Breastfeeding Characteristics of Late-Preterm Infants in a Kangaroo Mother Care Unit

Abstract

Objective:

To describe the breastfeeding characteristics of late-preterm infants (LPIs) in a kangaroo mother care (KMC) unit.

Materials and Methods:

In a 20-bed KMC unit, the breastfeeding of 73 purposively-selected LPIs' (mean gestational age: 34.8 weeks) was observed once-off, using the Preterm Infant Breastfeeding Behavior Scale. Participants' mean age was 9.5 days, mean number of days in the unit was 3.1 days, and mean number of days breastfeeding was 7.5 on observation.

Results:

Only 13.7% of participants were directly breastfeeding without supplementary naso- or orogastric feeding/cup-feeding and 86.3% received supplementary cup-feeding of expressed breast milk. Most participants did not exhibit obvious rooting (83.5%) and although most latched-on (97.3%), those who did, latched shallowly (93%). The mean longest sucking burst was 18.8 (standard deviation: 10.5) and approximately half the participants swallowed repeatedly (53.4%). The mean breastfeeding session duration was 17.8 minutes, but most participants breastfed for less than 10 minutes (76.7%). No statistically significant differences in breastfeeding characteristics were detected between participants of different chronological ages. A general trend toward more mature behaviors in participants' breastfeeding for more days was present for many breastfeeding characteristics. More infants exhibited the most mature behavior for each breastfeeding characteristic when the environment was quiet, rather than noisy and disturbing, except for depth of latching (quiet: 0%, disturbance: 15.2%).

Conclusion:

LPIs in this sample presented with subtle breastfeeding difficulties, highlighting their need for breastfeeding support. Further research is required to examine the effect of KMC on breastfeeding in LPIs.

Introduction

Late-preterm infants (LPIs), or those born between 34 and 36 weeks and 6 days gestational age (GA), have become a population of increased research interest since their vulnerabilities have been recognized. Feeding difficulties are one of the complications found to be more prevalent in this population than in term infants¹ and are one of the primary reasons for delays in discharge and hospital readmission of these infants.^1,2

LPIs may be at risk for feeding difficulties for several reasons.³ First, LPIs are still physiologically and neurologically immature.⁴ Second, various morbidities associated with late-preterm birth may negatively impact on feeding, such as hyperbilirubinemia, hypoglycemia, respiratory difficulties, and dehydration.^1,5,6 LPIs are more likely than term infants to be separated from their mothers for medical investigations and treatments.^3,7 Avoiding separation, as in kangaroo mother care (KMC), has a positive impact on breastfeeding and breast milk production.⁸ KMC may protect breastfeeding in this population, as lower rates of breastfeeding exclusivity and duration are found in LPIs compared to term infants,^9–12 thus KMC may allow them to better achieve the global standard of exclusive breastfeeding for the first 6 months of life.¹³

While research suggests that breastfeeding difficulties are important to consider in LPIs, literature is limited regarding specific breastfeeding characteristics of LPIs.¹⁴ Publications highlighting breastfeeding characteristics specific to LPIs^5,7,15,16 do not appear to be based on original research, but rather on clinical experience or are now older than 10 years. In addition, limited research is available regarding LPIs breastfeeding in KMC, an intervention known to promote breastfeeding.⁸

Increased knowledge of specific breastfeeding characteristics may be useful in early identification and intervention for breastfeeding difficulties that may place LPIs at risk for the negative cyclic implications that poor breastfeeding has on milk intake, infant physiological status, maternal anxiety, and milk supply.^{7,10,14,17–20} The aim of this study was to further investigate the breastfeeding characteristics of LPIs receiving KMC.

