwei

ght,

CA

=m

ean

corr

ecte

dag

eat

init

iati

onof

inte

rven

tion

(whe

rem

ore

than

one

figur

eis

give

nfo

rG

,BW

orC

Ath

isis

for

the

inte

rven

tion

and

cont

rolg

roup

ifth

ese

have

been

give

nse

para

tely

byau

thor

s)];

inte

rven

tion

deta

ilsan

dou

tcom

esar

eth

ose

iden

tifie

dby

the

auth

or;c

omm

ent=

our

com

men

tson

the

stud

y.R

CT,

rand

omiz

edco

ntro

lled

tria

l;R

T,su

bjec

tsra

ndom

ized

todi

ffer

ent

trea

tmen

tgr

oups

but

noco

ntro

l;N

ICU

,neo

nata

lint

ensi

veca

reun

it;S

CN

–sp

ecia

lcar

enu

rser

y,N

S,no

n-si

gnifi

cant

;BF,

brea

stfe

edin

g;E

BM

,exp

ress

edbr

east

milk

,OM

M,o

wn

mot

hers

milk

;NG

,nas

ogas

tric

.Qua

lity

rati

ngis

give

nas

ape

rcen

tage

for

each

stud

y;w

eha

vegr

aded

stud

ies

scor

ing

�70

%as

good

,50–

69%

asin

term

edia

tean

d<5

0%as

poor

,App

endi

x2.

*Fun

ded

byC

anon

Ave

nt(G

lem

sfor

d,Su

ffol

k,U

K)

who

also

supp

lied

the

ISIS

Man

ualp

umps

and

Egn

ellp

umps

(Am

eda,

Taun

ton,

UK

).†C

ream

atoc

riti

sa

mea

sure

used

tode

term

ine

fatc

onte

nt.‡

Supp

orte

din

part

bya

gran

tfro

mM

edel

aIn

c,M

cHen

ry,I

L,U

SA.§

Par

tfun

ded

byP

harm

acia

AB

,Sto

ckho

lm,S

wed

en.¶

IBC

LC

=In

tern

atio

nalB

oard

Cer

tifie

dL

acta

tion

Con

sult

ant:

thes

ear

eei

ther

heal

thpr

ofes

sion

als

orot

hers

wit

hba

ckgr

ound

inhe

alth

orso

cial

scie

nces

who

have

com

plet

edco

mpr

ehen

sive

cont

inui

nged

ucat

ion

inla

ctat

ion

(am

inim

umof

45ho

urs)

and

have

exte

nsiv

eex

peri

ence

ofla

ctat

ion

coun

selli

ng(9

00–6

000

hour

sde

pend

ing

onex

isti

ngqu

alifi

cati

ons)

.



et al. 2000; Rojas et al. 2003). Three studies comparedSSC during specified parental visits with traditionalcontact (fully clothed and wrapped infant held supinein parents’ arms) (Wahlberg et al. 1992; BlaymoreBier et al. 1996; Rojas et al. 2003); one other studycompared SSC with control infants but did notdescribe the intervention (SSC) conditions (Hurstet al. 1997). In the remaining study (Roberts et al.

2000), a programme of SSC was implemented follow-ing a 12-month control period which was notdescribed.The gestational ages of the infants includedin the studies ranged from 26 to 31 weeks with birth-weight ranging from just over 900 g to over 1500 g.Allstudies comprised very small samples; thus, the totalnumber of infants included in this section is 220. Noadverse outcomes were reported. Box 1 summarizesthe evidence.

Two of the four studies measuring breastfeedingoutcomes showed statistically significant increases inbreastfeeding at discharge from the NU (Wahlberget al. 1992; Blaymore Bier et al. 1996). One of thesealso showed an increase at 1-month following dis-charge (Blaymore Bier et al. 1996). One further studyshowed a borderline-significant increase in successfulbreastfeeding (odds ratios = 1.0 to 8.3, P = 0.06) asjudged by a lactation specialist (Rojas et al. 2003).Thetwo other studies which measured breastfeedingshowed no difference between the SSC group and thecontrol. Both of these were poor quality studies and inone (Roberts et al. 2000) the average daily contactbetween mother and baby was longer for comparisonmothers than for SSC mothers. Breast milk volumewas measured in two studies with one (Blaymore Bieret al. 1996) showing no difference and the other

(Hurst et al. 1997) demonstrating a significantincrease in milk volumes over 2 weeks.

In two studies, SSC was associated with significantlyfewer episodes of oxygen desaturation (BlaymoreBier et al. 1996; Rojas et al. 2003). There was no con-sistent impact of SSC interventions on infant growthin terms of weight gain and/or head circumference.

Cup-feeding

Some preterm or sick infants are initially fed enterallyvia a naso-gastric (NG) or oro-gastric (OG) tube untilthey are mature or well enough to take oral feeds.During the transition from ‘tube’ feeds to breastfeed-ing, the infant may be given supplements (’top-ups’)by tube, bottle or cup in addition to breastfeeds. Indeciding how to give supplements, or to feed theinfant during the mother’s absence from the unit,health professionals must consider what methodwill best support the successful establishment ofbreastfeeding.

For mothers planning to breastfeed or who werebreastfeeding, supplements given by cups were com-pared with the use of bottles (Mosley et al. 2001;Collins et al. 2004; Gilks & Watkinson 2004). Cupswere used with babies born at 29–35 weeks, althoughage 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 totalof 374 infants in this section. Box 2 summarizes theevidence.

The impact of cup-feeding on breastfeeding dura-tion was inconclusive. The largest and best qualitystudy (Collins et al. 2004) indicated higher breastfeed-ing rates in cup-fed infants at discharge; however,compliance with the study protocol was low withbottles introduced to over 50% of cup-fed infants.Thereasons for introducing bottles included mothers notliking 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

Box 1. Summary of evidence for use of SSCImpact on breastfeeding and breast milk volume:

• SSC was associated with increased breastfeeding at hospitaldischarge C

Other outcomes:

• SSC was associated with fewer episodes of oxygendesaturation A

Box 2. Summary of evidence for cup-feedingImpact on breastfeeding:The effects of cup use on breastfeeding/breast milk feeding D



recruited over 3.5 years in two large tertiary hospitalsand included infants (59% of the sample) who weretransferred out to one of the 54 participating periph-eral hospitals where potential variations in practice,staff training and unit ethos may have affected theresults. The two other studies (Mosley et al. 2001;Gilks & Watkinson 2004) did not show any overalleffect on breastfeeding. In most studies, few mothersmade the transition to full breastfeeding; thus,numbers were small in later stages of data collection.One good quality study monitored adverse eventsand noted no significant physiological adverse eventsbut did find that cup-fed infants had increased hospi-tal stay (Collins et al. 2004).

Expressing breast milk

Three studies evaluated techniques and types of pumpfor expressing breast milk on a range of outcomes.Theinfants in this section were all premature (29–30 weeks, although one study did not supply demo-graphic data). Two of the studies were small; thus, thetotal number of infants in this section was 213. Twostudies (Groh-Wargo et al. 1995; Jones et al. 2001)compared sequential expressing with simultaneousexpressing using an electric pump, while the third(Fewtrell et al. 2001) compared a hand pump with anelectric pump. One study also compared the use ofbreast 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 ofmothers’ breastfeeding or fully expressing at term.Milk volume was measured in all three studies withonly one, showing an increase in volume associatedwith simultaneous pumping and also with massage(Jones et al. 2001). Both studies comparing sequentialvs. simultaneous pumping had small numbers (n = 32and 36 respectively);however,one of these (Jones et al.

2001) was stopped early as interim data analysis clearlyidentified a significant effect in the simultaneouspumping group. Mothers also found that expressingwithout the use of breast massage was more difficult(Jones et al. 2001) (Box 3). A manual (hand) pumpcompared with an electric pump demonstrated nodifference in total volume of milk expressed, despitethe electric pump users being able to pump simulta-

neously (Fewtrell et al. 2001) and when compared insimilar conditions, i.e. breasts expressed sequentially,the manual pump users expressed greater volumes ofmilk and expressed a given volume more quickly. Fatcontent was not affected by pump type. Mothers alsoscored the manual pump more highly in terms of easeof use, amount of suction, comfort, pleasant to use and‘overall opinion’.

Galactogogues

Four small intervention studies were identified, two ofwhich measured both milk volume and breastfeeding(da Silva et al. 2001; Hansen et al. 2005), and twowhich measured milk volume only (Gunn et al. 1996;Fewtrell et al. 2006). The gestation at birth for infantsin this section ranged from 25 to 35 weeks althoughthe infants were older at the time of trial entry wasolder, e.g. 31.9/33.1 weeks (da Silva et al. 2001) or over31 days (Gunn et al. 1996). All the studies in thissection were very small with a total of 148 infants.Twostudies recruited women who had inadequate milksupply, (Gunn et al. 1996; da Silva et al. 2001) whilethe other two included all women who had given birthto a premature infant (Hansen et al. 2005; Fewtrellet al. 2006). One well-designed trial explored theshort-term use of domperidone for women with lowmilk production and showed increased milk volumesfrom baseline (da Silva et al. 2001). Growth hormone,used with mothers with poor milk supply, achieved amodest increase in milk volume from baseline to7 days (Gunn et al. 1996); however, neither metoclo-pramide nor oxytocin used with mothers of preterminfants had an effect on milk volume and/or breast-feeding duration (Hansen et al. 2005; Fewtrell et al.

2006). It is possible that the lack of effect from bothmetoclopramide and oxytocin was due to the fact that

Box 3. Summary of evidence for expressingImpact on milk volume:

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



both the studies were small; none of the women par-ticipating had identifiable milk inadequacy and thenumbers who could potentially have developed clini-cally significant milk inadequacy would have beensmaller still. Overall, none of the studies showedan increase in duration of breastfeeding; however,increasing milk volume may be a more important goalthan duration for mothers who are unable to achievesatisfactory volumes of breast milk (Box 4).

