Preterm Birth: Strategies for Establishing Adequate Milk Production and Successful Lactation

Seminars in Fetal & Neonatal Medicine 18 (2013) 155e159

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Seminars in Fetal & Neonatal Medicine

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Preterm birth: Strategies for establishing adequate milk production and successful lactation

Donna Geddes a,*, Peter Hartmann a, Elizabeth Jones b a School of Chemistry and Biochemistry, Faculty of Science, The University of Western Australia, M310, 35 Stirling Highway, Crawley, Perth, Western Australia 6009, Australia b Neonatal Unit, Maternity Hospital, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK

summary

Keywords: Whilst human milk has not evolved to meet the unique requirements of the preterm infant there are Breastfeeding unquestionable benefits to be gained via breast milk in terms of the development and health of the Breast milk infant. Many mothers of preterm infants struggle to achieve a full milk production for many reasons the Lactation mechanisms of which are still unclear. Strategies to enhance milk volume include early, frequent Milk expression Preterm simultaneous expression of milk combined with breast massage and a reduction of stress. However, Sucking these are not always successful, therefore a greater understanding of lactation physiology is required to devise more effective interventions to increase milk supply. The difficulty these infants experience transitioning to oral feeding and ultimately full breastfeeding further complicates lactation. In order to improve the health of these already compromised infants it is critical that more research be directed to this area so that they reap all the benefits that can be gained from breastfeeding. Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction 2. Physiology of preterm lactation

A consideration of the strategy for lactation in mammals can be In the extremely preterm infant there are particular difficulties in best described by considering the importance of the evolution of establishing lactation, due to the earlier stage of breast development lactation and how the pre-mammals fitted into a range of environ- at parturition and the inability of the newborn infant to suckle. Some ments that favored their reproductive success. In other vertebrates, mothers may not have reached secretory activation prior to delivery, strategies have been developed that result in the young being either so the mammary epithelium may not be sufficiently prepared by the born or hatched into restricted environments that have sufficient pregnancy hormones to synthesize milk efficiently. Poor placental special foods to ensure the survival of at least some of the young. function with low levels of placental lactogen may exacerbate this Thus numbers of birds and fish return to special breeding grounds to problem.1 Fortunately in the majority of mothers of preterm infants achieve reproductive success. However, mammals do not require compensatory breast growth can be achieved, even if somewhat special breeding grounds because the secretion of milk ensures that delayed, by early and frequent milk removal.2 However, many the young can be fully nourished wherever the adults can thrive. mothers still struggle to produce enough milk to meet their infant’s There is now strong evidence to suggest that the mammary nutritional requirements. The reasons for this are not entirely un- gland evolved from the inflammatory response e the innate im- derstood, but may be related to physiological and emotional chal- mune system e and that the nutrients in milk developed from lenges that mothers face following preterm delivery.3 components of the innate immune system quite late in the pre- mammalian lineage. Therefore mammary secretion first evolved 3. Composition of preterm milk to protect the hatchlings; later, it also provided unique and com- plete nourishment for the young. This has important ramifications The composition of human preterm milk differs from that of for the nourishment of the preterm baby, whose ability to mount a term milk. The reasons for these differences are unclear, but pre- defense against microbial attack is extremely limited. Thus the term milk typically has higher concentrations of protein, secretory protection provided by mother’s milk is vital. IgA and lipids. Protein levels in preterm milk are documented to be 15e20% higher than in term milk, with no differences in the indi- 4 * Corresponding author. Tel.: þ61 8 6888 3327. vidual proteins ; however; epidermal growth factor and secretory 5,6 7 E-mail address: [email protected] (D. Geddes). IgA (sIGA) levels are higher whereas leptin levels are lower. sIgA,