Materials and Methods

Institutional ethical clearance was obtained to conduct this descriptive, prospective observational study. Prospective data collection took place for 12 weeks, from September to November 2016, in an established KMC unit in a South African academic hospital. In the unit, 20 mothers lodge in an open dormitory, providing intermittent or continuous KMC to their infants. The KMC unit accepts healthy, low-birth weight, and premature infants and full-term infants with feeding difficulties, from high care and the neonatal intensive care unit. Infants should typically have established oral feeding on admission into this unit, where the Baby Friendly Hospital Initiative (BFHI)²¹ is implemented. Providing supplementary expressed, and occasionally donor, breast milk using a cup/by cup at 3-hourly feeding times in the unit ensures adequate milk intake. Direct breastfeeding is practiced in human immunodeficiency virus (HIV) exposed infants, as HIV positive mothers are on antiretroviral treatment during pregnancy and after birth, and their infants are placed on treatment from birth. If the mother's HIV viral load is high, pasteurization of expressed breast milk will take place.

Participant description

Nonprobability convenient sampling was used to select 73 LPIs (34 0/7 to 36 6/7) in a KMC unit. To provide a holistic view of LPIs in a KMC unit, infants with morbidities were not excluded. Participant and maternal characteristics are represented in Table 1.

Table 1.

Participant and Maternal Characteristics (n = 73)

	%	Mean	Standard deviation	Minimum	Maximum	Skewness
Infant characteristics
Birth weight (kg)^a		2.1	0.4	1.4	4.1	1.5
Current weight (kg)		2.1	0.4	1.4	3.9	1.5
NICU stay duration (days)		6	7.6	0	41	3
KMC stay duration (days)		3.1	2.6	1	14	2.2
Chronological age (days)		9.5	9.1	2	55	2.9
Breastfeeding duration (days)		7.5	6.7	0	43	2.8
Maternal characteristics
Age (years)		29	7.2	16	43	0.1
At least secondary education	57.1
Living in urban informal settlements^b	64.4
Previous breastfeeding experience	64.4

n < 73 due to missing values.

Often with inadequate sanitation, infrastructure, and basic services.

KMC, Kangaroo Mother Care; NICU, neonatal intensive care unit.

Many participants presented with factors that could potentially influence breastfeeding, including being one of a twin (35.6%), cesarean section delivery (61.6%), HIV exposure (27.4%), bronchopulmonary dysplasia (1.4%), transient tachypnea of the newborn (19.2%), patent ductus arteriosus not requiring surgery (13.7%), respiratory distress syndrome (RDS) (46.6%), receiving oxygen through nasal cannula at the time of data collection (15.1%), small for GA/intrauterine growth restriction (31.5%), hyperbilirubinemia (67.1%), congenital disorders (6.8%), including Down syndrome and hypospadias and craniofacial anomalies (6.8%), including microcephaly, microtia, and deformational plagiocephaly.

Data collection

Mothers provided voluntary informed consent (in English, Sepedi, or isiZulu). Background information was collected by medical file review and maternal interview. The Preterm Infant Breastfeeding Behavior Scale (PIBBS)¹⁶ was then completed following observation of one entire breastfeeding session. This validated tool, which the authors found had good interrater reliability (IRR), guides observations of preterm infants' breastfeeding.¹⁶ It sets out maturational steps for each breastfeeding characteristic, from immature to mature term behaviors.¹⁶ The checklist was completed by speech-language therapists (SLT), not mothers, as intended by the authors of the PIBBS, as not all mothers were English speaking.

Training in using the PIBBS took place between two SLT, and 22 participants' breastfeeding sessions were jointly observed by both SLT for IRR assessments. Cohen's Kappa values for five PIBBS items ranged from poor to very good,²² including latching-on (0.46, agreement: 76%), sucking (0.74, agreement: 85%), swallowing (0.37, agreement: 67%), dull, glazed, open eyes (1.0, agreement: 100%), open eyes active movements (1.0, agreement: 100%), and the letdown reflex (−0.07, agreement: 86%). Given these varying values, joint review of all 22 participants' results by both SLT took place to reach a consensus. Reasons for discrepancies, such as differing levels of visibility of the throat and mouth by two raters, were discussed, and criteria for observations of subsequent sessions by one rater were established.

Data analysis

Data were analyzed using IBM SPSS (Version 24). Cohen's Kappa Measure of Agreement was used to determine IRR. Descriptive statistics was calculated, and statistically significant differences and associations were determined using the Fisher's exact test and chi-squared test procedures. The Spearman's correlation coefficient was determined for ordinal data. p-Values under 0.05 were determined statistically significant.

