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A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit
Journal of Neonatal Nursing (2007) 13, 150e154
www.intl.elsevierhealth.com/journals/jneo
A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit M. Trajanovska a,b, S. Burns a, L. Johnston a,b,c,* a
Royal Children’s Hospital, Melbourne, Australia Murdoch Children’s Research Institute, Melbourne, Australia c The University of Melbourne, Melbourne, Australia b
Available online 22 June 2007
KEYWORDS Breastfeeding; NICU; Tertiary level care
Abstract Background: The World Health Organisation (WHO) and a substantial body of literature recommend breastfeeding from birth until at least 6 months of age. The nutritional, gastrointestinal, immunological, neurodevelopmental and psychosocial benefits of breastfeeding have been shown for term and preterm infants. Meeting the WHO recommendations for breastfeeding is problematic in the cohort of infants requiring hospitalisation in a neonatal intensive care unit (NICU) for management of complex medical and surgical conditions. Method: A retrospective audit of medical records of all infants admitted to the neonatal unit of the Royal Children’s Hospital, Melbourne, Australia between 2001 and 2003 was conducted. Results: One thousand, one hundred and sixty-three babies were admitted during the audit period. Babies discharged directly home were of significantly greater gestational age, higher birthweight and had a shorter length of stay than those babies transferred to another facility (P < 0.05). Fifty-six percent of the cohort was receiving breast milk on discharge from the neonatal unit. Babies exclusively breastfed on discharge were of greater gestational age and had a shorter length of stay in the NICU than those babies discharged on a combination of breast milk and formula, or formula alone (P < 0.001). Babies transferred to another facility, rather than discharged directly home, were less likely to be breastfed and more likely to receive enteral nutrition via intragastric tube feeds or a combination of bottle and tube feeds. Conclusion: Birthweight, gestational age, and length of stay in a neonatal intensive care unit are factors likely to influence breastfeeding in the cohort of babies requiring tertiary level care. ª 2007 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. School of Nursing, The University of Melbourne, Level 1/723 Swanston Street, Carlton, Vic. 3051, Australia. Tel.: þ61 3 8344 0768; fax: þ61 3 9347 4172. E-mail address: [email protected] (L. Johnston). 1355-1841/$ - see front matter ª 2007 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2007.05.005
A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit
Background In 2001 the World Health Organisation (WHO) issued a recommendation for the continuation of breastfeeding until 6 months of age, with the introduction of complementary foods thereafter (World Health Organisation, 2001). Benefits of breastfeeding have been identified as including a decreased risk of gastrointestinal infections (Kramer et al., 2001) and otitis media (Kramer et al., 2001) and an increased bonding between mother and infant (Arora et al., 2000). A mother’s decision to breastfeed their baby is usually made prior to, or during the pregnancy, with those mothers making the decision prior to pregnancy more likely to sustain breastfeeding (Arora et al., 2000; Jaeger et al., 1997; Shaker et al., 2004). The decision is based on such factors and beliefs as convenience (Anderson et al., 2002), ‘‘naturalness’’ (Arora et al., 2000; Wheeler et al., 2000), what is considered ‘‘best’’ for the baby (Anderson et al., 2002), and the partners’ preference (Scott et al., 1997; Wheeler et al., 2000). The proportion of mothers intending to breastfeed their healthy, term infant ranges from 77% to 87% in the USA and Australia, respectively (Chezem et al., 2003; Cooke et al., 2003). The nutritional, gastrointestinal, immunological, neurodevelopmental and psychosocial benefits of breastfeeding have also been shown for those infants born prematurely (Callen and Pinelli, 2005). Meeting the WHO recommendations is however, problematic for the cohort of babies requiring hospitalisation in neonatal intensive care early in life. Severity of illness and the associated complex medical interventions may preclude the successful establishment of breastfeeding in this population. Breastfeeding intention rates of mothers of preterm (Jaeger et al., 1997) and very low birthweight (VLBW) babies (Furman et al., 2002; Sable and Patton, 1998) admitted to neonatal intensive care are lower than those of mothers of healthy, term infants. Australian data suggests 80% of mothers of preterm infants indicated an intention to breastfeed, while in the UK, 70% of mothers reported an intention to breastfeed (Jaeger et al., 1997). This is in contrast to a study in the USA that reported a breastfeeding intention rate of 31% in mothers of VLBW infants, although an additional 13% reported an intention to partially breastfeed (Sable and Patton, 1998). While between 5% and 10% of mothers of healthy, term infants who had intended to breastfeed did not follow through with their feeding choice by time of discharge from hospital