1744-165X/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.siny.2013.04.001 156 D. Geddes et al. / Seminars in Fetal & Neonatal Medicine 18 (2013) 155e159 the major immunoglobulin found in breast milk, provides immune Although a hospital-grade electric breast pump is an effective protection for the infant via the formation of antibodies specificto tool to facilitate the collection of milk, it is essential that the breast those pathogens to which the mother and infant are exposed. Given shield used is a correct fit.17 The shield should match the anatom- the fragility and immaturity of the preterm infant and its increased ical configuration of the breast to eliminate friction of nipple tissue predisposition to infection the extra protection provided by breast against the sides of the tunnel, which may lead to severe nipple milk is essential to their health. Total lipid and total energy content excoriation. Milk drainage may also be compromised leading to is 20e30% higher in preterm milk and contains higher proportions maternal engorgement and a decrease in milk supply. of medium (MCFA) and long-chain polyunsaturated fatty acids Milk ejection occurs by the release of oxytocin, which binds to (LCPUFA).8 LCPUFA omega-3 fatty acid docosahexaenoic acid (DHA) the myoepithelial cells causing a contraction that expels milk from and the omega-6 fatty acid arachidonic acid (AA) are important as the alveoli. It is essential to effective milk removal and continued they enhance visual and neural function by their uptake into the milk synthesis. When this reflex is inhibited, the average milk yield membranes of the retina and brain. Indeed formula supplemented is less than 4% of available milk, and local mechanisms bring about with DHA and AA have shown improved visual and cognitive an inhibition in milk secretion.18 In stressful situations, expressing development compared to standard formula9 as well as better mothers experience difficulty with milk ejection. The early insti- growth and development.10 gation of skin-to-skin contact is thought to be beneficial in this Human milk also provides micronutrients in addition to mac- respect with mothers experiencing the feeling of milk ejection ronutrients including fat- and water-soluble vitamins, minerals and while in contact with their infant.19 It has been shown that mothers trace minerals. The concentration of many micronutrients is of VLBW infants who practised skin-to-skin contact were less likely influenced by the maternal diet and it is critical that the levels of to discontinue lactation before discharge and lactated on average 4 thiamin, riboflavin, vitamins B6 and B12, vitamin A, iron and iodine weeks longer than controls. Relaxation in the form of a tape has in particular are adequate.11 also been shown to increase milk volumes.20 Interestingly, the use Differences in preterm milk composition are less pronounced of nasal oxytocin spray does not markedly improve the milk yield after 4 weeks of lactation. Due to the immaturity of the preterm during the first 5 days post partum.21 infant and its unique needs, routine fortification of breast milk is Pumping technique also influences milk volume. Breast massage often required to provide adequate protein for growth as well as during single and double pumping with an electric breast pump minerals such as calcium and phosphorus to enhance bone increased milk volume. Similarly a combination of hand expression mineralization that would normally occur in the last trimester of of colostrum and hands-on pumping of mature milk also increased pregnancy. milk volume in mothers of preterm infants.14,22 A recent systematic review suggests that milk expression is a 4. Optimizing lactation success practice likely to be influenced by many factors other than use of breast pump.23 Some of the critical interventions mentioned During the first post-delivery encounter, neonatal staff should include: support and staff training, attitudes of staff, and psycho- include discuss the benefits of human milk, its role in the care of logical factors. A recent study evaluating peer support programmes preterm babies and the urgency to begin a milk expression in two neonatal intensive care units in the USA found that one of schedule. Early, frequent and effective milk expression is crucial to the most important aspects of the new mother’s relationship with the initiation of preterm lactation. There is a positive relationship the peer counselor was the shared experience of how difficult it can between milk volume and frequency and duration of pump use. be to provide milk while coping with the emotional toll of having Indeed mothers of very low birth weight (VLBW) infants have an infant in intensive care.24 produced adequate milk volumes at 5 weeks postpartum, pumped at least 45 times per week (>6 expressions/day).12 It has also been 6. Breastfeeding the preterm infant suggested that striving for daily milk volume of 750 mL/day may, by day 10, motivates mothers to continue to express on a regular To increase and maintain a milk supply that can support the basis.13 normal growth of the infant it is essential that the breast is effectively emptied of milk to ensure ongoing stimulation of milk syn- 5. Interventions to improve breast milk production thesis. The preterm infant is at high risk of feeding difficulties due to inherent neurological and developmental immaturity that may Mothers of preterm infants are dependent on milk expression be compounded further by co-morbidities such as chronic lung for weeks to months until an infant is able to breastfeed effectively. disease and intracranial haemorrhage. These factors may limit the Current evidence strongly suggests that double pumping (simul- strength of vacuum the infant can apply to the breast as well as taneous) with a hospital grade breast pump is more effective than impact co-ordination of sucking, swallowing and breathing, sequential pumping in the first 2 weeks.14 Double pumping has thereby impeding effective feeding. Whereas it is acknowledged appeared to stimulate more milk ejections and was a more efficient that feeding difficulties are common in the preterm infant (<37 and efficacious yielding milk with a higher volume and energy weeks of gestation) a