Results

Of the 73 participants, 97.3% were on full oral feeds (cup-feeding and/or breastfeeding) at the time of data collection and had been for a mean of 7.2 days (Standard deviation [SD]: 7.2, positively skewed: 2.8). Most participants (72.6%) began breastfeeding on the day of birth, but only 13.7% were directly breastfeeding without supplementary cup-feeding or naso- or orogastric feeding. Up to 26% of participants required several days of naso- or orogastric feeding (mean: 6.3, SD: 5.9) and 86.3% received cup-feeding of breast milk (mean: 6.0 days, SD: 7.3) to supplement breastfeeding. Few mothers (5.5%) had lactation difficulties at some point after giving birth. At the time of data collection, all mothers used their own expressed breast milk for supplementary cup-feeding or naso- or orogastric feeding, rather than donor milk or formula.

Table 2 indicates the breastfeeding characteristics exhibited by participants as a group and when divided into three chronological age groups. Breastfeeding characteristics are based on test items of the PIBBS. For the sake of clarity, in the present study, the test item “how much of the breast was inside the baby's mouth” is referred to as depth of latching, and “latching-on and staying fixed to the breast” is referred to as latching duration. According to the PIBBS,¹⁶ mature behaviors are obvious rooting, latching onto the nipple and some areola, latching-on for long durations, long sucking bursts, and repeated swallowing.¹⁶ Based on this classification, no participant exhibited the most mature behavior for every breastfeeding characteristic. Less than 50% of participants exhibited the most mature behavior for each breastfeeding characteristic according to the PIBBS, with the exception of repeated swallowing (53.3%). Most participants did not exhibit obvious rooting (83.5%). Most participants latched-on (97.3%), but those who did, latched shallowly (93%) and for less than 5 minutes (76.1%). Approximately half the participants exhibited long sucking bursts (46.6%), with a mean longest burst of 18.8 sucks, with considerable variation (SD: 10.5). Approximately half the participants exhibited repeated swallowing (53.4%); the other half swallowed occasionally (34.3%) or not at all (12.3%). Participants were held for breastfeeding for a mean of 17.8 minutes (SD: 4.6, positive skewness: 1.0) but most were held for under 10 minutes (76.7%).

Table 2.

Breastfeeding Characteristics According to Chronological Age Groups (n = 73)

