Breastfeeding the Late Pre-Term Infant (LPTI) was a presentation at the 2021 ALCI Spring Study Day by Liz Greene RGN, RM, RNT, IBCLC

Liz opened by acknowledging that we are seeing more of these late preterm infants (LPTI) due to a rise in the incidence of multiple birth pregnancies and resulting earlier gestation births, which in turn leads to a higher prevalence of feeding difficulties and increase in additional support required.

The LPTI is classified as 34+0 -36+6 week gestation, with moderate preterm infants (MPTI) being classified as 32+0 – 33+6 week gestation. Normal weight at 34+0 weeks (female and male respectively) >1.6-1.7kg and at 36+6 (female and male respectively) >2.2kg -2.3kg. This highlights the range of weight, maturation and significant development that is missed during this three-week period in utero.

British association of perinatal medicine (BAPNM) acknowledge that LPTI have specific needs that require more attention, and have established a working group for health care professionals; “Management of moderate preterm infants framework for practice” first draft is being prepared.

Alongside earlier gestation birth it is important to also acknowledge whether the LPTI was growth restricted in utero. Low birth weight is classified as <2.5kg – if body weight was <2nd centile for gestation the baby is smaller than average – resulting in less body fat and energy reserves which will impact upon oral feeding abilities. For this reason, despite maternal breast milk for LPTI infants being higher in protein and more tailored to increased requirements of the LPTI compared to the term infant, fortification of breast milk is often indicated particularly if growth restriction in utero or if growth has faltered since birth, static weight gain, concerns with length or head circumference etc. Donor milk is valuable for this cohort of infants but important to recognise nutritional limitations, and therefore these infants may require specific preterm infant formula to help meet increased nutritional requirements.

Liz highlighted the increasing role of Neonatal dietitians within this setting to improve the care and outcomes these infants and their families are experiencing and the balancing act that is required between volume targets, fluid requirements and growth targets, and establishing oral feeding successfully.

Anyone who is helping the mother to feed her late preterm infant should think about what has baby’s story been so far so that care can be individually tailored to infants’ needs – admission criteria for NNU vary between units. We know the LPTI is at increased risk of:

• Respiratory Distress Syndrome -reduced surfactant
• Hypothermia -reduced body weight and body fat
• Hypoglycaemia
• Jaundice
• Poor feeding -natural consequence is that baby has less energy available to feed vs challenges
• Suspected sepsis
• Increased risk of readmission following discharge

Ignition of BF usually encouraged from 32 weeks, bottle-feeding often from 33-34 weeks gestation. Individual assessment of oral feeding readiness is crucial -importance cannot be overlooked or underestimated particularly if goal of parent is to breastfeed.

Benefits of having a tool to undertake individual assessment

• Safe transition to oral feeding is key by assessing pace of baby’s developmental readiness
• Reduce problematic feeding issues in the future
• Working beyond the hospital stay and safeguarding future feeding
• Minimise feeding issues
• Focuses on readiness and ability of PTI

PIOFRAS (preterm infant oral feeding readiness assessment scale) and PIBBS (Preterm infant breastfeeding behaviour scale) focused on as specifically look at infant readiness rather than assessing feeding once already established with the aim to not start at pace beyond infant’s ability.

PIOFRAS

• Gestation of baby looked
• Non-nutritive suck used as starting point for feeding readiness and baby behavioural state -oral and body positions, reflexes etc.
• Movement of tongue -cupping, movement and sucking strength
• Babies alertness also looked at
• Stress signs during non-nutritive sucking -saliva accumulating, nasal nares trembling, colour changes or apnoea, tone changes, hiccupping, crying, refusal etc.
• Visual or felt observation on finger
• This tool was envisaged to be undertaken by oral therapists – limitations of staffing and skill set available

PIBBS

• Completed by the mother
• Advantage -similar to previous tool -rooting, suck, swallow, alertness, time baby actively sucking/swallowing, but also how mother feels baby is feeding

How can we support optimal feeding for mother and the late preterm baby?

Well documented that nasogastric tube feeding (NGT) and orogastric tube feeding (OGT) and bottle feeding standard practice with this cohort of infants.

1. Breastfeed/Hand express (HE) within 1 hour of birth

• The reason for birth between 34+0 -36+6 gestation may have required operative or assisted birth, oxytocin release could be inhibited by stress related to birth
• If either mother and/or baby requires medical and midwife/nursing care at birth, support mother to HE and collect colostrum as soon as possible
• Offering pictures of baby to aid HE of colostrum

2. Kangaroo care (KC) -want to facilitate as much as possible but realistic challenges i.e., space on NNU, maternal comfort, seating available -recliner i.e., laid back BF, if available they enhance the care available. Restricted growth infants can be difficult to hold. Gentle swaddle/cushions can be important to facilitate
3. Regular BF/expression and double electric pumping of breast milk -PTI may not have adequate strength suck to stimulate milk removal -therefore breast pump crucial if milk not being removed. Importance of keeping mother updated on infant’s progress if separated and providing photos to support with lactogenesis II

Keeping LPTI and mother together (“rooming in”/transitional care) increases:

• STS/KC
• BF initiation
• Lactogenesis II
• Use of cup/tube feeding as alternate to bottle teats
• Likelihood of BF continuation

Not all units have transitional care services, not a “place” but tailored support to these mothers and babies, increased workload to staff needs to be recognised

If we push oral feeding too much -negative future feeding behaviours are likely

Cup feeding:

• Can be commenced from 32 weeks onward
• Baby is using lips, tongue, jaw, which will help to develop, suck skills
• Can be messy -that is the norm
• Increased BF continuation
• Reduces bottle teat usage
• Unsure if this increases length of stay in hospital
• Cup feeding is infant driven -babies can lap milk earlier

“At breast” supplementer:

• Evidence of its success >37+0 weeks gestation
• Further research is need for LPTI
• Pre-requisites – readiness to feed, maintain a good latch, organised sucking and swallowing
• Known challenges – fiddly, cost of tubes, tube blockage or dislodged

Finger feeding:

• Suitable from 32+0 weeks onward
• Useful if baby has sucking/latching difficulties
• Breastmilk or alternative in a container level to baby or lower
• Tube taped to index finger

Elevated side lying:

• Acknowledges developmental stage of baby
• Recommended in NNU and transitional care settings
• Mimics cross cradle BF hold and paced feeding therefore easing the transition back to breastfeeding

“Prompts” that can lead to negative feeding behaviours

• Suddenly waking baby and commencing an oral feed
• Rubbing/moving baby’s jaw to suck-swallow
• Increasing the milk flow
• Chin and cheek support
• “Jiggling” the teat to encourage sucking/swallowing
• Tilting back baby’s head and neck during suck-swallowing

What are the key messages for supporting a mother to breastfeed her LPTI:

– Facilitate STS as often as possible

– HE and use of double electric breast pump in early days/weeks

– Individualised advice and support for mother based on observation of baby’s readiness for oral feeding

– Avoid/minimise separation of mother and baby

– Transitional care

– Tube and cup feeding increase likelihood of BF continuation

Jenni Ashcroft April 2021.

Jenni received a bursary of €100 from ALCI to attend the online ALCI Spring Study Day 2021.