151
(Anderson, 2002; Cooke et al., 2003; Shaker et al., 2004), almost 30% of mothers of premature and sick infants in Australia, did not follow through on their intention to breastfeed (Wheeler et al., 2000). Frequently identified factors impacting on the decision to cease breastfeeding in this population include separation from the infant (Jaeger et al., 1997), the infant’s medical condition, small size and fragility (Furman et al., 1998), and the NICU environment itself with high noise levels and lack of privacy (Furman et al., 1998; Nyqvist et al., 1994). Greater gestational age and larger birthweight have been shown to be positive predictors for the initiation and sustaining of breastfeeding (Powers et al., 2003; Scott et al., 2001). Australian and UK studies report rates of infants exclusively receiving breast milk1 on discharge from the NICU as between 45% and 62% (Jaeger et al., 1997; Wheeler et al., 2000; Yip et al., 1996) in comparison with rates for full term, healthy infants of 83% (Scott et al., 2001). The literature is replete with studies describing rates of, and factors impacting upon, breastfeeding in both the healthy, and preterm, populations. However, to date there has been little research addressing breastfeeding rates and sustainability in the population of infants with complex surgical conditions requiring prolonged management and a stay in the neonatal intensive care unit, where the introduction of enteral feeding of any type is substantially delayed. The aim of this study was to describe factors associated with the feeding outcomes at discharge of those babies requiring tertiary level, neonatal intensive care in Australia.
Method A retrospective audit was undertaken of medical records of all infants admitted to the neonatal unit (NNU) at the Royal Children’s Hospital, Melbourne, Australia between 2001 and 2003. The NNU is a 24bed intensive and special care nursery servicing a State-wide and often beyond, population of infants with complex medical, surgical, metabolic and genetic conditions. Data was analysed with SPSS Version 12.1 (SPSS Inc., Chicago, IL, USA). Tests used were descriptive statistics, one-way ANOVA and chi-square (or Fisher’s exact tests for cell 1 ‘‘Exclusive or full breastfeeding’’ is defined as no other liquid or solid from any other source enters the infant’s mouth except occasional tastes of other liquids, traditional foods, vitamins, medicines, etc. ‘‘Full breast milk feeding’’ refers to the infant receiving expressed breast milk in addition to breastfeeding (Labbok, 2000).
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counts less than 5). Data are reported as mean values unless otherwise stated. The study was approved as a clinical audit by the Human Research Ethics Committee of the Royal Children’s Hospital.
Results Records of 1163 babies admitted to the Neonatal Unit between 2001 and 2003 were reviewed. Five hundred and thirty-four babies were discharged directly home from the Unit, 572 were transferred to another hospital and a further 57 babies died. In keeping with the expected profile of babies admitted to this NNU, the majority (63%) of admissions required some form of surgical intervention for complex conditions including; cardiac abnormalities (n ¼ 28), tracheo-oesophageal fistula (n ¼ 16), congenital diaphragmatic hernia (n ¼ 12), gastroschisis (n ¼ 10) and exomphalos (n ¼ 6). The majority (77%) of mothers had indicated an intention to breastfeed their baby. Demographic characteristics of babies discharged home or to another hospital are shown in Table 1. Babies discharged directly home were of significantly greater gestational age and higher birthweight and gained more weight during their stay than those babies transferred to another hospital on discharge. More than 50% of the cohort of babies were receiving breast milk at time of discharge through exclusive breastfeeding, expressed breast milk or a combination of breast milk and formula. There were slightly more babies discharged directly home receiving breast milk in comparison to those babies transferred to another facility, although this was not statistically significant (Table 2). Similar numbers of babies were discharged home or to other hospitals receiving a combination of breast milk and formula feeds.
Table 1 Demographic characteristics of babies discharged home or transferred to another facility (mean values are shown) Characteristic
Discharged Transferred, n ¼ 572 home, n ¼ 534
Gestational age (weeks) 37.4 Birthweight (g) 3036.2 Length of stay (days) 12.0 Difference between 570.3 birthweight and weight at discharge (g) *P < 0.05.
