Lactation Counseling for Mothers of Very Low Birth Weight Infants: Effect on Maternal Anxiety and Infant Intake of Human Milk

Abstract

OBJECTIVE. Although it is well documented that breastfeeding promotes health and development of very low birth weight (VLBW) infants, lactation initiation among mothers of VLBW infants is low. Mothers are anxious about the health of their children, and medical staff may be reluctant to promote breastfeeding out of concern for increasing that anxiety. Therefore, the purpose of this study was to examine whether mothers of VLBW infants who initially planned to formula feed were different in terms of their level of anxiety and maternal stress compared with mothers who had planned to breastfeed their infants. The aims of this study were to (1) determine whether counseling mothers of VLBW infants who had initially planned to formula feed on the benefits of breast milk would increase their stress and anxiety levels, (2) assess whether mothers who initially had not planned to breastfeed changed their plans after counseling to provide breast milk, and (3) measure the amount of breast milk expressed by mothers who initially planned to formula feed. Their results were compared with those of mothers of VLBW infants who initially planned to breastfeed. METHODS. Initial plan to breastfeed (initial breastfeed group [IBG]; n = 115) or formula feed (initial formula feed group [IFG]; n = 81) was determined before counseling. All participants received counseling on infant health benefits, collection and storage of breast milk, and breast pump procurement. Maternal anxiety was measured using the State-Trait Anxiety Inventory (STAI), which was administered to mothers before and after counseling and every 2 weeks until infant discharge. Maternal stress was measured after counseling with the Parental Stressor Scale: NICU. Infant breast milk intake was measured throughout hospitalization. An exit questionnaire that pertained to the perceived benefits and efforts of expressing milk was administered close to the time of infant discharge. RESULTS. After lactation counseling, 100% of the IBG and 85% of the IFG initiated breast milk expression (used the electric breast pump in the hospital) for a total lactation initiation rate of 94%. After adjustment for the mothers who initiated milk expression but did not provide any breast milk, the lactation initiation rate for the entire group was 84%. Non-Hispanic black mothers and Non-Hispanic white mothers initiated milk expression at similarly high rates (95% vs 93%). Also, milk expression initiation was similar for low-income and non–low-income mothers (95% vs 92%). IFG and IBG STAI and Parental Stressor Scale: NICU scores were not significantly different, and there were no significant differences between groups in the change in anxiety after counseling. In addition, the mean difference scores (after counseling − before counseling) for STAI anxiety “state” were not significantly different between groups, even when controlling for “trait” anxiety. State anxiety declined during the first 6 weeks of infant hospitalization in a similar manner for both groups. Maternal trait but not state anxiety scores were inversely correlated with total infant breast milk intake. Breast milk intake (mL/kg per day) was greater in the infants of mothers in the IBG compared with the IFG at each week during the first month and for their entire hospital stay. Infant breast milk intake increased from weeks 1 to 3 in both groups and continued to rise in the fourth week for the IBG. However, breast milk intake declined at week 4 for the IFG. IBG infants received breast milk for 83% of the total fed hospital days (days that feedings were given) compared with 44% of total fed days for the IFG. The proportion of enteral intake that was breast milk was also greater for the IBG compared with IFG during the first 4 weeks and for the total hospitalization. However, the mothers in IFG were able to provide at least 50% of their infants' enteral intake for the first 3 weeks, 48.8% for the fourth week, and 32.8% of the enteral intake for the entire hospitalization. Infants of low-income women received significantly lower amounts of breast milk than did infants of non–low-income mothers. Race and income accounted for 36% of the variance in breast milk intake. Of the 184 mothers who initiated breast milk expression, 72 (39%) completed the exit questionnaire. Infant health benefits were the most common reasons cited by both groups for expressing milk. The most common reasons that both groups reported for ceasing milk expression were (1) low milk supply, (2) returning to work or school, and (3) inability to pump as often as needed. Almost all of the mothers reported that pumping was worth the effort (IBG 100%, IFG 87%), and 100% said that they were glad that the staff helped them with milk expression. CONCLUSION. Counseling mothers of VLBW infants increases the incidence of lactation initiation and breast milk feeding without increasing maternal stress and anxiety.

Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants

“…31 Providing lactation education and lactation support is effective at achieving high lactation initiation and duration of milk expression among mothers of VLBW infants. 19,32 We acknowledge that there are limitations of this study. First, the data were collected primarily for another purpose and for this present analysis of the association between high intake of HM and risk of NEC, the study power was relatively modest.…”

“…Study participants were delivered between May 2001 and August 2003, with birth weight between 700 and 1500 g. Their mothers participated in a study comparing anxiety levels before and after lactation counseling. 19 A prospective sample of 200 mother-infant pairs was targeted to provide a basis for detecting a pre-intervention/post-intervention difference of 0.4 standard deviation at 80% power in the State Trait Anxiety Scores, assuming a standard deviation of 10.6. Exclusion criteria for that study were illicit drug use during pregnancy, human immunodeficiency virus infection, age less than 18 years, and nonEnglish speaking.…”

Positive effect of NICU admission on breastfeeding of preterm US infants in 2000 to 2003

“…A Cochrane review of 34 trials (29 385 dyads) showed a lower risk 23 In a study of lactation consultant counseling in mothers of very low birth weight infants, after counseling was performed 85% of 81 mothers who initially planned to formula feed their infants initiated breastfeeding, and 100% of mothers who had initially intended to breastfeed were able to do so. 24 The investigators also demonstrated through psychological testing that this counseling did not increase maternal anxiety levels in either group. This runs counter to a belief that breastfeeding creates a burden on already-stressed mothers of NICU-admitted infants.…”

Combining hand techniques with electric pumping increases milk production in mothers of preterm infants

“…[2][3][4] Insufficient production in the first 6 weeks postpartum is the most common reason for discontinuing lactation, 2.8 times more frequent in mothers of preterm than those of term infants. [5][6][7] Also, average milk output in mothers of preterm infants has been shown to falter after 2 to 3 weeks, decline over the next 3 weeks and consistently remain below that of mothers of term infants. 6 Mothers of preterm infants are pump dependent for months before establishing non-pump-dependent breastfeeding, making the sustained, upward trajectory of milk production over months the critical factor.…”

“…For example, race and socioeconomic factors influence initiation rates for term infant mothers, but not for mothers who deliver prematurely and learn the protective benefits of their milk. 7 Modifiable variables are pumping initiation (time between birth and first expression), frequency and duration, and the longest interval between two pumping sessions (potential sleeping time). However, few studies have evaluated the use of manual techniques to increase milk yield and/or milk quality.…”