							Significance
				Chronological age (days)
Breastfeeding characteristics	Descriptive		Overall (%)	1–7 (%)	8–14 (%)	15+ (%)	Fisher's exact	Spearman's correlation coefficient	p-Value
Overall			Overall (%)	73 (100.0)	37 (50.7)	25 (34.2)	11 (15.1)
Rooting
None	N/A		26 (35.6)	13 (35.1)	11 (44.0)	2 (18.2)	0.366	0.096	0.424
Some			35 (47.9)	19 (51.4)	11 (44.0)	5 (45.4)
Obvious			12 (16.5)	5 (13.5)	3 (12.0)	4 (36.4)
Depth of latching
None	N/A		2 (2.8)	1 (2.7)	1 (4.0)	0 (0.0)	0.517	0.215	0.065
Part nipple			21 (28.8)	14 (37.8)	6 (24.0)	1 (9.1)
Whole nipple			45 (61.6)	20 (54.1)	16 (64.0)	9 (81.8)
Some areola			5 (6.8)	2 (5.4)	2 (8.0)	1 (9.1)
Latching duration (minutes)
None	Mean^a	4.6	2 (2.7)	1 (2.7)	1 (4.0)	0 (0.0)	0.807	0.002	0.986
<1	SD	3.2	9 (12.3)	6 (16.2)	2 (8.0)	1 (9.1)
1–5	Skewness	1.5	45 (61.6)	20 (54.1)	18 (72.0)	7 (63.6)
6–10	Kurtosis	2.6	14 (19.2)	7 (18.9)	4 (16.0)	3 (27.3)
≥11			3 (4.2)	3 (8.1)	0 (0.0)	0 (0.0)
Sucking
None	N/A		2 (2.7)	1 (2.7)	1 (4.0)	0 (0.0)	0.553	0.108	0.127
Licking			3 (4.1)	3 (8.2)	0 (0.0)	0 (0.0)
Single sucks			14 (19.2)	7 (18.9)	6 (24.0)	1 (9.1)
Short bursts			20 (27.4)	12 (32.4)	4 (16.0)	4 (36.4)
Long bursts			34 (46.6)	14 (37.8)	14 (56.0)	6 (54.5)
Longest sucking burst (number of sucks)^b
1–5	Mean	18.8	10 (14.7)	6 (18.1)	3 (12.5)	1 (9.1)	0.445	0.129	0.288
6–10	SD	10.5	12 (17.6)	5 (15.2)	5 (20.8)	2 (18.2)
11–15	Skewness	−0.2	8 (11.8)	5 (15.2)	2 (8.3)	1 (9.1)
16–20	Kurtosis	−1.6	5 (7.4)	2 (6.1)	1 (4.2)	2 (18.2)
21–25			5 (7.4)	5 (15.2)	0 (0.0)	0 (0.0)
≥26			28 (41.1)	10 (30.2)	13 (54.2)	5 (45.4)
Swallowing
None	N/A		9 (12.3)	6 (16.3)	3 (12.0)	0 (0.0)	0.369	0.216	0.071
Occasional			25 (34.3)	14 (37.8)	9 (36.0)	2 (18.2)
Repeated			39 (53.4)	17 (45.9)	13 (52.0)	9 (81.8)
Length of time baby was held for breastfeeding (minutes)
1–5	Mean	17.8	29 (39.7)	17 (45.9)	9 (36.0)	3 (27.3)	0.474	0.112	0.353
6–10	SD	4.6	27 (37.0)	11 (29.7)	12 (48.0)	4 (36.3)
11–15	Skewness	1.0	13 (17.8)	7 (18.9)	3 (12.0)	3 (27.3)
16–20	Kurtosis	0.9	3 (4.1)	2 (5.5)	1 (4.0)	0 (0.0)
≥21			1 (1.4)	0 (0.0)	0 (0.0)	1 (9.1)

Descriptive data for latching duration exclude infants latching <1 minute.

n < 73 as not all infants sucked.

SD, standard deviation.

No statistically significant differences in breastfeeding characteristics were detected between different chronological ages. However, a trend towards a higher percentage of older participants exhibiting mature behaviors could be seen for most breastfeeding characteristics, including rooting, depth of latching, sucking, and swallowing. Results of latching duration, longest sucking burst, and length of time held for breastfeeding did not show clear trends.

Table 3 shows similar results. Statistically significant differences were detected only for the breastfeeding characteristic of swallowing. However, there was a trend towards participants that exhibited the most mature behaviors according to the PIBBS classification, on average, to have been breastfeeding for longer than those exhibiting less mature behaviors, except for latching duration. Infants with more experience breastfeeding tended to breastfeed for shorter durations.

Table 3.

Breastfeeding Characteristics in Relation to Mean Number of Days Breastfeeding (n = 73)

Breastfeeding characteristic	Frequency (%)	Mean no. of days breastfeeding (SD)	Statistically significant p-values
Rooting
Not obvious/none	61 (83.6)	6.9 (5.3)	Not statistically significant
Obvious	12 (16.4)	10.3 (11.3)	Not statistically significant
Depth of latching
Whole nipple/less	68 (93.2)	7.4 (6.7)	Not statistically significant
Some areola	5 (6.8)	8.0 (6.1)	Not statistically significant
Latching duration (minutes)
<15	71 (97.3)	7.6 (6.7)	Not statistically significant
≥15	2 (2.7)	4.0 (0.0)	Not statistically significant
Sucking
Short bursts/less	39 (53.4)	6.7 (5.6)	Not statistically significant
Long bursts	34 (46.6)	8.3 (7.7)	Not statistically significant
Longest sucking burst (number of sucks)
<30	48 (65.6)	6.8 (5.2)	Not statistically significant
≥30	25 (34.4)	8.8 (8.7)	Not statistically significant
Swallowing
Occasional/none	34 (46.6)	5.8 (4.7)	0.04
Repeated	39 (53.4)	9.0 (7.7)	0.04
Length of time baby was held for breastfeeding (minutes)
<15	67 (91.8)	7.6 (6.9)	Not statistically significant
≥15	6 (8.2)	6.3 (2.7)	Not statistically significant

SD, standard deviation.