subset of infants referred to as late preterm content when compared to single pumping.15 (34e37 weeks of gestation) are often expected to progress more A novel pump (which can be utilized simultaneously; Medela rapidly with oral feeding despite being up to 8 weeks younger than AG, Baar, Switzerland) mimics the sucking pattern of an infant with the full-term infant. A third of brain growth occurs in the final 6e8 a two-phase programme. The initial rapid vacuum cycle rate is weeks of gestation, therefore late preterm infants are born with similar to that applied by the infant before milk ejection, and the w35% less brain volume than the term infant. Rapid brain devel- second phase consisting of a slower cycle rate is utilized after milk opment and formation of synapses occurs between 34 and 36 ejection to improve milk removal. Mothers of preterm infants who weeks along with maturation of the nervous system (35e38 weeks) used an experimental programme with a ‘newborn’ pattern such that coordination of breast- or bottle-feeding improves.25 comprised of a more random application of cycle rate demon- Given such a developmental continuum this population is at risk strated significantly greater daily and cumulative milk output at of feeding difficulties, and indeed a retrospective study showed that days 6e14 postpartum and greater milk output per minute spent 80% of readmissions of late preterm infants were due to jaundice pumping.16 and that breastfed late preterm infants were 1.8 times more likely D. Geddes et al. / Seminars in Fetal & Neonatal Medicine 18 (2013) 155e159 157 to need hospital care compared to their breastfed full-term coun- compared to the bottle for reasons such as the necessity to extend terparts.26 Insufficient milk intake is the likely cause of jaundice in the nipple to both facilitate milk flow and position the nipple this group due to poor feeding skills, which could be exacerbated by correctly in order to collect an appropriately sized oral bolus and early discharge after delivery, particularly if secretory activation has achieve clearance of milk from the oral cavity. During breastfeeding not occurred. Close observation and attention to feeding during the the availability of milk is transient and flow rates are variable due to nursery stay as well as a good breastfeeding support post discharge the milk ejection reflex; thus, a preterm infant must suck effectively may be strategies that could prevent readmission of these infants.25 and coordinate suckingeswallowing and breathing during the period in which milk is available. By contrast, milk is always 7. Intragastric tube feeding available from the bottle and sometimes flows without the application of vacuum, explaining in part the lower vacuums applied and Preterm infants are often fed via a nasogastric or orogastric the more effective and efficient feeds compared to breastfeeding, at feeding prior to and during transition to oral feeds. During the least during the establishment of breastfeeding. Strength of vac- establishment of breastfeeding, supplementation via tube rather uum applied to the bottle is positively related to the volume of milk than via bottle is conducive to higher rates of breastfeeding at ingested and efficiency of milk transfer. Nevertheless, breastfeeding discharge.27 However, the presence of the feeding tube during a elicits better physiological responses in that infants experience bottle feed may have detrimental cardiorespiratory effects.28 The fewer desaturation episodes compared to bottle-feeding.35 provision of a pacifier during feeding has been shown to have pos- Little work has been carried out during breastfeeding in the itive effects such as increased intestinal transit time, a reduction in preterm infant. Geddes et al.36 have recently shown that breast- time to discharge29 and calmer behavioural state; however, a feeding vacuums are typically lower in the preterm infant Cochrane review did not find consistent benefits, although it compared to the term infant. Further evidence of the importance of confirmed that transition time to bottle-feeds and bottle-feeding vacuum comes from studies of conditions that typically impede performance were improved. Prolonged tube feeding is not desir- oral feeding such as prematurity, bronchopulmonary disease and able as it has been associated with poor sucking ability and increased cleft lip and/or palate infants. Weaker intra-oral vacuums have feeding difficulties later in pregnancy.30 Oro-gastric tubes may also been associated with these conditions compared to infants with no distort the malleable plate, lips and gums as well as cause laryngeal feeding issues or more mild disease.37 trauma and subglottic stenosis further complicating feeding.31 10. Nipple shields 8. Initiation and establishment of breastfeeding Preterm infants often have difficulty attaining and maintaining It is a requirement of many neonatal intensive care units (NICUs) good attachment to the breast, sustaining long suck bursts, and that infants reach full oral feeds before discharge from hospital and they tire easily, falling asleep at the breast. Nipple shields are often this milestone is usually the last met prior to discharge.32 Rapid used to assist infants to breastfeed by enabling the infant to attach progression to oral feeds is highly desirable but determination of to the breast for sustained periods and increase milk transfer. The the readiness of the infant to feed can be difficult. Corrected mechanism by which the nipple shield confers these benefits has gestational age, infant weight and infant behaviour are both com- not yet been elucidated. Further, long-term studies of nipple shield mon indicators. Developmental assessments are based on the use have not been carried out, although Meier et al.’s data do not premise that behavioural organization is indicative of central ner- suggest that they have a detrimental effect in this population.38 vous system maturation. Alertness and the ability to maintain this state is one sign recognized to implement oral feeding as well as 11. Alternative methods of feeding during the establishment other oral behaviours such as mouthing, hand and tongue sucking, of breastfeeding hand-to-mouth and hand swipes.32 