Postnatal support for breastfeeding

The interventions in this section varied considerablyfrom the provision of structured breastfeeding coun-selling programme delivered by a ‘research lactationconsultant’ (Pinelli et al. 2001); support and assistancefrom an International Board Certified Lactation Con-sultant (Gonzalez et al. 2003) and peer support deliv-ered by women with breastfeeding experience fromthe local community (Merewood et al. 2006). Thestudies also measured different outcomes includingbreastfeeding duration (Pinelli et al. 2001), breast-feeding at 12 weeks (Merewood et al. 2006), exclusiv-ity of breastfeeding (Pinelli et al. 2001; Merewoodet al. 2006), volume of breast milk feeds as measuredby test-weighing (Pinelli et al. 2001) and whether theinfant received breast milk feeds by any means(breast, bottle or tube) during hospitalisation and atdischarge (Gonzalez et al. 2003). They targeted differ-ent audiences with support being provided to bothparents (Pinelli et al. 2001) or to mothers only(Gonzalez et al. 2003; Merewood et al. 2006). Further-more, the mothers in two studies planned to breast-feed (Pinelli et al. 2001; Merewood et al. 2006)compared with the other study where feeding inten-tion was not solicited (Gonzalez et al. 2003). Thepopulation recruited by Pinelli et al. was relativelyadvantaged, highly motivated to breastfeed and had

good community support. The populations in theother two studies (Gonzalez et al. 2003; Merewoodet al. 2006) appeared more mixed and included a highpercentage of African American women who tend tohave lower rates of breastfeeding (Ryan et al. 1997).The age of the infants varied; 36% of infants in onetrial were born after 37 weeks (Gonzalez et al. 2003)while the gestational range for the other studies was26–37 weeks. The studies had larger numbers than inthe other sections involving a total of 586 infants.

Because of differences in the type of intervention,population recruited and outcomes measured anyconclusions in this section must be interpreted withcaution; however, in the two higher quality studies(Gonzalez et al. 2003; Merewood et al. 2006) addi-tional postnatal support was associated withincreased provision of breast milk feeding (Box 5).

Discussion and recommendations

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

The majority of papers in this review targeted thepreterm or LBW infant. Our selection procedureaimed to identify interventions that evaluatedfeeding in other infant groups which might be admit-ted to the NU but we did not identify any such

Box 4. Summary of evidence for use of galactogoguesImpact on breastfeeding and breast milk volume:

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

Box 5. Summary of evidence for additional PN supportImpact on breast milk feeding:

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

*This grading should be considered with caution as although twogood quality studies showed an effect on breastfeeding the out-comes were measured at different times (discharge and12 weeks) and the interventions differed greatly (InternationalBoard Certified Lactation Consultant support vs. peer support)



studies. Indeed, many of the studies included in thisreview excluded infants with congenital abnormali-ties or mothers who had a history of illicit drug use.Most of the studies reviewed in full (14) recruitedonly preterm infants. Three studies (Blaymore Bieret al. 1996; Hurst et al. 1997; Pinelli et al. 2001)recruited LBW infants but these infants alsoappeared to be preterm. One study (Gonzalez et al.

2003) included all infants in the unit during the studytime period of which over 60% were either LBW orpremature. This study, which showed a significantincrease in breast milk feeding during hospital stayand at discharge, did not identify an associationbetween gestational age and outcome by multivariateanalysis. Premature infants and infants, who are LBWbecause of foetal growth restriction, are likely torespond differently to feeding interventions but anydifference between these two groups was notadequately evaluated in the reviewed articles.

Skin-to-skin contact was associated with increasedbreastfeeding in two out of the four studies that mea-sured this outcome, and a tendency towards moresuccessful breastfeeding in a further study. However,there was no consistent effect on breastfeeding ratesfollowing discharge from the unit. A CochraneReview of the use of KMC for LBW infants (Conde-Agudelo et al. 2003) also noted some improvement inbreastfeeding but the authors expressed concernsabout study methods and could not recommendroutine use of KMC for LBW infants.The four papersin the Cochrane review were based in countries withnon-westernized healthcare systems and were noteligible for inclusion here; however, neither theCochrane Review nor the papers reviewed herereported 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 infantby seeing, holding and touching him (Roller 2005).Mothers have described KMC as calming and posi-tive, providing comfort for themselves and theirinfant (Roller 2005). In a qualitative study, the imple-mentation of KMC guidelines in Sweden was associ-ated with improved parental and infant well-being(Wallin et al. 2005). However, resistance to imple-menting KMC has been noted in both developed

(Wallin et al. 2005) and developing countries(Charpak & Ruiz-Paláez 2006) often because ofKMC being considered as substandard care, improperor unusual and resulting in extra work for staff. Lackof privacy and space in some units can also be prob-lematical and continuous KMC contact is not alwaysencouraged (Charpak & Ruiz-Paláez 2006). The evi-dence reviewed here and elsewhere suggests thatKMC or SSC is beneficial for both infant and motherand, given its recent systematic application in NU inSweden, can be used successfully in high-tech NU.From the research already completed, it is not clearwhich 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 andfurther research is, therefore, needed.

Additional postnatal support was associated withan increased likelihood of the infant receiving somebreast milk by any means in two out of three studies.Postnatal support from a trained person (peer or pro-fessional) is associated with increased breastfeedingamong mothers of healthy term infants who wantsupport and/or who want to breastfeed, although out-comes differed according to population demographicsand/or intentions (Renfrew et al. 2005). Additionalsupport has received little attention for infants admit-ted to NU but it is possible that it might prove ben-eficial for a mother trying to feed her infant in thismore difficult environment. The studies in this reviewvaried considerably in their approach to providingsupport; thus, further research is needed to evaluatethe impact of postnatal support and to determine themost effective and acceptable method of delivery.Peer support is one such method of delivering addi-tional support and such initiatives have been increas-ing in number and popularity in the UK (Dykes 2005;Britten et al. 2006). The evidence for the effectivenessof peer support varies with some showing increases insome breastfeeding where offered proactively towomen who want to breastfeed (Renfrew et al. 2005)or increases in exclusive breastfeeding but not in anybreastfeeding (Britton et al. 2006). We identified onlyone eligible study using peer support in the NU(Merewood et al. 2006), which showed increasedbreast milk feeding by any means at 12 weeks follow-ing discharge. However, we identified one other study



(Agrasada et al. 2005) based in the Philippines whichused peer support for term LBW infants, some ofwhom were admitted to the NU for 12–24 h. Breast-feeding support was provided by village women whohad had personal positive experience of breastfeedingand had received additional training. Compared withcomparison and a control group mothers, those whohad received peer breastfeeding counselling were sig-nificantly more like to be exclusively breastfeeding at2 weeks and 6 months, to continue to breastfeed andto be breastfeeding at 6 months. The peer supportstudy (Merewood et al. 2006) is one of only twostudies which demonstrated an impact on feedingbeyond discharge from the NU (the other being anincrease in breastfeeding at 1 month associated withSSC) (Blaymore Bier et al. 1996). Thus, furtherresearch is recommended to identify how best peersupport might be delivered in this environment in amanner that is both acceptable and accessible toparents and staff.

Neonatal staff frequently require to give supple-mental feeds to infants within the NU or to providefeeds when the mother is absent. These feeds shouldbe given in a manner which supports the transition tosuccessful breastfeeding, if this is the mothers wish,but the choice of method is limited by what is cur-rently available. The evidence that the skills used tofeed from a bottle differ from those used at the breast,has led to concerns about ‘nipple confusion’ where abreastfed infant may become confused if given abottle (Neifert et al. 1995). Therefore, there is nowa tendency to offer breast milk either by cup or tube(NG/OG). However, it is likely that the skills used forcup-feeding also differ from breastfeeding as sug-gested by Dowling and colleagues in a study of eightpreterm infants, in which the authors also had con-cerns about the small volumes of milk actuallyingested by cup-feeding (Dowling et al. 2002). ACochrane review of cupfeeding for infants unable tofully breastfeed (Flint et al. 2007) reviewed fourstudies and could not recommend cup-feeding overbottle-feeding as it conferred no significant benefitsand was associated a longer hospital stay. In ourreview, which included three of the four studies in theCochrane review, cup-feeding was associated withincreased breastfeeding at discharge in one of the

three studies reviewed but overall there was no accu-mulated evidence of an effect from cup-feeding. Thismay be due in part to few mothers making the tran-sition to breastfeeding; however, protocol violationsindicate a need for further exploration of the accept-ability of cup-feeding. While the evidence for nippleconfusion and cup-feeding is limited, there may be arisk in removing cups from this environment alto-gether as this may reinforce a culture of bottle-feeding. Neonatal staff have expressed concernsabout the psychological impact supplementing bybottle may have on the mother especially if she ishaving difficulty with breastfeeding (McInnes, unpub-lished) and while this may be the case, it has notreceived any attention in the research literature. Thepossibility that cup-feeding unnecessarily complicatesbreastfeeding should also be considered. The evi-dence from this review suggests that it is essential toexplore the use of cup-feeding in more detail from theperspective of both the mother and NU staff.

Dummy use is part of the ‘nipple confusion’ debate;however, none of the studies reviewed provideduseful evidence on the impact of dummies on breast-feeding in the NU because of study design, protocolviolations and very few mothers achieving full breast-feeding and/or maintaining breastfeeding once home(Mosley et al. 2001; Collins et al. 2004). Dummy usehas not been consistently associated with breastfeed-ing duration in healthy term babies (Renfrew et al.