Table 4 indicates the differences in breastfeeding characteristics between participants with and without RDS. No statistically significant differences were detected. However, a larger percentage of participants without RDS tended to exhibit the most mature behaviors according to the PIBBS classification than the percentage of participants with RDS, except for latching duration. A larger percentage of participants with RDS tended to breastfeed for longer durations than the percentage of participants without RDS.

Table 4.

Participants' Breastfeeding Characteristics in Relation to Diagnosis of Respiratory Distress Syndrome (n = 73)

		Diagnosis of RDS
Breastfeeding characteristic	Overall (%)	Absent (%)	Present (%)	Statistically significant p-values
Overall (%)	73 (100.0)	39 (53.4.)	34 (46.6)
Rooting
Not obvious/none	61 (83.6)	31 (79.5)	30 (88.2)	Not statistically significant
Obvious	12 (16.4)	8 (20.5)	4 (11.8)	Not statistically significant
Depth of latching
Whole nipple/less	68 (93.2)	36 (92.3)	32 (94.1)	Not statistically significant
Some areola	5 (6.8)	3 (7.7)	2 (5.9)	Not statistically significant
Latching duration (minutes)
<15	71 (97.3)	34 (97.1)	26 (96.3)	Not statistically significant
≥15	2 (2.7)	1 (2.9)	1 (3.7)	Not statistically significant
Sucking
Short bursts/less	39 (53.4)	19 (48.7)	20 (58.8)	Not statistically significant
Long bursts	34 (46.6)	20 (51.3)	14 (41.2)	Not statistically significant
Longest sucking burst (number of sucks)
<30	43 (63.2)	21 (55.3)	22 (73.3)	Not statistically significant
≥30	25 (36.8)	17 (44.7)	8 (26.7)	Not statistically significant
Swallowing
Occasional/none	34 (46.6)	15 (38.5)	19 (55.9)	Not statistically significant
Repeated	39 (53.4)	24 (61.5)	15 (44.1)	Not statistically significant
Length of time baby was held for breastfeeding (minutes)
<15	67 (91.8)	37 (94.9)	30 (88.2)	Not statistically significant
≥15	6 (8.2)	2 (5.1)	4 (11.8)	Not statistically significant

RDS, respiratory distress syndrome.

The letdown reflex was perceived in 98.6% of mothers, and no breast problems were reported. The participants' general behavior varied, with many infants exhibiting several behaviors during one breastfeeding session (Table 5).

Table 5.

General Behavior During Breastfeeding

General behavior	Frequency (%) ^a
Closed eyes, no movements	58 (79.5)
Cried, fussed audibly	21 (28.8)
Open eyes, dull/glazed look	15 (20.5)
Closed eyes, active movements	14 (19.2)
Drowsy, open eyes, heavy lidded	13 (17.8)
Eyes wide open, achieved eye contact	4 (5.5)
Open eyes, active movements	4 (5.5)
Eyes wide open, looked tense/afraid	1 (1.4)

Total% >100 as participants exhibited >1 behavior.

The influence of environment on breastfeeding characteristics is depicted in Table 6. Only the breastfeeding characteristic of rooting showed statistically significant differences between a quiet and a disturbing environment. However, the results do indicate a trend for the remaining breastfeeding characteristics. When the environment was quiet and private, rather than disturbing, more infants exhibited the most mature behavior for each breastfeeding characteristic, except for depth of latching. Participants breastfeeding when the environment was quiet tended to be held for breastfeeding for longer.

Table 6.

