From: Kerstin Hedberg Nyqvist [mailto:[log in to unmask]]
Sent: 23. januar 2002 18:28
To: [log in to unmask]
Cc: [log in to unmask]
Subject: Premies and readiness to breastfeed

Dear Lacnetters!
It has been very interesting to read the discussion regarding breastfeeding
preterm infants, as this was the subject of my doctoral dissertation and is
still the focus of my current clinical and research activities (please see
references below).
Common "old" assumptions that preterm infants cannot be breastfed until
34-34 weeks (sometimes used as meaning PCA = postconceptional age) still
seem to prevail, inspite of overwhelming research evidence of the contrary.
In my research, I followed 71 infants, born at a gestation of 26 to 35
weeks, until discharge from hospital. The mothers commenced breastfeeding as
soon as the infants did not need ventilator/CPAP, from 26 postmenstrual
weeks (corresponding to 24 weeks PCA). Irrespective of maturational level on
the first day with breastfeeding, all infants demonstrated rooting, latched
on, and sucked (there were a few exceptions, infants at 33-35 weeks PMA
(31-32 PCA). Soon after that, they showed some milk intake at the breast.
57/71 infants were discharged with full breastfeeding, at a median
maturational level of 36 weeks PMA (34 PCA), ranging between 33-40 (31-38
PCA). Infants with a longer period of ventilator support took more time to
reach full breastfeeding. From this, we concluded that it is incorrect to
use criteria expressed as so and so maturational weeks or weight. The only
valid criterion is that the infant can breathe on his/her own and is not
fragile. (Additional oxygen through nasal prongs is no contraindication for
breastfeeding.)
In agreement with neurophysiological findings by other researchers, our data
indicated that early experience (exposure to the mother's breast)
contributed to earlier emergence of competent behavior at the breast. The
development of motor skills is not "programmed" to occur at a certain
maturational level - instead the experience triggers development. Of course,
there is a lower limit to this - in this case extreme prematurity,
associated with need of ventilator support etc.
A huge volume of research has been published on the Kangaroo Mother Care
(KMC) method. In these studies, preterm infants are fed at the breast from a
low maturational level - without any "training" or preparation, other than
what is achieved at the mother's breast.
Regarding feeding cues: Very early during gestation the fetus practices
rooting, sucking (finger sucking) and swallowing (reported in studies using
ultrasound - see Prechtl and de Vries for references). All preterm infants
enter the extrauterine world with considerable experience of these activies.
Therefore, no "training " is needed - but we must offer preterm infants
regular opportunity to suck (on a pacifier, on his own fingers/hands), as
part of the normal developmental process. Readiness to suck can occur
spontaneosly, but preterm infants differ from term infants in that they very
often show readiness as soon as they are offered the stimulus of gentle
touch on the lips - also when they seem to be asleep, or not active.
Regarding bottle feeding: It has been demonstrated in numerous studies
(already in the 1980's by Paula Meier) that bottle feeding is associated
with impaired respiration and saturation, and fatigue in preterm infants
(increased energy consumption), in contrast with breastfeeding. The reason:
at the breast the infant is able to co-ordinate sucking and breathing. You
sometimes hear nurses say that the breastfeeding sessions should be
restricted to 30 minutes (example), so the infant does not get tired. This
is just one more of the old assumptions, which has been proved incorrect by
research.
In addition, the infant uses a different sucking technique during
bottle-feeding (compared to breastfeeding): uses different muscles, in a
different way. So, today there is ample evidence that bottle-feeding
interferes with breastfeeding - is counterproductive - and should be
introduced with extreme caution (if ever). And not before breastfeeding is
introduced.
Regarding co-ordination of suck-swallow-breath: Also healthy fullterm
infants can show initial difficulties. The preterm infant's initial feeding
pattern is to make a few sucks, then swallow and breathe, and suck again
(pauses in respiration during sucking). During a transitional period, the
infant gradually begins to alternate between this immature pattern, and a
pattern with periods of long sucking periods interspersed with hardly
noticeable rapid breaths. The mature sucking pattern follows next, with very
long sucking periods. Please note: an immature sucking pattern is sufficient
for managing full breastfeeding!
Mothers should be informed about this, and about the fact that the preterm
infant needs long breastfeeding sessions, in order to suck enough and be
satisfied. This is part of the normal developmental process. One more thing:
before the infant reaches term age, the mother must be in control of the
frequency of feeding (see to it that the infants has a sufficient number of
feeding sessions per 24 hours. Before term age, the CNS has not yet matured
regarding control of hunger and sleep-wake transition. On-demand feeding can
be established later on,
I noticed that cup-feeding is rarely mentioned in connection with this
issue. This is a simple, natural method for oral feeding of preterm infants,
evaluated in research from a maturational level of 30 weeks. It does not
interfere with the sucking technique used during breastfeeding, and does not
compromise the infant to the same extent as bottle-feeding.
Regarding "moms asking: when can I breastfeed": This information should be
given to mothers spontaneously, in advance, the NICU staff: "When your baby
is off the CPAP, and we see that he handles it (abour one day or so), you
can begin to offer the breast." This wonderful event should not be delayed
without a special reason.
Please excuse this long letter, but I wanted to contribute to a discussion
that seemed to lack certain professional "substance".
Kerstin Hedberg Nyqvist, RN PhD IBCLC
Dept. of Women's and Children's Health, University Children's Hospital,
Uppsala, Sweden
REFERENCES
Nyqvist KH, Ewald U, Sjödén P-O. Supporting a preterm infant's behavior
during breastfeeding: A case report. Journal of Human Lactation
1996;12:221-28
Nyqvist KH, Ewald U, Sjödén P-O. Development of preterm infants'
breastfeeding behavior. Early Human Development 1999; 55:247-264
Nyqvist KH, Ewald U. Infant and maternal factors in the development of
breastfeeding behavior and breastfeeding outcome in preterm infants. Acta
Paediatrica 1999;88:1194-1203
Nyqvist KH. The development of preterm infants' milk intake during breast
feeding. Journal of Neonatal Nursing. Journal of Neonatal Nursing
2001;7(2):48-52
Nyqvist KH, Färnstrand C, Edebol Eeg-Olofsson K, Ewald U. Early Oral
Behaviour in Preterm Infants during Breastfeeding: an EMG Study. Acta
Pediatrica, 2001;90:658-63

             ***********************************************
The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(TM)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html