2005); however, comparison between dummy use interm healthy infants and their use for preterm orLBW babies may be unhelpful. In NU, dummies areoften used to enable non-nutritive sucking (NNS),and a review of this practice (Pinelli & Symington2005) demonstrated that NNS was associated withsignificantly reduced hospital stay and improved tran-sition to bottle-feeding but did not include breast-feeding as an outcome. Further research is needed toidentify potential effects on breastfeeding of pretermNNS devices for ill or ventilated babies.

Given that expressing breast milk may be the mostimportant thing a mother can do for her pre-terminfant, there has been very little research into thisarea. Mothers speak of frustration and lack of supportwhen expressing (Jaeger et al. 1997) but those whosucceed experience a sense of satisfaction or reward



(Miracle et al. 2004; Bernaix et al. 2006). In the studiesin this review, however, the authors reported thatalthough mothers appeared motivated to express,they rarely did so at the level recommended in thestudy protocol, which warrants further investigation.The frequency of expressing recommended by healthprofessionals in these studies varied from four toeight times per day. There also appears to be littleconsensus in the published literature regarding fre-quency 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 breastsuggests that frequency of expressing may not beabsolute (Hartmann et al. 2003) and although 8–10times per day may be required to initiate lactationonce milk supply is established (a few days to2 weeks), frequency may then depend on breaststorage capacity (Spatz 2006). In addition, there wasno consensus on whether individual pumping sessionsshould be for a set period of time or until milk stopsflowing, or whether short-frequent pumping is prefer-able to longer less frequent sessions. Interventions,such as relaxation, visualization and back massage arethought to increase milk supply but were not identi-fied in this literature search. Neither were any studieswhich evaluated the use of hand expression a methodsometimes favoured by mothers especially whenexpressing very small amounts of milk in the earlydays.

The production of sufficient breast milk is impor-tant for all mothers expressing breast milk for theirinfant in the NU. However, the stressful environmentof the NU, separation of the mother from her infantand the need to stimulate and maintain lactationsolely by milk expression can cause milk supply prob-lems. For mothers who are unable to meet theirinfant’s needs, even small increases in expressed milkare important. For those mothers pharmacologicalintervention may be required and there is some evi-dence that short-term use of Domperidone orGrowth Hormone may be beneficial. However, long-term use of these or their impact on breastfeeding wasnot evaluated. Milk supply is affected by the fre-quency 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 3hours (Fewtrell et al. 2006) or 5–6 times a day, (Gunnet al. 1996) although two studies did not give anyinformation. A comparison of the effectiveness ofgalactogogues with other techniques to increase milksupply, such as increasing the frequency of expressingand/or additional support, is recommended.

Limitations

This review is restricted to experimental studies thatevaluated the impact of an intervention on breast-feeding or breast milk supply; thus, non-experimentalstudies and those which did not have breastfeeding orbreast milk as an outcome were not included. Quali-tative studies which explore the beliefs and experi-ences of parents and staff, were included in aqualitative synthesis published elsewhere (McInnes& Chambers 2006). This review was one of series ofreviews conducted concurrently and in order to beconsistent this dictated a number of limitations to oursearch strategy. Thus, we only included published lit-erature, the search commenced from 1990, and weincluded only papers published in English. When weupdated our search in December 2007, we did notidentify any non-English publications (from 1990 to2007) which fulfilled our inclusion criteria. The popu-

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 beenestablished 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



lation group of mainly preterm infants may limit thegeneralizability to other infant groups in the NU.

The studies varied widely in intervention type,duration (of intervention and of data collection) andoutcomes (type of outcome and time of collection),and many studies did not examine potential con-founding variables, such as population demographics.All of this makes it difficult to draw any firm conclu-sions about effective practice. Of the papers reviewedin full the majority (13 out of 18) of the studies hadsmall sample sizes (<100), making the results less gen-eralizable. Finally, because of the specific nature ofsome of the interventions, the results may not be gen-eralizable to other populations or cultures.

Fourteen of the 18 papers in this review reported‘breastfeeding’ as an outcome although only twopapers (Pinelli et al. 2001; Collins et al. 2004) used aninternationally recognized definition for breastfeed-ing (Labbok & Krasovec 1990; World Health Organi-zation 1991). Only six studies differentiated betweenexclusive and partial breastfeeding; however, it wasalso not clear in many of the studies whether breast-feeding meant feeding at the breast or being fedbreast milk by other means. Future research requiresmore useful definitions of breastfeeding. Simply usingthe definitions applied to healthy term infants maynot be helpful for the preterm/sick infant as it isimportant to differentiate between whether an infantwas fed breast milk by bottle, tube or cup andat-breast breastfeeding. It is accepted that manypreterm/sick infants will receive some breast milkduring their hospitalization but it is also clear that fewgo on to breastfeed despite the known advantages ofbreastfeeding (at the breast) over breast milk feeding(by bottle, cup or tube) (Buckley & Charles 2006).

Conclusion

Current recommendations for increasing breastfeed-ing among term healthy infants suggest that effectiveinterventions should be identified and that each area(geographical and clinical) should consider the bestpackage of interventions for their population groupand that this should be informed by the views ofpractitioners 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 toidentify the best approach to supporting mothers infeeding their infants. In the environment of the NU, itmay be necessary to consider feeding alongside theother aspects of parenting a small, sick or preterminfant. Given the physical and emotional benefits ofexpressing and breastfeeding for both the infant andthe mother, future interventions should work towardssupporting mothers to express milk where requiredand should identify ways to maximize milk produc-tion in terms of both volume and duration. Once theinfant is able to feed at the breast, effective strategiesneed to be developed to support the mother in thisimportant step to ensure effective breastfeeding andthe mother’s confidence in her role.

Conflicts of interest

None declared.

References

Agrasada G.V., Gustafsson J., Kylberg E. & Ewald U.(2005) Postnatal peer counselling on exclusive breast-feeding of low-birthweight infants: a randomized, con-trolled trial. Acta Paediatrica 94, 1109–1115.

Key messages

• Human milk is the optimal form of nutritionfor the preterm or LBW neonate and althoughmany mothers will express breast milk fortheir infant few go on to breastfeed.• Interventions to promote breastfeeding inthe NU appear to be task orientated and lackconsistency.• There are substantial gaps in our knowledgeof what aids breastfeeding in the NU and moreresearch is needed to identify what practicesare effective in supporting breastfeeding in theNU.• Currently skin-to-skin and/or postnatalsupport offers the most promise for increasingbreastfeeding for the preterm/LBW infant.



Anderson P., Doyle L. & the Victoria Infant CollaborativeStudy Group. (2003) Neurobehavioural outcomes ofschool-age children born extremely low birthweight orvery preterm in the 1990s. Journal of the AmericanMedical Association 289, 3264–3272.

Bernaix L.W., Schmidt C.A., Jamerson P.A., Seiter L. &Smith J. (2006) The NICU experience of lactation andits relation to family management style. Maternal ChildNursing 31, 95–100.

Bhutta A.T., Cleves M.A., Casey P.H., Cradock M. &Anand K.J.S. (2002) Cognitive and behavioural outcomesof school-aged children who were born preterm. Journalof the American Medical Association 288, 728–737.

Blaymore Bier J-A, Ferguson A.E., Morales Y., LieblingJ.A., Archer D., Oh W. et al. (1996) Comparison of skin-to-skin contact with standard contact in low-birth-weightinfants who are breastfed. Archives of Pediatric andAdolescent Medicine 150, 1265–1269.

Bolling K., Grant C., Hamlyn B. & Thornton A. (2007)Infant Feeding Survey 2005, The Information Centre.Available at: http://www.ic.nhs.uk/webfiles/publications/breastfeed2005/InfantFeedingSurvey190506_PDF.pdf

Britten J., Hoddinott P. & McInnes R. (2006) Breastfeed-ing peer support: health service programmes in Scot-land. British Journal of Midwifery 14, 12–19.

Britton C., McCormick F.M., Renfrew M.J., Wade A. &King S.E. (2006) Support for breastfeeding mothers.Cochrane Database of Systematic Reviews, Issue 1. Art.No.: CD001141. doi: 10:1002/14651858.CD001141.pub3

Buckley K.M. & Charles G.E. (2006) Benefits and chal-lenges of transitioning preterm infants to at-breast feed-ings. International Breastfeeding Journal 1, Issue 13. doi:10.1186/1746-4358-1-13

Centre for Reviews and Dissemination (2001) UndertakingSystematic Reviews of Research on Effectiveness: CRD’sGuidance for Those Carrying out or CommissioningReviews. University of York. Available at: http://www.york.ac.uk/inst/crd/pdf/crd4_ph5.pd

Charpak N. & Ruiz-Paláez J.G. (2006) Resistance toimplementing Kangaroo Mother Care in developingcountries and proposed solutions. Acta Paediatrica 95,529–534.

Collins C.T., Ryan P., Crowther C.A., McPhee A.J.,Paterson S. & Hiller J.E. (2004) Effects of bottles,cups, and dummies on breastfeeding in preterm infants:a randomised controlled trial. British Medical Journal329, 193–198.

Conde-Agudelo A., Diaz-Rossello J.L. & Belizan J.M.(2003) Kangaroo mother care to reduce morbidity andmortality in low birthweight infants. Cochrane Databaseof Systematic Reviews, Issue 2. Art. No: CD002771. doi:10.1002/14651858.CD002771

Dall’Oglio I., Salvatori G., Bonci E., Nantini B.,D’Agostino G. & Dotta A. (2007) Breastfeeding promo-

tion in neonatal intensive care unit: impact of a newprogram toward a BFH1 for high-risk infants. Acta Pae-diatrica 96, 1626–1631.

Dowling D.A., Meier P.P., DiFore J.M., Blatz M. & MartinR.J. (2002) Cup-feeding for preterm infants: mechanicsand safety. Journal of Human Lactation 18, 13–20.