Listening to amplified sounds of breathing and swallowing during bottle-feeding has been shown Bottle-feeds still tend to be the preferred method of suck to improve the caregiver’s response to the infant resulting in better feeding in the absence of the mother or as a supplement to infant state and physiological responses (e.g. less desaturation ep- breastfeeding rather than intragastric tube feeds. No particular isodes).33 Nyqvist takes a different approach by encouraging bottle-feeding system has been proven to be beneficial for the breastfeeding as soon and as frequently as possible rather than preterm population as a whole, and this may simply reflect the assessing readiness for oral feeding.34 This approach may be facil- variability in development and health status of the infants.32 itated not only by the provision of breast milk but by the modu- Cup feeding is used in some nurseries with the intention of lation of infant physiological responses with respect to suckling and avoiding nipple confusion. The ‘cups’ vary in size and shape; skin-to-skin contact with the mother. Many preterm infants are however, for the technique to be effective it requires patience and supplemented by bottle-feeds while establishing breastfeeding, as experience as research has shown that ingested volumes may be milk intake volumes from the breast are often lower than the feed small due to a large amount of milk lost during feeding. Never- volume prescribed by the neonatologist due to weak sucking theless studies have shown both fewer desaturation episodes and a pressures, poor suckeswallowebreathe coordination and the en- greater incidence of breastfeeding at 3 months compared to bottle- ergy expended necessitating the need for complementary feeds. feeding.39 Supplemental milk can also be delivered via a tube taped to 9. Breastfeeding versus bottle-feeding either the side of the nipple or the caregiver’s finger. The tube is attached to a milk reservoir or a milk-filled syringe (finger feeding) Supporting the immature infant to achieve oral feeding is or reservoir and the infant siphons the milk while sucking on the challenging for support staff as they work to improve sucking skills mother’s finger. This method was devised to reduce nipple confu- according to the infant’s development and health. Recognition of sion, but there appears to be only one study showing an increase in the differences between feeding modes will allow adjustment of breastfeeding rates at discharge.40 feeding strategies accordingly. Alternative methods of feeding (excluding the artificial teat) There are marked differences between breastfeeding and bottle- have been favored with the intention of avoiding nipple confusion, feeding. Generally stronger vacuums are applied to the breast the incidence of which is not known. There has been no systematic 158 D. Geddes et al. / Seminars in Fetal & Neonatal Medicine 18 (2013) 155e159 or mechanistic study of this phenomenon in either term or preterm more accurate and reliable than clinical indicators.51 Test weighing infants and with current knowledge severely lacking it is difficult to has the potential to improve transition to full breastfeeding by develop feeding methods that will enhance feeding development, bolstering the mother’s confidence as infant milk intakes increase particularly in the absence of breastfeeding as with the preterm over time34 and facilitates calculated reduction of supplementation infant. as breastfeeding is established. This measurement has the potential to enhance breastfeeding if managed well within the NICU and is 12. Interventions to enhance feeding currently being employed as a routine measure in some nurseries in the USA and Europe. There has been concerted effort in the last few years to accelerate maturation of oral feeding with the application of a stimulus. One intervention to improve times to oral feeding involves the applica- 14. Conclusions tion of a non-nutritive suck-burst pattern via an ‘active’ pacifier and is based on the premise that this input primes swallow circuits as In spite of the importance of the evolution of lactation in well as improving orofacial motor control. This patterned oro- mammals, it has not been a factor in the improved survival of cutaneous simulation enhances oral feeding skills beyond those premature infants. In the past, premature babies did not survive so expected by maturation alone especially in infants with sucking it cannot be claimed that breast milk has evolved to provide ben- fi difficulties and those with respiratory distress syndrome.41,42 e ts for preterm babies. However, recent research has shown that fi ’ Other combinations of oral and non-oral stimulation include modi ed mother s breast milk is the preferred food for these in- sucking on a pacifier; stroking the cheeks, lips, gums and tongue; fants. The establishment of breastfeeding in premature babies not stroking the head, neck, back, arms and legs; passive movement of only provides the infant with protection and nourishment but also the limbs.43 All of these interventions improved the volume and provides a multitude of positive stimuli for the infant. The normal fl efficiency of milk intake as well as transition time to oral feeding. function of the milk ejection re ex is crucial to successful breast fl Further it was found that oral stimulation alone improved both expression and breastfeeding. This re ex is facilitated by the sucking and expression pressures as well as the coordination of release of oxytocin. This hormone also has calming and connecting fl fi swallowing and respiration compared to the non-oral and com- functions that oppose the ight, freeze or ght response and fa- bined groups.44 It is encouraging that a small pilot study has been cilitates bonding between mother and infant. Given the multitude fi successful in the application of stimulus by the mother or a family of bene ts conferred by breastfeeding it is imperative that research member indicating the potential for a family-centered approach.45 is directed to understanding lactation physiology, particularly after preterm birth, in order to ensure that these at-risk infants reap the fi 13. Assessments of feeding bene ts of both breast milk and breastfeeding.