35.1* 2472.0* 11.2 429.9*
Table 2 Feed intake of babies discharged directly home or transferred to another facility Type of feed
Total cohort, n (%)
Breast 599 (56) milk Formula 312 (30) Combined 151 (13)
Discharged home, n (%)
Transferred, n (%)
304 (58)
295 (55)
151 (29) 70 (13)
161 (30) 81 (15)
At the time of discharge from the NNU, babies exclusively breastfed were of significantly greater gestational age and had a shorter length of stay than those babies discharged on a combination of breast milk and formula, or formula alone. Babies fed a combination of breast milk and formula were heavier at birth and those babies fed formula alone had the greatest weight gain by time of discharge, although they also had the longest length of stay (Table 3). Exclusive breastfeeding was the most common method of feeding at discharge. This was significantly different for babies discharged directly home when compared to those babies transferred with babies transferring to another facility more likely to be fed via intragastric tube or receiving nutrition via a combination of approaches (Table 4). Breastfeeding babies discharged from the unit were significantly different from those babies bottle- or tube-fed with respect to having a higher birthweight (P < 0.01), being of greater gestational age (P < 0.01), and having a shorter length of stay (P < 0.01) (Table 5).
Discussion Breastfeeding is globally recognised as the optimum approach to provision of infant nutrition. Table 3 Demographic characteristics and feed intake of total cohort at discharge (mean values are shown) Characteristic
Breast Formula, Combined, milk, n ¼ 312 n ¼ 151 n ¼ 599
Gestational age 36.6 35.4 (weeks) Birthweight (g) 2859.3 2513.6 Length of stay (days) 9.2 17.8 384.3 832.5 Difference between birthweight and weight at discharge (g) *P < 0.001.
36.9* 2831.6* 10.9* 313.7*
A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit Table 4 Method of feeding at discharge home (n ¼ 523) or on transfer to another facility (n ¼ 533) Feeding method
Discharged home, n (%)
Transferred, n (%)
Breastfeeding Bottle feeding Intragastric tube feeding Combined Gastrostomy
226 (43.2) 159 (30.4) 12 (2.3)
66 (12.4)* 81 (15.2) 164 (30.8)
125 (23.9) 1 (0.2)
220 (41.3) 2 (0.4)
P < 0.001.
There is a substantial body of literature describing factors that influence a woman’s decision to breastfeed, breastfeeding rates in healthy infants, and barriers to the initiation or sustaining of breastfeeding in both the healthy and premature infant population. However, there is little information available on the breastfeeding outcomes of those babies admitted to a tertiary paediatric referral centre for management of complex medical and surgical conditions. This study sought to describe current rates of breastfeeding on discharge of infants from such a centre, and undertake an exploratory analysis of the factors that might impact on breastfeeding sustainability. The majority of mothers in our study (77%), indicated an intention to breastfeed; a figure consistent with the international literature. Donath and colleagues have reported maternal intention to be a stronger predictor of both breastfeeding initiation and duration than other demographic factors, such as maternal age and level of education, combined (Donath and Amir, 2003). Intended breastfeeding duration was significantly associated with breastfeeding outcomes at 1 week and 4 months postpartum in a recent study of an Australian cohort of mothers with healthy infants (Blyth et al., 2004). Data from the Pregnancy Risk Assessment and Monitoring System indicates younger women and those of lower socioeconomic status are more likely to cease breastfeeding in the first month for reasons including sore nipples, inadequate milk supply, the infant
Table 5
153