Dykes F. (2005) Government funded breastfeeding peersupport projects: implications for practice. Maternal andChild Nutrition 1, 21–31.

Dyson L., Renfrew M.J., McFadden A., McCormick F.,Herbert G. & Thomas J. (2006) Promotion of Breast-feeding Initiation and Duration. Evidence into practicebriefing, National Institute for Clinical Excellence, UK.Available at: http://www.nice.org.uk

Fenton T.R., Tough S.C. & Belik J. (2000) Breast milksupplementation for preterm infants: parental prefer-ences and post-discharge lactation duration. AmericanJournal of Perintology 17, 329–333.

Fewtrell M.S., Lucas P., Collier S., Singhal A., AhluwaliaJ.S. & Lucas A. (2001) Randomised trial comparing theefficacy of a novel manual breast pump with a standardelectric breast pump in mothers who delivered preterminfants. Pediatrics 107, 1291–1297.

Fewtrell M.S., Loh K.L., Blake A., Ridout D.A. &Hawdon J.M. (2006) Randomised double blindtrial of oxytocin nasal spray in mothers expressingbreast milk for preterm infants. Archives of Disease inChildhood Fetal Neonatal Edition 91, F169–F174.

Flacking R., Ewald U., Hedberg Nyqvist K. & Starrin B.(2006) Trustful bonds: a key to ‘becoming a mother’ andto reciprocal breastfeeding. Stories of mothers of verypreterm infants at a neonatal unit. Social Science andMedicine 62, 70–80.

Flint A., New K. & Davies M.W. (2007) Cup feedingversus other forms of supplemental enteral feeding fornewborn infants unable to fully breastfeed (Review).Cochrane Database of Systematic Reviews, Issue 2. Art.No. CD005092. doi: 10.1002/14651858

Furman L., Minich N. & Hack M. (2002) Correlates of lac-tation in mothers of very low birthweight infants. Pediat-rics 109, e57.

Gilks J. & Watkinson M. (2004) Improving breastfeedingrates in preterm babies: cup feeding versus bottlefeeding. Journal of Neonatal Nursing 10, 118–120.

Gonzalez K.A., Meinzen-Derr J., Burke B.L., Hibler A.J.,Kavinsky B., Hess S. et al. (2003) Evaluation of a lactationsupport service in a children’s hospital neonatal intensivecare unit. Journal of Human Lactation 19, 286–292.

Groh-Wargo S., Toth A., Mahoney K., Simonian S., WasserT. & Rose S. (1995) The utility of a bilateral breastpumping system for mothers of premature infants. Neo-natal Network 14, 31–36.

Gunn A.J., Gunn T.R., Rabone D.L., Breier B.H., BlumW.F. & Gluckman P.D. (1996) Growth hormone



http://www.ic.nhs.uk/webfiles/publications

http://www.york.ac.uk/inst/crd/pdf/crd4_ph5.pd

http://www.york.ac.uk/inst/crd/pdf/crd4_ph5.pd

http://www.nice.org.uk

increases breast milk volumes in mothers of preterminfants. Pediatrics 98, 279–282.

Gunn T.R., Thompson J.M.D., Jackson H., McKnight S.,Buckthought G. & Gunn A.J. (2000) Does early hospitaldischarge with home support of families with preterminfants affect breastfeeding success? A randomised trial.Acta Paediatrica 89, 1358–1363.

Hansen W.H., McAndrew S., Harris K. & ZimmermanM.B. (2005) Metoclopramide effect on breastfeeding thepreterm infant: a randomised trial. Obstetrics and Gyne-cology 105, 383–389.

Hartmann P.E., Cregan M.D., Ramsay D.T., Simmer K. &Kent J.C. (2003) Physiology of lactation in pretermmothers: initiation and maintenance. Pediatric Annals 32,351–355.

Hedberg Nyqvist K., Sjoden P. & Ewald U. (1994) Mothersadvice about facilitating breastfeeding in a NeonatalIntensive Care Unit. Journal of Human Lactation 10,237–243.

Higgins J.P.T. & Green S. (eds) (2006) Cochrane Hand-book for Systematic Reviews of Interventions 4.2.6. JohnWiley & Sons: Chichester, UK. Available at: http://www.cochrane.org/resources/handbook/Handbook4.2.6Sep2006.pdf

Hurst N.M., Valentine C.J., Renfro L., Burns P. & Ferlic L.(1997) Skin-to-skin holding in the neonatal intensivecare unit influences maternal milk volume. Journal ofPerinatology 17, 213–217.

Hurst N.M., Meier P.P., Engstrom J.L. & Myatt A. (2004)Mothers performing in-home measurement of milkintake during breastfeeding of their preterm infants:maternal reactions and feeding outcomes. Journal ofHuman Lactation 20, 178–187.

Jaeger M.C., Lawson M. & Filteau S. (1997) The impact ofprematurity and neonatal illness on the decision tobreastfeed. Journal of Advanced Nursing 25, 729–737.

Jones E. & Spencer S.A. (2007) Optimising theprovision of human milk for preterm infants. Archives ofDisease in Childhood Fetal and Neonatal Edition 92,236–238.

Jones E., Dimmock P.W. & Spencer S.A. (2001) A ran-domised controlled trial to compare methods of milkexpression after preterm delivery. Archives of Disease inChildhood Fetal Neonatal Edition 85, F91–F95.

Klassen A.F., Lee S.K., Raina P., Chan H.W.P., Mathew D.& Brabyn D. (2004) Health status and health-related quality of life in a population-based sample ofneonatal intensive care graduates. Pediatrics 113, 594–600.

Kliethermes P.A., Cross M., Lanese M.G., Johnson K.M. &Simon S.D. (1999) Transitioning preterm infants withnasogastric tube supplementation: increased likelihoodof breastfeeding. Journal of Obstetrics, Gynecology andNeonatal Nursing 28, 264–273.

Knight C.H., Peaker M. & Wilde C.J. (1998) Local controlof mammary development and function. Reviews ofReproduction 3, 104–112.

Labbok M. & Krasovec K. (1990) Toward consistency inbreastfeeding definitions. Family Planning 21, 226–230.

Lupton D. & Fenwick J. (2001) They’ve forgotten that I’ma mum: constructing and practising motherhood inspecial care nurseries. Social Science and Medicine 53,1011–1021.

McInnes R.J. & Chambers J.A. (2006) A Synthesis ofQualitative Studies Exploring Psychosocial Factors Relat-ing to Infant Feeding and the Breastfeeding of Babies inNeonatal Units 1990–2005. NHS Health Scotland: Edin-burgh. Available at: http://www.healthscotland.com/documents/1701.aspx

Meier P.P., Brown L.P., Hurst N.M., Spatz D.L., EngstromJ.L., Borucki L.C. et al. (2000) Nipple shields for preterminfants: effect on milk transfer and duration of breast-feeding. Journal of Human Lactation 16, 106–114.

Meier P.P., Engstrom J.L., Mingolelli S.S., Miracle D.J. &Kiesling S. (2004) The Rush Mothers’ Milk Club: breast-feeding interventions for mothers with very-low-birth-weight infants. Journal of Obstetrics, Gynecology andNeonatal Nursing 33, 164–174.

Merewood A., Philipp B.L., Chawla N. & Cimo S. (2003)The Baby Friendly Hospital Initiative increases breast-feeding rates in a US neonatal intensive care unit.Journal of Human Lactation 19, 166–171.

Merewood A., Chamberlain L.B., Cook J.T., Philipp B.L.,Malone K. & Bauchner H. (2006) The effect of peercounselors on breastfeeding rates in the neonatal inten-sive care unit. Archives of Pediatric and AdolescentMedicine 160, 681–685.

Miracle D.J., Meier P.P. & Bennett P.A. (2004) Mothers’decisions to change from formula to mothers’ milk forVLBW babies. Journal of Gynecology and NeonatalNursing 33, 692–703.

Moore E.R., Anderson G.C. & Bergamn N. (2007). Earlyskin-to-skin contact for mothers and their healthynewborn infants. Cochrane Database of SystematicReviews, Issue 2. Art. No. CD003519. doi: 10.1002/14651858

Moser K., Power C. & Li L. (2003) Social inequalities inlow birthweight in England and Wales: trends and impli-cations for future population health. Journal of Epidemi-ology and Community Health 57, 687–691.

Mosley C., Whittle C. & Hicks C. (2001) A pilot study toassess the viabiity of a randomised controlled trial ofmethods of supplementary feeding of breast-fed pre-term babies. Midwifery 17, 150–157.

Neifert M., Lawrence R.A. & Seacat J. (1995) Nipple con-fusion: toward a formal definition. Journal of Pediatrics126, S125–S129.



http://www.cochrane.org/resources/handbook

http://www.cochrane.org/resources/handbook

http://www.healthscotland.com

Nyström K. & Axelsson K. (2002) Mothers’ experienceof being separated from their newborn. Journal ofObstetrics, Gynecology and Neonatal Nursing 31, 275–282.

Oddy W.H. & Glenn K. (2003) Implementing the BabyFriendly Hospital Initiative: the role of finger feeding.Breastfeeding Review 11, 5–9.

Örtenstrand A., Waldenström U. & Winbladh B. (1999)Early discharge of preterm infants needing limitedspecial care, followed by domiciliary nursing care. ActaPaediatrica 88, 1024–1030.

Örtenstrand A., Winbladh B., Nordström G. & Walden-ström U. (2001) Early discharge of preterm infants fol-lowed by domiciliary nursing care: patients’ anxiety,assessment of infant health and breastfeeding. ActaPaediatrica 90, 1190–1195.