Despite the importance of the development of safe and efficient oral feeding in the preterm infant there are still few accurate and Practice points reliable assessment tools available to the clinician to determine the success of an intervention. Most are based on bottle-feeding with Early and effective milk removal is crucial for the initiation of lactation. few specifically designed for breastfeeding. Rigorous testing has not Triggering the milk ejection reflex is essential for been carried out and ideally more objective measures of feeding are effective milk removal. required that are not biased by observer error. Skin-to-skin contact increases milk production and fa- The Neonatal Oral Motor Assessment Score is designed to cilitates feeding at the breast. identify and classify oral-motor patterns associated with poor Effective and efficient oral feeding depends on the feeding. Despite contrasting results pertaining to validity of the tool development of adequate infant vacuum. and its poor predictability46 it has been used for longitudinal There are no accurate subjective clinical assessments of studies of term breastfed and bottle-fed infants,47 progression of effective breastfeeding. feeding in small-for-gestational-age preterm infants48 and infants Test weighing of infants before and after breastfeeding with bronchopulmonary dysplasia.49 measures milk intake. The Infant Breastfeeding Assessment Tool (IBAT) subjectively assesses infant behaviour, attachment, feeding and the mother’s perception of feeding. IBAT has variable reliability, lacks predictive Research directions validity and has a low association with milk intake in VLBW preterm infants.46 Methods of enhancing breast milk production. The Preterm Infant Breastfeeding Behavior Scale assesses infant Interventions to accelerate oral feeding and breast- behaviour, attachment, sucking bursts and swallowing. It has feeding duration. adequate inter-rater reliability between health professionals but is Accurate clinical assessments/measurements of 46 poor between mothers and health professionals. breastfeeding the preterm infant. The Early Feeding Skills assessment (EFS) focuses on specific feeding skills such as the ability to remain engaged, organization of oral motor movements, coordination of sucking, swallowing and Conflict of interest statement breathing as well as the maintenance of physiological stability. EFS consists of a three-part 36-item checklist measuring oral feeding None declared. readiness, oral feeding skill and oral feeding recovery and has not been tested for validity.46 Funding source Test weighing is an objective method that measures the effec- tiveness of breastfeeding by weighing the infant before and after D.T. Geddes and P.E. Hartmann receive a salary as part of an breastfeeding to determine the volume of milk ingested. This unrestricted research grant provided by Medela AG. There was no method has proven feasible in the preterm population50 as well as involvement of the funding source in producing this manuscript. D. Geddes et al. / Seminars in Fetal & Neonatal Medicine 18 (2013) 155e159 159

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