having difficulties and perceptions that the infant was not satiated (Ahluwalia et al., 2005). Infant factors have also been shown to influence the likelihood of successful initiation and sustainability of breastfeeding. In a study of preterm infants, higher birthweight, lesser requirements for respiratory support and an absence of bottle feeding were positive predictors for higher infant competence with breastfeeding (Nyqvist and Ewald, 1999). A recent review of the literature regarding breastfeeding in the preterm infant population (Callen and Pinelli, 2005) reported average breastfeeding rates in the USA at approximately 50% at hospital discharge. Australian data indicates that whilst 90% of mothers initiate breastfeeding, only 48% are breastfeeding at 1 month postpartum (Blyth et al., 2004). Similarly, the current study shows 56% of babies discharged from the NNU were receiving breast milk, with 43% of those babies discharged home, exclusively breastfed. Strategies shown to aid in the initiation and sustainability of breastfeeding include non-nutritive sucking and kangaroo mother care that may aid in the transition from gavage to breastfeeding. It is recognised breastfeeding the fragile infant not only has benefits for the infant, but may enhance the maternaleinfant attachment process with mothers being provided an opportunity to participate in their baby’s care (Meier, 2001). Resources to aid in the sustaining of a breast milk supply in those mothers expressing milk for their sick infant range from provision of written information to the support of lactation consultants. Studies of such interventions have, to date, been non-experimental in design with no data provided regarding outcomes in comparison to non-intervention control groups. Longitudinal studies are required to identify barriers to breastfeeding in this population and potential interventions to enhance breastfeeding duration (Callen and Pinelli, 2005). This small, retrospective audit provides baseline information with respect to breastfeeding outcomes in the cohort of complex babies requiring tertiary level neonatal care in an Australian setting. The data, while in agreement with previously published literature, provides no information on the sustainability of breastfeeding in this population after
Demographic characteristics and feeding regimes of total cohort at discharge (mean values are shown)
Characteristic
Breastfeeding
Bottle feeding
Tube feeding
Gestational age (weeks) Birthweight (g) Length of stay (days)
37.9 3199.7 6.1
36.1 2662.0 11.7
33.1* 1999.1* 16.4*
*P < 0.001.
154 discharge home, particularly in light of the WHO recommendations. Further research needs to be undertaken, preferably using a longitudinal approach, to determine breastfeeding sustainability and reasons for cessation. Such information could be used to inform the development of resources for families both within the acute care sector, but probably more importantly, in the community.
Acknowledgements The authors would like to thank Elizabeth Perkins and Jo Brooks for their assistance in data collection.
References Ahluwalia, I., Morrow, B., Hsia, J., 2005. Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System. Pediatrics 116 (6), 1408e1412. Anderson, D.M., 2002. Feeding the ill or preterm infant. Neonatal Network 21 (7), 7e14. Anderson, E.S., Jackson, A., Wailoo, M.P., Petersen, S.A., 2002. Child care decisions: parental choice or chance? Child: Care. Health and Development 28 (5), 391e401. Arora, S., McJunkin, C., Wehrer, J., Kuhn, P., 2000. Major factors influencing breastfeeding rates: Mother’s perception of father’s attitude and milk supply. Pediatrics 106 (5), E67. Blyth, R.J., Creedy, D.K., Dennis, C.L., Moyle, W., Pratt, J., De Vries, S.M., et al., 2004. Breastfeeding duration in an Australian population: the influence of modifiable antenatal factors. Journal of Human Lactation 20 (1), 30e38. Callen, J., Pinelli, J., 2005. A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants. Advances in Neonatal Care 5 (2), 72e88. Chezem, J., Friesen, C., Boettcher, J., 2003. Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices. Journal of Obstetric, Gynecologic and Neonatal Nursing 32 (1), 40e47. Cooke, M., Sheehan, A., Schmied, V., 2003. A description of the relationship between breastfeeding experiences, breastfeeding satisfaction, and weaning in the first 3 months after birth. Journal of Human Lactation 19 (2), 145e156. Donath, S.M., Amir, L.H., 2003. Relationship between prenatal infant feeding intention and initiation and duration of