Pinelli J. & Symington A. (2005) Non-nutritive sucking forpromoting physiologic stability and nutrition in preterminfants. Cochrane Database of Systematic Reviews, Issue4. Art. No. CD001071. doi: 10.1002/14651858.CD001071.pub2.

Pinelli J., Atkinson S.A. & Saigal S. (2001) Randomisedtrial of breastfeeding support in very low birth weightinfants. Archives of Pediatric and Adolescent Medicine155, 548–553.

Renfrew M.J., Dyson L., Wallace L.M., D’Souza L.,McCormick F. & Spiby H. (2005) The Effectiveness ofPublic Health Interventions to Promote the Duration ofBreastfeeding: Systematic Reviews of the Evidence.National Institute for Health and Clinical Excellence:London. Available at: http://www.nice.org.uk.

Rey E. & Martinez H. (1983) Manejo Racional del ninoPremature. Universidad Nacional: Bogota.

Roberts K.L., Paynter C. & McEwan B. (2000) A compari-son of Kangaroo Mother Care and conventional cud-dling care. Neonatal Network 19, 31–35.

Rojas M.A., Kaplan M., Quevedo M., Sherwonit E., FosterL.B., Ehrenkranz R.A. et al. (2003) Somatic growth ofpreterm infants during skin-to-skin care versus tradi-tional holding: a randomised controlled trial. Develop-mental and Behavioural Pediatrics 24, 163–168.

Roller C.G. (2005) Getting to know you: mothers’ experi-ences of Kangaroo Care. Journal of Obstetrics, Gynecol-ogy and Neonatal Nursing 34, 210–217.

Ryan A.S. (1997) Resurgence of breastfeeding in theUnited States. Pediatrics 99, e12.

SIGN (2004) Scottish Intercollegiate Network Guidelines(SIGN), Scotland. Available at: http://www.sign.ac.uk/guidelines/fulltext/50/section6.html

Schanler R.J., Hurst N.M. & Lau C. (1999) The use ofhuman milk and breastfeeding in premature infants.Clinical Perinatology 25, 379–397.

Spatz D.L. (2006) State of the science: use of human milkand breast-feeding for vulnerable infants. Journal ofPerinatal and Neonatal Nursing 20, 51–55.

Spencer N., Bambang S., Logan S. & Leicester G. (1999)Socioeconomic status and birth weight: comparison ofan area-based measure with the Registrar General’ssocial class. Journal of Epidemiology and CommunityHealth 53, 495–498.

Stein R.E.K., Siegel M.J. & Bauman L.J. (2006) Are chil-dren of moderately low birth weight at increased risk forpoor health? A new look at an old question. Pediatrics118, 217–223.

Wahlberg V., Affonso D.D. & Persson B. (1992) A retro-spective, comparative study using the Kangaroo Methodas a complement to the standard incubator care. Euro-pean Journal of Public Health 2, 34–37.

Wallin L., Rudberg A. & Gunningberg L. (2005) Staffexperiences in implementing guidelines for KangarooMother Care – a qualitative study. International Journalof Nursing Studies 42, 61–73.

Wilde C.J., Addey C.C., Bryson J.M., Finch L.M., KnightC.H. & Peaker M. (1998) Autocrine regulation of milksecretion. Biochemical Society of Symposium 63, 81–90.

World Health Organization (1991) Indicators for AssessingBreast-Feeding Practice. WHO: Geneva.

da Silva O.P., Knoppert D.C., Angelini M.M. & Forret P.A.(2001) Effect of domperidone on milk production inmothers of premature newborns: a randomised, double-blind, placebo-controlled trial. Canadian Medical Asso-ciation Journal 164, 17–21.



http://www.nice.org.uk

http://www.sign.ac.uk

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)P

ract

isin

gM

idw

ife;

5(4)

:18–

20.

Pro

mot

ing

succ

essf

ulpr

eter

mbr

east

feed

ing:

part

1.N

otan

inte

rven

tion

stud

yJo

nes

L.S

penc

erA

.(20

02)

Pra

ctis

ing

Mid

wif

e;5(

5):2

2–4.

Pro

mot

ing

succ

essf

ulpr

eter

mbr

east

feed

ing:

part

2.N

otan

inte

rven

tion

stud

yJo

nes

L.S

penc

erA

.(20

02)

Pra

ctis

ing

Mid

wif

e;5(

6):1

8–9.

Est

ablis

hing

succ

essf

ulpr

eter

mbr

east

feed

ing:

part

3.N

otan

inte

rven

tion

stud

yK

enne

dyT

S.O

akla

ndM

J.Sh

awR

D.N

utri

tion

inC

linic

alP

ract

ice.

2000

;15

(1):

30–5

.A

nutr

itio

nin

terv

enti

onw

ith

fam

ilies

oflo

w-b

irth

-wei

ght

infa

nts.

Bre

astf

eedi

ngor

brea

stm

ilkno

tan

outc

ome

Mar

inel

liK

A,B

urke

GS,

Dod

dV

L(2

001)

.Jou

rnal

ofP

erin

atol

ogy;

21(6

):35

0–35

5.A

com

pari

son

ofth

esa

fety

ofcu

p-fe

edin

gsan

dbo

ttle

-fee

ding

sin

prem

atur

ein

fant

sw

hose

mot

hers

inte

ndto

brea

stfe

edB

reas

tfee

ding

orbr

east

milk

not

anou

tcom

eM

cCai

nG

C(1

995)

Jour

nalo

fP

edia

tric

Nur

sing

,10(

1):3

–8.

Pro

mot

ion

ofpr

eter

min

fant

nipp

lefe

edin

gw

ith

non-

nutr

itiv

esu

ckin

g.B

reas

tfee

ding

orbr

east

milk

not

anou

tcom

eM

cCai

nG

C.G

arts

ide

PS.

2002

New

born

and

Infa

ntN

ursi

ngR

evie

ws;

2(3)

:18

7–93

.B

ehav

iora

lres

pons

esof

pret

erm

infa

nts

toa

stan

dard

-car

ean

dse

mi-

dem

and

feed

ing

prot

ocol

.B

reas

tfee

ding

orbr

east

milk

not

anou

tcom

e?M

cCai

nG

C.G

arts

ide

PS.

Gre

enbe

rgJM

.Lot

tJW

.(20

01)

Jour

nalo

fP

edia

tric

s;13

9(3)

:374

–9.

Afe

edin

gpr

otoc

olfo

rhe

alth

ypr

eter

min

fant

sth

atsh

orte

nsti

me

toor

alfe

edin

g.[s

eeco

mm

ent]

.B

reas

tfee

ding

orbr

east

milk

not

anou

tcom

e?M

eier

PP.

(200

3)P

edia

tric

Ann

als.

Vol

.32(

5):3

17–3

25.

Supp

orti

ngla

ctat

ion

inm

othe

rsw

ith

very

low

birt

hw

eigh

tin

fant

s.N

otan

inte

rven

tion

stud

yM

eier

PP.

Eng

stro

mJL

.Man

gurt

enH

H.E

stra

daE

.Zim

mer

man

B.K

oppa

rthi

R.J

(199

3)O

bste

tG

ynec

olN

eona

talN

urs.

22(4

):33

8–47

.B

reas

tfee

ding

supp

ort

serv

ices

inth

ene

onat

alin

tens

ive-

care

unit

.N

otan

inte

rven

tion

stud

y



App

endi

x1.

cont

.A

utho

r&

cita

tion

Tit

leR

easo

nno

tin

clud

ed

Mei

erP

P.E

ngst

rom

JL.M

ingo

lelli

SS.M

irac

leD

J.K

iesl

ing

S.(2

004)

JOG

NN

–Jo

urna

lof

Obs

tetr

ic,G

ynec

olog

ic,&

Neo

nata

lNur

sing

.33(

2):1

64–7

4.T

heR

ush

Mot

hers

’Milk

Clu

b:br

east

feed

ing

inte

rven

tion

sfo

rm

othe

rsw

ith

very

-low

-bir

th-w

eigh

tin

fant

s.In

terv

enti

onev

alua

ted

byre

tros

pect

ive

case

note

anal

ysis

wit

hno

com

pari

son

grou

pM

eier

PP.

Lys

akow

skiT

Y.E

ngst

rom

JL.K

avan

augh

KL

.Man

gurt

enH

H.

(199

0)J

Ped

iatr

Gas

troe

nter

olN

utr;

10(1

):62

–5.

The

accu

racy

ofte

stw

eigh

ing

for

pret

erm

infa

nts.

Bre

astf

eedi

ngor

brea

stm

ilkno

tan

outc

ome

Mey

erE

C.C

ollC

T.L

este

rB

M.B

ouky

dis

CF.

McD

onou

ghSM

.Oh

W.(

1994

)P

edia

tric

s;93

(2):

241–

6.Fa

mily

-bas

edin

terv

enti

onim

prov

esm

ater

nalp

sych

olog

ical

wel

l-be

ing

and

feed

ing

inte

ract

ion

ofpr

eter

min

fant

s.B

reas

tfee

ding

orbr

east

milk

not

anou

tcom

eM

eza

CV

,Pow

ellN

J,C

ovin

gton

C(1

998)

Occ

upat

iona

lThe

rapy

Jour

nalo

fR

esea

rch,

18(3

):71

–83.

The

influ

ence

ofol

fact

ory

inte

rven

tion

onno

n-nu

trit

ive

suck

ing

skill

sin

apr

emat

ure

infa

nt.