Breastfeeding Characteristics in Relation to the Environment (n = 73)

		Influence of the environment
Breastfeeding characteristic	Overall (%)	Some disturbance (%)	Quiet/private (%)	Statistically significant p-values
Overall (%)	73 (100.0)	33 (45.2)	40 (54.8)
Rooting
Not obvious/none	61 (83.6)	31 (93.9)	30 (75.0)	0.03
Obvious	12 (16.4)	2 (6.1)	10 (25.0)	0.03
Depth of latching
Whole nipple/less	68 (93.2)	28 (84.8)	40 (100.0)	Not statistically significant
Some areola	5 (6.8)	5 (15.2)	0 (0.0)	Not statistically significant
Latching duration (minutes)
<15	71 (97.3)	33 (100.0)	38 (95.0)	Not statistically significant
≥15	2 (2.7)	0 (0.0)	2 (5.0)	Not statistically significant
Sucking
Short bursts/less	39 (53.4)	18 (54.5)	21 (52.5)	Not statistically significant
Long bursts	34 (46.6)	15 (45.5)	19 (47.5)	Not statistically significant
Longest sucking burst (number of sucks)
<30	48 (65.6)	24 (72.7)	24 (60.0)	Not statistically significant
≥30	25 (34.4)	9 (27.3)	16 (40.0)	Not statistically significant
Swallowing
Occasional/none	34 (46.6)	18 (54.5)	16 (40.0)	Not statistically significant
Repeated	39 (53.4)	15 (45.5)	24 (60.0)	Not statistically significant
Length of time baby was held for breastfeeding (minutes)
<15	67 (91.8)	33 (100.0)	34 (85.0)	Not statistically significant
≥15	6 (8.2)	0 (0.0)	6 (15.0)	Not statistically significant

Discussion

Results highlight specific breastfeeding characteristics and difficulties in this sample of 73 LPIs receiving KMC. Most participants were not exhibiting obvious rooting (83.5%), which was unexpected, as this reflex is expected from 28 weeks GA.²³ However, rooting can be influenced by reduced alertness,²⁴ which may have been the case in this study, as the predominant behavior while breastfeeding was closed eyes without movements (79.5%). For breastfeeding, rooting is important, as it gives an indication of feeding readiness and may impact on successful latching.^24,25 Latching was indeed affected in this sample. Although most latched-on (97.3%), latching was shallow, only onto the nipple or less, in 93% of participants who latched-on. Poor latching, often highlighted in LPIs,^5,14,26 is concerning, as this may impact on the efficiency of milk transfer.²⁴

Immaturity in sucking and swallowing were also expected, given previous research indicating that neurological immaturity in LPIs may impact on these characteristics and being able to coordinate these with breathing only matures and is refined in the third trimester.^5,14,26,27 The suck-swallow-breathe ratio for efficient breastfeeding in term infants is 1-1-1 to 3-1-1.²³ Less frequent swallowing may indicate poor milk transfer.²³ While repeated swallowing was observed in approximately half the participants (53.4%), 46.6% were not swallowing or swallowing only occasionally and may thus not have achieved adequate milk transfer.

The majority (67.8%) of participants' longest sucking bursts were within the norms for term infants.²³ However, this mean value reflects the longest sucking burst. The average sucking burst length throughout the breastfeeding session may have been shorter, as 53.4% of participants exhibited short sucking bursts or less. Nevertheless, Nyqvist²⁸ states that even with short sucking bursts, preterm infants can be successful breast-feeders if milk transfer is efficient. However, results of this study suggest that participants as a group may have had inefficient milk transfer, given the number of participants with shallow latching and infrequent swallowing. Infrequent swallowing may be observed if an infant is exhibiting non-nutritive sucking, rather than nutritive sucking.²⁵ Non-nutritive sucking creates slower milk transfer with the risk of insufficient intake if the breastfeeding session is short.²⁴