M. Trajanovska et al. breastfeeding: a cohort study. Acta Paediatrica 92 (3), 352e356. Furman, L., Minich, N.M., Hack, M., 1998. Breastfeeding of very low birth weight infants. Journal of Human Lactation 14 (1), 29e34. Furman, L., Minich, N., Hack, M., 2002. Correlates of lactation in mothers of very low birth weight infants. Pediatrics 109 (4), e57. Jaeger, M.C., Lawson, M., Filteau, S., 1997. The impact of prematurity and neonatal illness on the decision to breast-feed. Journal of Advanced Nursing 25 (4), 729e737. Kramer, M.S., Chalmers, B., Hodnett, E.D., Sevkovskaya, Z., Dzikovich, I., Shapiro, S., et al., 2001. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 285 (4), 413e420. Labbok, M., 2000. Breastfeeding Abstracts 19 (3), 19e21. Meier, P.P., 2001. Breastfeeding in the special care nursery. Prematures and infants with medical problems. Pediatric Clinics of North America 48 (2), 425e442. Nyqvist, K., Ewald, U., 1999. Infant and maternal factors in the development of breastfeeding behaviour and breastfeeding outcome in preterm infants. Acta Paediatrica 88 (11), 1194e1203. Nyqvist, K.H., Sjoden, P.O., Ewald, U., 1994. Mothers’ advice about facilitating breastfeeding in a neonatal intensive care unit. Journal of Human Lactation 10 (4), 237e243. Powers, N.G., Bloom, B., Peabody, J., Clark, R., 2003. Site of care influences breastmilk feedings at NICU discharge. Journal of Perinatology 23 (1), 10e13. Sable, M.R., Patton, C.B., 1998. Prenatal lactation advice and intention to breastfeed: selected maternal characteristics. Journal of Human Lactation 14 (1), 35e40. Scott, J.A., Binns, C.W., Aroni, R.A., 1997. The influence of reported paternal attitudes on the decision to breastfeed. Journal of Paediatrics and Child Health 33 (4), 305e307. Scott, J.A., Landers, M.C., Hughes, R.M., Binns, C.W., 2001. Factors associated with breastfeeding at discharge and duration of breastfeeding. Journal of Paediatrics and Child Health 37 (3), 254e261. Shaker, I., Scott, J.A., Reid, M., 2004. Infant feeding attitudes of expectant parents: breastfeeding and formula feeding. Journal of Advanced Nursing 45 (3), 260e268. Wheeler, J., Chapman, C., Johnson, M., Langdon, R., 2000. Feeding outcomes and influences within the neonatal unit. International Journal of Nursing Practice 6 (4), 196e 206. World Health Organisation, 2001. The Optimal Duration of Exclusive Breastfeeding. Report of an Expert Consultation. Geneva, Switzerland, 28e30 March 2001. Yip, E., Lee, J., Sheehy, Y., 1996. Breast-feeding in neonatal intensive care. Journal of Paediatrics and Child Health 32 (4), 296e298.
www.intl.elsevierhealth.com/journals/jneo
A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit M. Trajanovska a,b, S. Burns a, L. Johnston a,b,c,* a
Royal Children’s Hospital, Melbourne, Australia Murdoch Children’s Research Institute, Melbourne, Australia c The University of Melbourne, Melbourne, Australia b
Available online 22 June 2007
KEYWORDS Breastfeeding; NICU; Tertiary level care
Abstract Background: The World Health Organisation (WHO) and a substantial body of literature recommend breastfeeding from birth until at least 6 months of age. The nutritional, gastrointestinal, immunological, neurodevelopmental and psychosocial benefits of breastfeeding have been shown for term and preterm infants. Meeting the WHO recommendations for breastfeeding is problematic in the cohort of infants requiring hospitalisation in a neonatal intensive care unit (NICU) for management of complex medical and surgical conditions. Method: A retrospective audit of medical records of all infants admitted to the neonatal unit of the Royal Children’s Hospital, Melbourne, Australia between 2001 and 2003 was conducted. Results: One thousand, one hundred and sixty-three babies were admitted during the audit period. Babies discharged directly home were of significantly greater gestational age, higher birthweight and had a shorter length of stay than those babies transferred to another facility (P < 0.05). Fifty-six percent of the cohort was receiving breast milk on discharge from the neonatal unit. Babies exclusively breastfed on discharge were of greater gestational age and had a shorter length of stay in the NICU than those babies discharged on a combination of breast milk and formula, or formula alone (P < 0.001). Babies transferred to another facility, rather than discharged directly home, were less likely to be breastfed and more likely to receive enteral nutrition via intragastric tube feeds or a combination of bottle and tube feeds. Conclusion: Birthweight, gestational age, and length of stay in a neonatal intensive care unit are factors likely to influence breastfeeding in the cohort of babies requiring tertiary level care. ª 2007 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. School of Nursing, The University of Melbourne, Level 1/723 Swanston Street, Carlton, Vic. 3051, Australia. Tel.: þ61 3 8344 0768; fax: þ61 3 9347 4172. E-mail address: [email protected] (L. Johnston). 1355-1841/$ - see front matter ª 2007 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jnn.2007.05.005