Bre

astf

eedi

ngor

brea

stm

ilkno

tan

outc

ome

Mile

sR

.,C

owan

F.,G

love

rV

.,et

al.(

2006

)E

arly

Hum

anD

evel

opm

ent;

82(7

):44

7–45

5.A

cont

rolle

dtr

ialo

fsk

in-t

o-sk

inco

ntac

tin

extr

emel

ypr

eter

min

fant

s.N

oin

fant

feed

ing

data

pres

ente

d(a

utho

rco

ntac

ted

but

nore

ply)

Min

chin

M.M

inog

ueC

.Mee

han

M.M

cDon

nell

G.S

haw

S.D

onoh

ueL

.C

ampb

ellN

.Wat

kins

A.(

1996

)B

reas

tfee

ding

Rev

iew

;4(2

):87

–8.

Exp

andi

ngth

eW

HO

/UN

ICE

FB

aby

Frie

ndly

Hos

pita

lIni

tiat

ive

(BF

HI)

:el

even

step

sto

opti

mal

infa

ntfe

edin

gin

apa

edia

tric

unit

.N

otan

inte

rven

tion

stud

y

Mor

ton

JA.(

2003

)P

edia

tric

Ann

als;

32(5

):30

8–31

6.T

hero

leof

the

pedi

atri

cian

inex

tend

edbr

east

feed

ing

ofth

epr

eter

min

fant

.N

otan

inte

rven

tion

stud

yM

usok

eR

N.(

1990

)In

tJ

Gyn

aeco

lObs

tet;

31Su

ppl1

:57–

9.B

reas

tfee

ding

prom

otio

n:fe

edin

gth

elo

wbi

rth

wei

ght

infa

nt.

Not

anin

terv

enti

onst

udy

Nyq

vist

KH

,Ew

ald

U.A

cta

Pae

diat

r19

99;8

8(1

1):1

194–

1203

.In

fant

&m

ater

nalf

acto

rsin

the

deve

lopm

ent

ofB

Fbe

havi

our

&B

Fou

tcom

ein

pret

erm

infa

nts.

Not

anin

terv

enti

onst

udy

Nyq

vist

KH

.(20

02)

Jour

nalo

fP

edia

tric

Nur

sing

;17(

4):2

46–5

6.B

reas

tfee

ding

inpr

eter

mtw

ins:

Dev

elop

men

tof

feed

ing

beha

vior

and

milk

inta

kedu

ring

hosp

ital

stay

and

rela

ted

care

givi

ngpr

acti

ces.

Not

anin

terv

enti

onst

udy

Nyq

vist

KH

.Ew

ald

U.S

jode

nP

O.J

Hum

Lac

t.12

(3):

221–

8,19

96Se

p.Su

ppor

ting

apr

eter

min

fant

’sbe

havi

our

duri

ngbr

east

feed

ing:

aca

sere

port

.N

otan

inte

rven

tion

stud

yN

yqvi

stK

H.S

tran

dell

E.J

ourn

alof

Neo

nata

lNur

sing

.199

9M

ar;5

(2):

31–6

.A

cup

feed

ing

prot

ocol

for

neon

ates

:eva

luat

ion

ofnu

rses

’and

pare

nts’

use

oftw

ocu

ps.

Not

anin

terv

enti

onst

udy

Pau

lVK

,Sin

ghM

,Deo

rari

AK

,Pac

heco

J,Ta

neja

U.(

1996

)In

dian

Jour

nalo

fP

edia

tric

s;63

(1):

87–9

2M

anua

land

pum

pm

etho

dsof

expr

essi

onof

brea

stm

ilk.

Exc

lude

dby

loca

tion

(Ind

ia)

Pan

tazi

M.J

aege

rM

C.L

awso

nM

.(19

98)

Jour

nalo

fH

uman

Lac

tati

on;1

4(4)

:29

1–6

Staf

fsu

ppor

tfo

rm

othe

rsto

prov

ide

brea

stm

ilkin

pedi

atri

cho

spit

als

and

neon

atal

unit

s.N

otan

inte

rven

tion

stud

y

Rit

chie

JF.(

1998

)Jo

urna

lof

Neo

nata

lNur

sing

.Mar

;4(2

):13

–7.

Imm

atur

esu

ckin

gre

spon

sein

prem

atur

eba

bies

:cup

feed

ing

asa

tool

inin

crea

sing

mai

nten

ance

ofbr

east

feed

ing.

Not

anin

terv

enti

onst

udy

Roc

haN

MN

,Mar

tine

zF

E,J

orge

SM.(

2002

)Jo

urna

lof

Hum

anL

acta

tion

;18

(2):

132–

138.

Cup

orbo

ttle

for

pret

erm

infa

nts:

effe

cts

onox

ygen

satu

rati

on,w

eigh

tga

inan

dbr

east

feed

ing

Exc

lude

dby

loca

tion

(Bra

zil)

Ros

sE

S.B

row

neJV

.200

2.Se

min

ars

inN

eona

tolo

gy.7

(6):

469–

75.

Dev

elop

men

talp

rogr

essi

onof

feed

ing

skill

s:an

appr

oach

tosu

ppor

ting

feed

ing

inpr

eter

min

fant

s.N

otan

inte

rven

tion

stud

y

Sank

aran

K.P

apag

eorg

iou

A.N

inan

A.S

anka

ran

R(1

996)

.Jou

rnal

ofth

eA

mer

ican

Die

teti

cA

ssoc

iati

on.9

6(11

):11

45–9

.A

rand

omiz

ed,c

ontr

olle

dev

alua

tion

oftw

oco

mm

erci

ally

avai

labl

ehu

man

brea

stm

ilkfo

rtifi

ers

inhe

alth

ypr

eter

mne

onat

es.

Bre

astf

eedi

ngor

brea

stm

ilkno

tan

outc

ome



App

endi

x1.

cont

.A

utho

r&

cita

tion

Tit

leR

easo

nno

tin

clud

ed

Saun

ders

RB

,Fri

edm

anC

B,S

tram

oski

PR

(199

1)Jo

urna

lof

Obs

tetr

ic,

Gyn

ecol

ogic

,&N

eona

talN

ursi

ng.2

0(3)

:212

–8.

Feed

ing

pret

erm

infa

nts:

sche

dule

orde

man

d?B

reas

tfee

ding

orbr

east

milk

not

anou

tcom

eSc

hubi

ger

G.S

chw

arz

U.T

onz

O(1

997)

Eur

opea

nJo

urna

lof

Ped

iatr

ics.

156(

11):

874–

7.U

NIC

EF

/WH

Oba

by-f

rien

dly

hosp

ital

init

iati

ve:d

oes

the

use

ofbo

ttle

san

dpa

cifie

rsin

the

neon

atal

nurs

ery

prev

ent

succ

essf

ulbr

east

feed

ing?

Neo

nata

lStu

dyG

roup

.

Not

base

din

ane

onat

alun

it(t

erm

heal

thy

infa

nts

inpo

stna

tal

war

d)Si

ddel

lE,M

arin

elli

K,F

rom

anR

D,e

tal.

(200

3)Jo

urna

lof

Hum

anL

acta

tion

,19

(3):

293–

302.

Eva

luat

ion

ofan

educ

atio

nali

nter

vent

ion

onbr

east

feed

ing

for

NIC

Unu

rses

.B

reas

tfee

ding

orbr

east

milk

not

anou

tcom

eSi

skP

M.L

ovel

ady

CA

.Dill

ard

RG

.Adv

ance

sin

Exp

erim

enta

lMed

icin

e&

Bio

logy

.554

:307

–11,

2004

.USA

Eff

ect

ofed

ucat

ion

and

lact

atio

nsu

ppor

ton

mat

erna

ldec

isio

nto

prov

ide

hum

anm

ilkfo

rve

ry-l

ow-b

irth

-wei

ght

infa

nts.

Com

pari

son

stud

y

Sisk

PM

.Lov

elad

yC

A.D

illar

dR

G,G

rube

rK

J.(2

006)

.Ped

iatr

ics;

117(

1):

e67-

e75

Lac

tati

onco

unse

lling

for

mot

hers

ofve

rylo

wbi

rthw

eigh

tin

fant

s:ef

fect

onm

ater

nala

nxie

tyan

din

fant

inta

keof

hum

anm

ilkFe

edin

gou

tcom

ere

late

dto

inte

ntio

nra

ther

than

inte

rven

tion

Sloa

nN

L,C

amac

hoLW

L,R

ojas

EP,

Ster

nC

.(19

94)

Lan

cet;

344:

782–

785.

Kan

garo

om

othe

rm

etho

d:an

RC

Tof

anal

tern

ativ

em

etho

dof

care

for

stab

ilise

dL

BW

Infa

nts.

Exc

lude

dby

loca

tion

(Euc

ador

)Sp

atz

DL

.(20

04)

Jour

nalo

fP

erin

atal

&N

eona

talN

ursi

ng.1

8(4)

:385

–96.

Ten

step

sfo

rpr

omot

ing

and

prot

ecti

ngbr

east

feed

ing

for

vuln

erab

lein

fant

s.N

otan

inte

rven

tion

stud

ySp

atz

DL

.(20

05)

Jour

nalo

fP

erin

atal

Edu

cati

on;1

4(1)

:30–

8.R

epor

tof

ast

aff

prog

ram

topr

omot

ean

dsu

ppor

tbr

east

feed

ing

inth

eca

reof

vuln

erab

lein

fant

sat

ach

ildre

n’s

hosp

ital

.N

otan

inte

rven

tion

stud

y

War

ren

I.Ta

nG

C.D

ixon

PD

.Gha

usK

.(20

00)

Jour

nalo

fN

eona

talN

ursi

ng.

Mar

;6(2

):43

–4,4

6–8.

Bre

astf

eedi

ngsu

cces

san

dea

rly

disc

harg

efo

rpr

eter

min

fant

s:th

ere

sult

ofa

dedi

cate

dbr

east

feed

ing

prog

ram

me.