Although the mean length of time held for breastfeeding was 17.8 minutes (Positive skewness: 1.0), most participants were held for breastfeeding for under 10 minutes (76.7%). Typically, breastfeeding session length is not an accurate indicator of successful breastfeeding, as this may vary considerably depending on the infant.²⁴ A short breastfeeding session may indicate an efficient breast-feeder, able to achieve sufficient milk intake in a short period.²⁴ The results suggest that participants, as a group, were not efficient breast-feeders and the shorter time held for breastfeeding may be an indication of poor endurance, a difficulty frequently highlighted in LPIs.^5,7,19 One explanation for poor endurance may be respiratory difficulties, which was present in many participants in this sample²⁵ (15% required oxygen at the time of evaluation and almost 50% had RDS). However, results indicated that more infants with RDS had breastfeeding sessions longer than 15 minutes, than infants without RDS. This longer breastfeeding session duration may be due to these infants requiring longer rest periods and periods of catch-up breathing within the session. Length of time held for breastfeeding may also have been influenced by the mothers being aware that they would be top-up cup-feeding at a later stage. This may have contributed to shorter breastfeeding sessions to allow time for cup-feeding. In addition, Nyqvist²⁸ states that regular top-up cup-feeding may decrease milk intake at the breast, also potentially contributing to shorter breastfeeding sessions.

It was surprising that less than 55% of participants exhibited the most mature behavior for each breastfeeding characteristic, according to the PIBBS. Nyqvist et al.¹⁶ found that 60% to 64% of LPIs exhibited the most mature behavior for each characteristic. Fewer breastfeeding difficulties were expected in this study, given the known positive influence of KMC on breastfeeding.⁸ Nyqvist et al.¹⁶ did not specify whether infants with morbidities were included in their sample, which may explain these differing results. In this sample, many participants presented with medical risk factors which previous research has associated with feeding difficulties, such as RDS.^19,29–32 For example, the results of the present study appear to support that RDS may impact on breastfeeding. Although these results should be interpreted with caution due to a lack of statistical significance, Table 4 indicates that a larger percentage of participants without RDS exhibited mature breastfeeding characteristics than the percentage of participants with RDS, except for latching duration. Infants in the KMC unit are typically admitted for weight gain and feeding difficulties. These infants may have higher percentages of morbidity, with a resultant higher percentage of infants with feeding difficulties than would be typical of healthy LPIs immediately discharged. However, LPIs in general are more likely to present with many of these medical risk factors than term infants,^2,32 making it important that LPIs with these conditions not be overlooked.

Although results did not indicate statistical significance, there appeared to be a trend toward older participants exhibiting more mature breastfeeding characteristics. In addition, all breastfeeding characteristics were more mature in infant breastfeeding for more days, with the exception of latching duration. The results of latching duration may have been influenced by the fact that only two participants latched-on longer than 15 minutes. Participants with more experience directly breastfeeding tended to breastfeed for shorter sessions, which may be an indication of better breastfeeding efficiency. Although these results should be interpreted with caution given the limited statistical significance, the trends tentatively suggest that with time and experience (infant and maternal), the maturity of breastfeeding may improve. This is a concept supported by literature.^33,34

The most frequent behavior exhibited by participants was closed eyes and no movements, which may indicate sleepy or drowsy behavior, a predominant state in preterm infants.²⁵ This behavior is ambiguous, as deep sleep or drowsiness may hinder or promote breastfeeding, respectively.²⁴ However, the second most frequently observed behavior, crying and fussing, would clearly hinder successful breastfeeding.²⁴ Few participants presented with alert behaviors, which would promote successful direct breastfeeding.^24,25

Results of this study suggest that a quiet private environment fosters more mature direct breastfeeding characteristics, given that more participants exhibited mature behaviors for all breastfeeding characteristics, except for depth of latching, when the environment was quiet. Participants breastfeeding when the environment was quiet tended to breastfeed for longer, which may reflect the lack of disturbance in the environment. Although these results should be interpreted with caution, given the limited statistical significance, they are in line with literature that states that successful oral feeding requires adequate behavioral state organization,²⁵ and preterm infants are easily overstimulated by environmental disturbance.³⁵ The open-dormitory setup may thus interfere with preterm infants who may have difficulty with state regulation. Although these results provide preliminary information regarding the possible impact of the environment on breastfeeding characteristics, observation of multiple breastfeeding sessions to further investigate this concept would be valuable. This would allow for a better understanding of the extent to which environment impacts on breastfeeding success and to what extent other factors, such as an infant's individual temperament, may impact on breastfeeding.