A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit
Background In 2001 the World Health Organisation (WHO) issued a recommendation for the continuation of breastfeeding until 6 months of age, with the introduction of complementary foods thereafter (World Health Organisation, 2001). Benefits of breastfeeding have been identified as including a decreased risk of gastrointestinal infections (Kramer et al., 2001) and otitis media (Kramer et al., 2001) and an increased bonding between mother and infant (Arora et al., 2000). A mother’s decision to breastfeed their baby is usually made prior to, or during the pregnancy, with those mothers making the decision prior to pregnancy more likely to sustain breastfeeding (Arora et al., 2000; Jaeger et al., 1997; Shaker et al., 2004). The decision is based on such factors and beliefs as convenience (Anderson et al., 2002), ‘‘naturalness’’ (Arora et al., 2000; Wheeler et al., 2000), what is considered ‘‘best’’ for the baby (Anderson et al., 2002), and the partners’ preference (Scott et al., 1997; Wheeler et al., 2000). The proportion of mothers intending to breastfeed their healthy, term infant ranges from 77% to 87% in the USA and Australia, respectively (Chezem et al., 2003; Cooke et al., 2003). The nutritional, gastrointestinal, immunological, neurodevelopmental and psychosocial benefits of breastfeeding have also been shown for those infants born prematurely (Callen and Pinelli, 2005). Meeting the WHO recommendations is however, problematic for the cohort of babies requiring hospitalisation in neonatal intensive care early in life. Severity of illness and the associated complex medical interventions may preclude the successful establishment of breastfeeding in this population. Breastfeeding intention rates of mothers of preterm (Jaeger et al., 1997) and very low birthweight (VLBW) babies (Furman et al., 2002; Sable and Patton, 1998) admitted to neonatal intensive care are lower than those of mothers of healthy, term infants. Australian data suggests 80% of mothers of preterm infants indicated an intention to breastfeed, while in the UK, 70% of mothers reported an intention to breastfeed (Jaeger et al., 1997). This is in contrast to a study in the USA that reported a breastfeeding intention rate of 31% in mothers of VLBW infants, although an additional 13% reported an intention to partially breastfeed (Sable and Patton, 1998). While between 5% and 10% of mothers of healthy, term infants who had intended to breastfeed did not follow through with their feeding choice by time of discharge from hospital
151
(Anderson, 2002; Cooke et al., 2003; Shaker et al., 2004), almost 30% of mothers of premature and sick infants in Australia, did not follow through on their intention to breastfeed (Wheeler et al., 2000). Frequently identified factors impacting on the decision to cease breastfeeding in this population include separation from the infant (Jaeger et al., 1997), the infant’s medical condition, small size and fragility (Furman et al., 1998), and the NICU environment itself with high noise levels and lack of privacy (Furman et al., 1998; Nyqvist et al., 1994). Greater gestational age and larger birthweight have been shown to be positive predictors for the initiation and sustaining of breastfeeding (Powers et al., 2003; Scott et al., 2001). Australian and UK studies report rates of infants exclusively receiving breast milk1 on discharge from the NICU as between 45% and 62% (Jaeger et al., 1997; Wheeler et al., 2000; Yip et al., 1996) in comparison with rates for full term, healthy infants of 83% (Scott et al., 2001). The literature is replete with studies describing rates of, and factors impacting upon, breastfeeding in both the healthy, and preterm, populations. However, to date there has been little research addressing breastfeeding rates and sustainability in the population of infants with complex surgical conditions requiring prolonged management and a stay in the neonatal intensive care unit, where the introduction of enteral feeding of any type is substantially delayed. The aim of this study was to describe factors associated with the feeding outcomes at discharge of those babies requiring tertiary level, neonatal intensive care in Australia.