Not

anin

terv

enti

onst

udy

Whe

eler

JL.J

ohns

onM

.Col

lieL

.Sut

herl

and

D.C

hapm

anC

.(19

99)

Bre

astf

eedi

ngR

evie

w.7

(2):

15–8

.P

rom

otin

gbr

east

feed

ing

inth

ene

onat

alin

tens

ive

care

unit

.N

otan

inte

rven

tion

stud

y

Whi

te-T

raut

RC

.Nel

son

MN

.Silv

estr

iJM

.Vas

anU

.Lit

tau

S.M

elee

dy-R

eyP.

Gu

G.P

atel

M.(

2002

)D

evel

opm

enta

lMed

icin

e&

Chi

ldN

euro

logy

;44(

2):

91–9

7.

Eff

ect

ofau

dito

ry,t

acti

le,v

isua

l,an

dve

stib

ular

inte

rven

tion

onle

ngth

ofst

ay,

aler

tnes

s,an

dfe

edin

gpr

ogre

ssio

nin

pret

erm

infa

nts.

Bre

astf

eedi

ngor

brea

stm

ilkno

tan

outc

ome

Whi

twor

thC

M;T

oppi

ngA

.(19

96)

Jour

nalo

fN

eona

talN

ursi

ng;2

(2):

20–2

3.T

hein

terf

ace

betw

een

polic

y,qu

alit

yan

dre

sear

ch:a

nac

tion

rese

arch

appr

oach

topr

omot

esu

cces

sful

brea

stfe

edin

g.N

otan

inte

rven

tion

stud

y

Wol

dtE

H.(

1991

)N

eona

talN

etw

ork.

9(5)

:53–

56.

Bre

astf

eedi

ngsu

ppor

tgr

oup

inth

eN

ICU

.N

otan

inte

rven

tion

stud

y



Appendix 2: Quality assessment tool

Author:Title:

Methods Quality Assessment Criteria Fully met Partially met Not met Not applicable

Clear aims/hypotheses and objectivesClear description of interventionRecruitment method givenSample size/power calculations givenPopulation demographics givenExplicit inclusion/exclusion criteriaBaseline characteristics statistically equalMethod of allocation describedBlinding of researchersBlinding of participantsGroups treated equally aside from interventionData recorded and presented in detailComplete follow-up with drop-outs fully explainedAttrition rate given for both control and experimental groupAnalysis by intention to treat (N/A for older studies)Analysis appropriate and details givenConclusions substantiated by dataLimitations of study discussedSubject Quality Assessment CriteriaDefinition of breastfeedingFollow-up of authors requiredAuthor 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 applicableitems. For example, if a study did not meet the criteria for sample size calculation, partially met the criteria for demographic data (e.g. some ofthe characteristics of interest may be missing such as ‘age’), and fully met the remaining criteria with the exception of the item ‘analysis byintention 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%



App

endi

x3:

Oth

erst

udie

sno

tin

clud

edin

the

full

arti

cle

(9pa

pers

)C

itat

ion

Cou

ntry

Stud

yty

peQ

ualit

yra

ting

Asp

ect

ofbr

east

feed

ing

Par

tici

pant

sL

ocat

ion

Sam

ple

size

n=

x

Inte

rven

tion

deta

ilsSt

udy

Out

com

e/s

Inte

rven

tion

effe

cton

outc

ome?

Com

men

t

Ear

lyD

isch

arge

Gun

net

al.

(200

0)N

ewZ

eala

ndR

CT

78%

Ear

lydi

scha

rge

wit

hho

me

supp

ort

Pre

term

(<37

wee

ks).

90%

plan

ned

toB

F.66

%of

Eur

opea

nor

igin

s,17

%M

aori

,39%

prim

igra

vid

NIC

U/S

CN

n=

308

Ear

lydi

scha

rge

grou

p:m

etcr

iter

iafo

rdi

scha

rge

wit

hout

need

for

wei

ght

gain

.Vis

ited

daily

for

1st

7–10

days

and

24h

tele

phon

esu

ppor

t.C

ontr

olgr

oup:

disc

harg

edw

hen

mee

ting

crit

eria

and

sust

aine

dpa

tter

nof

wei

ght

gain

BF

dura

tion

BF

excl

usiv

ity

Wei

ght

ofin

fant

No

diff

eren

ceN

odi

ffer

ence

No

diff

eren

ce

Yes

. Ear

lydi

scha

rge

wit

had

equa

tesu

ppor

tdo

esno

tap

pear

toaf

fect

BF

rate

s.T

here

was

ahi

ghra

teof

refu

sals

om

ayno

tbe

acce

ptab

leto

allp

aren

tsN

odi

ffer

ence

inre

-adm

issi

ons

↑m

ater

nals

atis

fact

ion

Ört

enst

rand

etal

.(20

01)

Swed

enQ

uasi

-ex

peri

men

tal

71%

Ear

lydi

scha

rge

(ED

G)

wit

hho

me

supp

ort

and

pare

ntal

anxi

ety

Par

ents

ofpr

eter

min

fant

s(

<37

wee

ks).

65%

prim

ipar

ous,

53%

educ

ated

tohi

ghsc

hool

leve

l,33

%be

yond

high

scho

olN

SCU

/hom

en

=75

ED

G:i

nfan

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illin

need

ofsp

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rem

ainl

yN

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edin

g;ca

repl

anni

ngpr

ior

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rge,

dom

icili

ary

care

and

supp

ort

bym

obile

phon

e.C

ontr

olgr

oup:

rout

ine

care

,hom

efo

rte

stpe

riod

befo

redi

scha

rge,

clin

ical

lyw

ell,

gain

ing

wei

ght,

noN

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eds

Par

enta

lanx

iety

BF

ED

GM

othe

rsle

ssan

xiou

s(s

tate

)at

disc

harg

e(P

<0.

01)

No

sign

ifica

ntdi

ffer

ence

sin

BF

but

tend

ency

tow

ards

less

BF

inE

DG

at6/

12(P

=0.

06)

Poss

ibly

,alt

houg

hve

ryhi

ghB

Fra

tes

and

acu

ltur

eof

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BF

outc

ome

was

only

smal

lpar

tof

the

stud

y

Oth

ersi

ngle

topi

csM

erew

ood

etal

.(20

03)

USA

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si-e

xper

imen

tal

72%

Bab

yFr

iend

lyH

ospi

tal

Init

iati

ve(B

FH

I)

All

babi

esad

mit

ted

toN

ICU

duri

ng19

95(p

re-B

FH

I)or

1999

(pos

tB

FH

I).6

7%bl

ack,

17%

His

pani

c,10

%w

hite

.28%

unin

sure

dN

ICU

n=

227

All

10st

eps

ofth

eB

FH

Ipo

licie

sw

ere

impl

emen

ted

and

the

BF

HI

stat

usw

asgr

ante

din

1999

.Dat

aco

llect

edfr

omal

linf

ants

adm

itte

din

1995

prio

rto

polic

yim

plem

enta

tion

and

1999

follo

win

gB

FH

Ist

atus

bein

gaw

arde

d

BF

init

iati

onA

nyB

Fat

2w

eeks

Exc

lusi

veB

Fat

2w

eeks

Any

BF

at6

wee

ks

↑(P

<0.

001)

↑(P

<0.

001)

↑(N

S)↑

(1/8

vs.6

/9)

Incr

ease

dB

Fas

soci

ated

wit

hB

FH

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atus

.Mot

hers

wer

esu

pplie

dw

ith

elec

tric

pum

psw

hich

mig

htby

them

selv

esha

veim

prov

edB

F.V

ery

smal

lnum

bers

(17)

for

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6w

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.Cul

tura

llyve

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ffer

ent

from

UK

popu

lati

ons

Hur

stet

al.

(200

4)1

USA

RC

T64

%

Test

wei

ghin

gP

rete

rmin

fant

s(3

1–36

wee

ks).

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her

mai

ntai

ned

lact

atio

nin

NIC

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plan

ned

toB

Fpo

stdi

scha

rge.

64%

Cau

casi

an,3

2%A

fric

anA

mer

ican

orH

ispa

nic.

71%

prim

ipar

ous.

20%

prev

ious

BF

expe

rien

ceN

ICU

/hom

en

=46

Inte

rven

tion

:mot

hers

supp

lied

wit

hel

ectr

onic

scal

e&

inst

ruct

edto

test

-wei

ghbe

fore

&af

ter

each

feed

.Sup

plem

ents

dete

rmin

edby

pres

crib

edvo

lum

esin

disc

harg

epl

an&

cons

ulta

tion

wit

hpr

imar

yca

repr

ovid

er.

Con

trol

:Sup

plem

enta

tion

dete

rmin

edon

basi

sof

clin

ical

indi

ces

&co

nsul

tati

onw

ith

prim

ary

care

prov

ider

BF

dura

tion

wit

hre

spec

tto

BF

goal

Wei

ght

gain

BF

conc

erns

Per

cept

ion

ofte

stw

eigh

No

diff

eren

ce(1

/3m

etor

exce

eded

goal

)N

odi

ffer

ence

No

diff

eren

ceSc

ale

was

help

fuli

ntr

ansi

tion

toB

F

Mat

erna

lfee

dbac

ksu

gges

ted

that

this

type

ofin

terv

enti

onsh

ould

bein

divi

dual

ized

.Bot

tles

&ni

pple

shie

lds

wer

eus

eddu

ring

tran

siti

onw

hich

may

have

affe

cted

resu

lts

but

noda

tagi

ven

Thi

sw

asa

smal

lsam

ple

and

com

bine

dw

ith

sam

ple

attr

itio

nre

nder

edfo

llow

-up

ofco

ntin

ued

brea

stfe

edin

gin

adeq

uate

.