Although lactation difficulties in mothers of LPIs may impact on the success of breastfeeding,¹⁹ few had lactation difficulties in this study, possibly associated with the positive influence of KMC and regular expressing of breast milk.³⁶ The letdown reflex was perceived in almost all mothers (98.6%) and no breast problems were reported. Thus, maternal factors appear not to have impacted significantly on the participants' breastfeeding.

The breastfeeding characteristics indicate subtle difficulties, which may have placed this sample of LPIs at risk for decreased milk transfer and intake by direct breastfeeding alone. A previous study found that 33% of LPIs required some form of nutritional support, in addition to breastfeeding.³⁷ The higher percentage of infants requiring supplementary naso- or orogastric feeding (26%) and cup-feeding (86.3%) in the current study may be due to top-up cup-feeding being common in the KMC unit to ensure adequate milk intake. While this volume-driven supplementation may have increased the percentage of participants receiving cup-feeding, it nevertheless indicates a concern that direct breastfeeding alone would be insufficient. This need for supplementation in LPIs has been discussed in literature,^7,20,37 and cup-feeding specifically has been highlighted as an effective transition to direct breastfeeding in LPIs.³⁸ However, Nyqvist²⁸ states that for preterm infants, more frequent cue-based direct breastfeeding sessions may promote greater milk intake at the breast than regular scheduled direct breastfeeding with top-up cup-feeding. The author adds that cup-feeding should only be occasional.

SLT and other healthcare professionals working with LPIs should be vigilant for subtle breastfeeding difficulties, which may typically be overlooked. Increased knowledge regarding breastfeeding characteristics may allow for more specific and individualized support for this population, such as prioritizing a quiet environment and allowing infants to “practice” suckling at the nipple, even if direct breastfeeding is not yet established. Interventions such as cue-based breastfeeding sessions with occasional cup-feeding to supplement breastfeeding should be considered and further investigated.^28,38 Such interventions should be used to best support these vulnerable LPIs, who may be at risk for cognitive and behavioral difficulties well beyond infancy.³⁹

A number of study limitations should be mentioned. First, the GA of participants was based on the New Ballard Score, which is not as reliable as ultrasounds for determining GA.⁴⁰ Although observation is considered the least-invasive method of assessing breastfeeding,¹⁶ the presence of an observer may nevertheless impact on maternal and infant behavior. Observations may also be subjective, as indicated by IRR results. An isolated breastfeeding session was observed, which may not give an indication of the average breastfeeding performance of participants. Due to the admission criteria in the KMC unit, it was not possible to observe infants on a specific constant day after birth. Keeping the day of observation constant, and thus chronological age and breastfeeding experience constant, may have allowed further investigation into differences in breastfeeding characteristics between infants of 34 weeks GA, as opposed to those of 35 or 36 weeks GA.

A similar study with a larger sample would allow for more in-depth analysis of factors impacting on breastfeeding characteristics in LPIs, such as RDS and other medical factors. Further investigation into the efficiency of milk transfer in LPIs by test weighing, as well as investigating whether nutritive or non-nutritive sucking is their predominant sucking characteristic, should take place. In addition, determining the impact of a mother's previous breastfeeding experience on breastfeeding characteristics would be valuable. Including immediately-discharged healthy LPIs in a future study may be valuable for better generalization and evaluation of the impact of KMC on breastfeeding characteristics. Term and very premature infants can also be included to compare the level of maturity of breastfeeding characteristics. To date, no original research could be found regarding breastfeeding characteristics of LPIs receiving KMC. While results of this study highlight that further investigation is still required, this study may provide exploratory information, which may serve as a basis for further research in this field.

Conclusion

In this sample of LPIs in a KMC unit, participants exhibited specific breastfeeding characteristics and difficulties. This knowledge may allow for more individualized feeding support for this vulnerable and often overlooked population, potentially preventing negative cyclical implications of poor breastfeeding and unrealistic expectations of those working with LPIs. Further research is still required to examine the effect of KMC on breastfeeding in LPIs.

Footnotes

Acknowledgments

Thanks go to the Pediatric Department of Kalafong Hospital, the healthcare staff, all participants' mothers, and Dr. Dion van Zyl, statistician, for making this study possible.

Disclosure Statement

No competing financial interests exist.

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