Method A retrospective audit was undertaken of medical records of all infants admitted to the neonatal unit (NNU) at the Royal Children’s Hospital, Melbourne, Australia between 2001 and 2003. The NNU is a 24bed intensive and special care nursery servicing a State-wide and often beyond, population of infants with complex medical, surgical, metabolic and genetic conditions. Data was analysed with SPSS Version 12.1 (SPSS Inc., Chicago, IL, USA). Tests used were descriptive statistics, one-way ANOVA and chi-square (or Fisher’s exact tests for cell 1 ‘‘Exclusive or full breastfeeding’’ is defined as no other liquid or solid from any other source enters the infant’s mouth except occasional tastes of other liquids, traditional foods, vitamins, medicines, etc. ‘‘Full breast milk feeding’’ refers to the infant receiving expressed breast milk in addition to breastfeeding (Labbok, 2000).
152
M. Trajanovska et al.
counts less than 5). Data are reported as mean values unless otherwise stated. The study was approved as a clinical audit by the Human Research Ethics Committee of the Royal Children’s Hospital.
Results Records of 1163 babies admitted to the Neonatal Unit between 2001 and 2003 were reviewed. Five hundred and thirty-four babies were discharged directly home from the Unit, 572 were transferred to another hospital and a further 57 babies died. In keeping with the expected profile of babies admitted to this NNU, the majority (63%) of admissions required some form of surgical intervention for complex conditions including; cardiac abnormalities (n ¼ 28), tracheo-oesophageal fistula (n ¼ 16), congenital diaphragmatic hernia (n ¼ 12), gastroschisis (n ¼ 10) and exomphalos (n ¼ 6). The majority (77%) of mothers had indicated an intention to breastfeed their baby. Demographic characteristics of babies discharged home or to another hospital are shown in Table 1. Babies discharged directly home were of significantly greater gestational age and higher birthweight and gained more weight during their stay than those babies transferred to another hospital on discharge. More than 50% of the cohort of babies were receiving breast milk at time of discharge through exclusive breastfeeding, expressed breast milk or a combination of breast milk and formula. There were slightly more babies discharged directly home receiving breast milk in comparison to those babies transferred to another facility, although this was not statistically significant (Table 2). Similar numbers of babies were discharged home or to other hospitals receiving a combination of breast milk and formula feeds.
Table 1 Demographic characteristics of babies discharged home or transferred to another facility (mean values are shown) Characteristic
Discharged Transferred, n ¼ 572 home, n ¼ 534
Gestational age (weeks) 37.4 Birthweight (g) 3036.2 Length of stay (days) 12.0 Difference between 570.3 birthweight and weight at discharge (g) *P < 0.05.
35.1* 2472.0* 11.2 429.9*
Table 2 Feed intake of babies discharged directly home or transferred to another facility Type of feed
Total cohort, n (%)
Breast 599 (56) milk Formula 312 (30) Combined 151 (13)
Discharged home, n (%)
Transferred, n (%)
304 (58)
295 (55)
151 (29) 70 (13)
161 (30) 81 (15)
At the time of discharge from the NNU, babies exclusively breastfed were of significantly greater gestational age and had a shorter length of stay than those babies discharged on a combination of breast milk and formula, or formula alone. Babies fed a combination of breast milk and formula were heavier at birth and those babies fed formula alone had the greatest weight gain by time of discharge, although they also had the longest length of stay (Table 3). Exclusive breastfeeding was the most common method of feeding at discharge. This was significantly different for babies discharged directly home when compared to those babies transferred with babies transferring to another facility more likely to be fed via intragastric tube or receiving nutrition via a combination of approaches (Table 4). Breastfeeding babies discharged from the unit were significantly different from those babies bottle- or tube-fed with respect to having a higher birthweight (P < 0.01), being of greater gestational age (P < 0.01), and having a shorter length of stay (P < 0.01) (Table 5).
Discussion Breastfeeding is globally recognised as the optimum approach to provision of infant nutrition. Table 3 Demographic characteristics and feed intake of total cohort at discharge (mean values are shown) Characteristic
Breast Formula, Combined, milk, n ¼ 312 n ¼ 151 n ¼ 599
Gestational age 36.6 35.4 (weeks) Birthweight (g) 2859.3 2513.6 Length of stay (days) 9.2 17.8 384.3 832.5 Difference between birthweight and weight at discharge (g) *P < 0.001.