App

endi

x3.

cont

.C

itat

ion

Cou

ntry

Stud

yty

peQ

ualit

yra

ting

Asp

ect

ofbr

east

feed

ing

Par

tici

pant

sL

ocat

ion

Sam

ple

size

n=

x

Inte

rven

tion

deta

ilsSt

udy

Out

com

e/s

Inte

rven

tion

effe

cton

outc

ome?

Com

men

t

Dal

l’Ogl

ioet

al.

(200

7)It

aly

Qua

si-e

xper

iem

enta

l60

%

Ase

ries

ofch

ange

sto

prom

ote

BF

New

born

sad

mit

ted

toth

eN

eona

tal

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t.G

esta

tion

rang

e25

–41

wee

ks(m

ean

34+

wee

ks);

birt

hwei

ght

rang

e70

0–42

10(m

ean

2250

+g)

.D

ata

colle

cted

atth

ree

tim

epo

ints

(199

8,20

00,2

002)

NIC

Un

=20

4

Inte

rven

tion

:Dur

ing

1998

:roo

mw

ith

pum

psm

ade

avai

labl

e;in

form

atio

n&

supp

ort

byan

IBC

LC

;sta

fftr

aini

ng.D

urin

g20

00:p

amph

let

onB

Fa

pret

erm

infa

ntfo

rre

lati

ves;

prop

osal

for

sim

ulta

neou

sm

ilkco

llect

ion;

use

ofdo

mpe

rido

ne;w

eekl

yB

Fm

eeti

ngs

wit

hth

em

othe

rs.

Con

trol

:clin

ical

data

colle

cted

for

infa

nts

hosp

ital

ized

inth

efir

st6

mon

ths

of19

98pr

ior

toth

ein

terv

enti

on

Feed

ing

onfir

stda

yho

me

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ing

at1

mon

th>

disc

harg

eFe

edin

gat

2m

onth

s>

disc

harg

e

↑B

F(a

ny)

1998

to20

00(2

1.2

to64

%,P

<0.

01)

↑B

F(a

ny)

1998

to20

02(2

1.2

to51

.2%

,P<

0.05

)N

odi

ffer

ence

2000

to20

02↑

BF

(any

)19

98to

2000

(19.

7%to

46%

P<

0.00

1)↓

BF

(any

)20

00to

2002

(46%

to35

.9%

,P<

0.04

)N

S19

98vs

.200

0vs

.200

2(1

9.7%

vs.4

0%vs

.28.

2%)

The

pres

enta

tion

ofre

sult

sin

this

pape

rw

asdi

fficu

ltto

follo

w.A

tdi

scha

rge

from

the

unit

ther

ew

asan

incr

ease

inan

yB

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tlit

tle

chan

geov

erth

elo

nger

peri

od.I

tw

asno

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leto

stat

ew

hat

elem

ents

ofth

epr

ogra

mm

eof

inte

rven

tion

sw

ere

effe

ctiv

ean

dit

was

also

not

clea

rif

the

inte

rven

tion

sad

ded

betw

een

2000

and

2002

wer

eof

bene

fitor

inde

edha

da

nega

tive

effe

ct.T

heau

thor

ssu

gges

ted

that

this

inte

rven

tion

follo

wed

the

BF

HI

but

asit

did

not

follo

wth

ecl

ear

step

sou

tlin

edin

the

BF

HI

orre

ceiv

ea

BF

HI

awar

dit

coul

dno

tbe

cons

ider

edw

ith

the

abov

epa

per

Klie

ther

mes

etal

.(1

999)

USA

RC

T53

%

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ogas

tric

(NG

)vs

.bot

tle

supp

lem

ent-

atio

nInfa

nts

wei

ghin

g1–

2.5

kgw

hose

mot

hers

plan

ned

toB

F.41

%pr

evio

usB

Fex

peri

ence

Lev

elII

IIn

tens

ive

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eN

urse

ryn

=84

All

part

icip

ants

rece

ived

stan

dard

BF

educ

atio

n,an

elec

tric

pum

p&

wer

eco

ntac

ted

twic

ea

wee

kto

offe

rsu

ppor

t&

enco

urag

emen

t&

colle

ctda

ta.I

fth

em

othe

rw

asno

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aila

ble

for

BF

orif

supp

lem

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requ

ired

1gr

oup

rece

ived

oral

feed

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le&

the

othe

rby

NG

tube

.N

on-n

utri

tion

alsu

ckin

gw

asfa

cilit

ated

byus

eof

finge

rsor

paci

fier.

NG

feed

ing

ceas

edw

hen

mot

her

bega

nro

omin

gin

ther

eaft

ersu

pple

men

tsw

ere

give

nby

cup

orsy

ring

e

BF

prac

tice

Hig

her

BF

rate

sin

NG

grou

pat

allt

imes

(Sig

nific

ant

but

nost

atis

tics

supp

lied)

Met

hod

ofsu

pple

men

tati

onpr

edic

tive

ofB

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tcom

eat

disc

harg

e(P

<0.

0001

),3

days

(P<

0.00

01,3

/12

(P=

0.00

06),

6/12

(P=

0.00

2)

Elim

inat

ion

ofbo

ttle

sfr

ompr

eter

mfe

edin

gre

gim

ere

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men

ded.

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repo

rted

data

and

lack

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finit

ion

offu

ll&

part

ialB

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ffec

tof

paci

fier

use

not

reco

rded

Cup

-fee

ding

used

tofa

cilit

ate

tran

siti

onto

full

BF

inN

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oup

but

noda

taon

this

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ntw

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tH

ospi

tals

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erse

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ts

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eren

ceat

disc

harg

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odi

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ence

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ifica

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but

sign

ifica

ntly

mor

ew

hich

requ

ired

stim

ulat

ion

inN

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oup

Mei

eret

al.(

2000

)U

SAQ

uasi

-exp

erim

enta

l46

%

Use

ofni

pple

shie

lds

(NS)

Pre

term

infa

nts

(25–

37w

eeks

).A

llin

fant

sw

ere

bein

gB

F.71

%w

hite

non-

His

pani

c,21

%A

fric

anA

mer

ican

.41%

twin

s.N

ICU

n=

34

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rosp

ecti

vean

alys

isof

data

ofin

fant

spa

rtic

ipat

ing

inan

othe

rst

udy.

Feed

volu

mes

mea

sure

din

allf

eeds

,dat

aco

llect

edfr

omfe

edim

med

iate

lypr

ior

tous

eof

NS

and

for

1st

feed

usin

gN

S.U

seof

NS

was

indi

cate

dby

adva

nced

prac

tice

nurs

e.M

ilkvo

lum

em

easu

red

byte

stw

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infa

nt.

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nts

self

-con

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led

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ume

ofm

ilktr

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erre

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whe

nN

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ed(P

=0.

0001

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fant

sha

dal

lbee

nra

ndom

ized

to2

diff

eren

tin

terv

enti

ons,

give

nsm

alln

umbe

rsth

ism

ayha

veaf

fect

edre

sult

s.A

llm

othe

rsha

dad

equa

tem

ilksu

pply

,no

evid

ence

that

NS

will

corr

ect

milk

tran

sfer

prob

lem

sif

inad

equa

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pply

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cati

ons

for

NS

use

Dur

atio

nof

NS

use

Dur

atio

nof

BF

60%

poor

latc

h,30

%in

fant

falli

ngas

leep

,9%

othe

r(e

gpa

in)

NS

used

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am

ean

of33

days

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stat

isti

cala

ssoc

iati

onbe

twee

nN

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e&

BF

dura

tion



App

endi

x3.

cont

.C

itat

ion

Cou

ntry

Stud

yty

peQ

ualit

yra

ting

Asp

ect

ofbr

east

feed

ing

Par

tici

pant

sL

ocat

ion

Sam

ple

size

n=

x

Inte

rven

tion

deta

ilsSt

udy

Out

com

e/s

Inte

rven

tion

effe

cton

outc

ome?

Com

men

t

*Fen

ton

etal

.(20

00)

Can

ada

RC

T38

%

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ast

milk

enri

chm

ent

asa

pow

der

vs.a

liqui

dPar

ents

ofV

LB

Win

fant

s(�

1.5

kg)

who

sem

othe

rch

ose

toB

F.35

%ha

dB

Fpr

evio

usly

n=

63fa

mili

es(7

1in

fant

s)N

ICU

Infa

nts

wer

egi

ven

supp

lem

ents

whi

chw

ere

mix

edw

ith

brea

stm

ilk.S

uppl

emen

tsw

ere

eith

erpo

wde

ror

liqui

d.L

iqui

dsu

pple

men

tsw

ere

mix

edw

ith

the

sam

evo

lum

eof

milk

,whi

lepo

wde

rsu

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men

tsre

quir

edto

bem

ixed

wit

hm

ore

brea

stm

ilk

Par

enta

latt

itud

esto

enri

chm

ent

BF

dura

tion

vs.i

nten

ded

dura

tion

Pow

der

pref

erre

dov

erliq

uid

(P<

0.01

)In

fant

sfe

dliq

uid

wer

eB

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orte

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onre

lati

veto

thei

rgo

al(P

<0.

05)

Dur

atio

nof

BF

may

bem

axim

ized

byco

nsid

erin

gpa

rent

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des

toty

peof

enri

chm

ent

and

the

amou

ntof

brea

stm

ilkre

quir

ed

Odd

y&

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n(2

003)

Aus

tral

iaQ

uasi

-exp

erim

enta

l-7

%

Fing

erfe

edin

gA

llpr

eter

m(<

37w

eeks

)ba

bies

born

in19

98or

in20

01Sp

ecia

lCar

eN

urse

ryn

=35

Fing

erfe

edin

gin

trod

uced

aspa

rtof

the

impl

emen

tati

onof

the

Bab

yFr

iend

lyH

ospi

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Documents

Infants admitted to neonatal units – interventions to improve breastfeeding outcomes: a systematic review 1990–2007