36.9* 2831.6* 10.9* 313.7*
A retrospective study of breastfeeding outcomes in an Australian neonatal intensive care unit Table 4 Method of feeding at discharge home (n ¼ 523) or on transfer to another facility (n ¼ 533) Feeding method
Discharged home, n (%)
Transferred, n (%)
Breastfeeding Bottle feeding Intragastric tube feeding Combined Gastrostomy
226 (43.2) 159 (30.4) 12 (2.3)
66 (12.4)* 81 (15.2) 164 (30.8)
125 (23.9) 1 (0.2)
220 (41.3) 2 (0.4)
P < 0.001.
There is a substantial body of literature describing factors that influence a woman’s decision to breastfeed, breastfeeding rates in healthy infants, and barriers to the initiation or sustaining of breastfeeding in both the healthy and premature infant population. However, there is little information available on the breastfeeding outcomes of those babies admitted to a tertiary paediatric referral centre for management of complex medical and surgical conditions. This study sought to describe current rates of breastfeeding on discharge of infants from such a centre, and undertake an exploratory analysis of the factors that might impact on breastfeeding sustainability. The majority of mothers in our study (77%), indicated an intention to breastfeed; a figure consistent with the international literature. Donath and colleagues have reported maternal intention to be a stronger predictor of both breastfeeding initiation and duration than other demographic factors, such as maternal age and level of education, combined (Donath and Amir, 2003). Intended breastfeeding duration was significantly associated with breastfeeding outcomes at 1 week and 4 months postpartum in a recent study of an Australian cohort of mothers with healthy infants (Blyth et al., 2004). Data from the Pregnancy Risk Assessment and Monitoring System indicates younger women and those of lower socioeconomic status are more likely to cease breastfeeding in the first month for reasons including sore nipples, inadequate milk supply, the infant
Table 5
153
having difficulties and perceptions that the infant was not satiated (Ahluwalia et al., 2005). Infant factors have also been shown to influence the likelihood of successful initiation and sustainability of breastfeeding. In a study of preterm infants, higher birthweight, lesser requirements for respiratory support and an absence of bottle feeding were positive predictors for higher infant competence with breastfeeding (Nyqvist and Ewald, 1999). A recent review of the literature regarding breastfeeding in the preterm infant population (Callen and Pinelli, 2005) reported average breastfeeding rates in the USA at approximately 50% at hospital discharge. Australian data indicates that whilst 90% of mothers initiate breastfeeding, only 48% are breastfeeding at 1 month postpartum (Blyth et al., 2004). Similarly, the current study shows 56% of babies discharged from the NNU were receiving breast milk, with 43% of those babies discharged home, exclusively breastfed. Strategies shown to aid in the initiation and sustainability of breastfeeding include non-nutritive sucking and kangaroo mother care that may aid in the transition from gavage to breastfeeding. It is recognised breastfeeding the fragile infant not only has benefits for the infant, but may enhance the maternaleinfant attachment process with mothers being provided an opportunity to participate in their baby’s care (Meier, 2001). Resources to aid in the sustaining of a breast milk supply in those mothers expressing milk for their sick infant range from provision of written information to the support of lactation consultants. Studies of such interventions have, to date, been non-experimental in design with no data provided regarding outcomes in comparison to non-intervention control groups. Longitudinal studies are required to identify barriers to breastfeeding in this population and potential interventions to enhance breastfeeding duration (Callen and Pinelli, 2005). This small, retrospective audit provides baseline information with respect to breastfeeding outcomes in the cohort of complex babies requiring tertiary level neonatal care in an Australian setting. The data, while in agreement with previously published literature, provides no information on the sustainability of breastfeeding in this population after
Demographic characteristics and feeding regimes of total cohort at discharge (mean values are shown)
Characteristic
Breastfeeding
Bottle feeding
Tube feeding
Gestational age (weeks) Birthweight (g) Length of stay (days)
37.9 3199.7 6.1
36.1 2662.0 11.7
33.1* 1999.1* 16.4*
*P < 0.001.
154 discharge home, particularly in light of the WHO recommendations. Further research needs to be undertaken, preferably using a longitudinal approach, to determine breastfeeding sustainability and reasons for cessation. Such information could be used to inform the development of resources for families both within the acute care sector, but probably more importantly, in the community.
Acknowledgements The authors would like to thank Elizabeth Perkins and Jo Brooks for their assistance in data collection.
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