1 Lactation Cessation Among Mothers of Very Low Birth Weight Infants Ashley Hartley, Cla ra Engelmann, and Leslie Parker College of Nursing, Univer sity of Florida Breast milk improves the health of very low birth weight infants (<1500g) by decreasing the incidence of necrotizing enterocolitis, late onset sepsis, and improving neurodevelopmental outcomes. Unfortunately, mothers of very low birth weight infants cease lactating much earlier th an mothers of term infants and little information exists regarding the etiology of this early cessation. Therefore, the purpose of this study was to determine the etiology of lactation cessation in mothers of premature very low birth weight infants. Mother s of infants less than 32 weeks gestation and less than 1500 grams who neonatal intensive care unit were interviewed either in person or over the phone regarding their reasons for lactation cessation. Fifty four mothers completed the interview. Reasons for lactation cessation included insufficient breast milk production, lack of t ime, stress, ve ry low birth weight infants cease lactation for a variety of reasons, with the most common being insufficient breast milk production. Information regarding why mothers of very low birth weight infants cease lactation is critical to determin ing strategies t o facilitate a longer lactation in this population and thus increas ing c onsumption of breast milk by the s e vulnerable infants INTRODUCTION remature very low birth weight (VLBW) infants are at significant risk for complications of prematurity. Late onset sepsis, necrotizing enterocolitis (NEC), sudden infant death syndrome (SIDS), retinopathy of prematurity, and neurodevelopmental delays are a mong the many issues that arise in this vulnerable population. However, breast milk consumption has been shown to reduce the risk of SIDS by 50% ( Vennemann et al, 2009), provide a sixfold decrease in the incidence of NEC ( Sisk, Lovelady, Dillard, Gruber, & O'shea, improve mental, motor, and behavior ratings at ages 18 Bertino et al, 2012), and lower the rates of hospital readmissions a fter discharge (Schanler, 2011). Furthermore, benefits of breast milk persist throughout the lifespan. There are increases in intelligence scores, white matter, and total brain volume in children and adolescents who were fed breast milk as infan ts in the NICU (Bertino et al 2012). It has also been shown to reduce the incidence of t ypes 1 and 2 diabetes, obesity, asthma, and certain cancers (Gartner et al, 2005). Unfortunately, mothers of VLBW infants often cease lactating earlier than mothers of full term infants, thereby decreasing the amount of ive. Beyond the benefits to the infant, supplying breast milk is also beneficial to the mother. In an article published by L.M. Gartner in the journal Pediatrics he discussed how breast milk production aids in the postpartum period by reducing bleeding, a ccelerating uterine involution, and promoting quicker weight loss to return to pre pregnancy baseline. Evidence also suggests a reduction in the risk of developing breast and ovarian cancers, as well as protection against osteoporosis after menopause (Gart ner et al, 2005). Encouraging successful lactation should be seen as a means of promoting optimal health outcomes for both the mother and child. Despite the variance in hospital stays, only 49% of preterm mothers are breastfeeding at discharge compared to 69% of term mothers (Callen & Pinelli, 2005 ). This discrepancy arises due to barriers faced by preterm mothers in initiating and sustaining successful lactation. While the exact mechanism for these lactation difficulties are unknown, premature mothers do not have sufficient quantities of hormones t o stimulate milk production that are present in later term pregnancy. VLBW infants in particular require lengthy hospital stays after birth, so mothers of this population are required to depend on mechanical breast expression along with decreased stimulati on from deficient skin to skin contact, lack of suckling, and inability to hear the baby crying when not at the bedside (Callen et al 2005). These compounding factors elicit difficulties in the lactation period for the VLBW mother and can lead to stress an d discouragement as she tries to meet the nutritional needs of her infant. This qualitative study aims to identify reasons for early lactation cessation among mothers of VLBW infants. After identifying perceived barriers to successful sustained lactation, we can then formulate interventions to combat these issues and potentially increase lactation duration in this population. The overall goal is to improve outcomes of vulnerable VLBW infants by providing them more access to ast milk. P
A SHLEY H ARLEY C LARA E NGELMANN & L ESLIE P ARKER University of Florida | Journal of Undergraduate Research | Volume 19, Issue 2 | Spring 201 8 2 METHODS Procedure Inclusion criteria consisted of women over 18 years of age with an infant born at or before 32 weeks gestation weighing less than 1500 grams on the neonatal intensive care unit (NICU) at UF Health Shands Hospital. Following app roval from the Institutional Review Board, mothers fitting the criteria were recruited to participate in the study. Subjects were gathered as a part of a larger randomized control trial (RCT) investigating interventions to increase lactation success. If th e mother assented, a written consent form was signed on the unit either before or after delivery. Milk logs of the mothers enrolled in the RCT were monitored to identify any moms that had stopped supplying breast milk n this identification, the mothers were contacted to confirm they had ceased lactation and to extend an invitation to participate in an interview. A total of 54 mothers participated in the interview process. Mothers were interviewed either over the phone o r in person while visiting their baby in the NICU. Questions addressed the s while breast pumping and focused on determining factors influencing their decision to stop supplying breast milk. A thematic analysis was performed on the trans cribed interviews. Limitations Limitations to this study include the fact that the subjects were only enrolled from one NICU. Some interviews were also conducted retrospectively, allowing for errors in memory that could have lead to false reporting. The na ture of direct questioning could have elicited responses participants may have felt we wanted to hear or that they felt would not disappoint the interviewer. RESULTS Seven themes were identified among the responses as precipitating factors for lactation ce ssation: 1) Insufficient production, 2) Lack of time, 3) Stress, 4) Baby being in Within each theme, mothers cited several aspects of their experience that either contributed to or detracted from the ir lactation success. A majority of subjects attributed more than one factor to her decision to stop breast pumping. For insufficient production, women reported ways in which they tried to facilitate production, such as hand massage, warm showers, medicati ons, and pumping at the bedside. Despite their increased efforts they were still unable to produce milk in sufficient quantities, which ultimately lead to their decision to stop pumping. Mothers often felt they did not have enough time to dedicate to the rigorous pumping schedule that requires pumping every 2 3 hours. When they had other children at home, had returned to work, had to get up throughout the night to pump after a long day, or had to travel to and from the hospital, many mothers found it diff icult to find time to set aside for pumping. Stress also added to the difficulty. Not only were mothers often stressed simply by their baby being in the hospital, but the pumping schedule, their work and school responsibilities, and even the pressure to s upply enough milk for their babies added undue psychological stress on these women. Several issues surrounding their bab ies being in the NICU made breast pumping a difficult endeavor for many of these mothers. A major contributor was the lack of stimulation resulting from being separated from their infant mothers also reported that even when trying to pump at the bedside, the environment of th e NICU was not relaxed enough for them to pump comfortably. Oftentimes women suffered from pain while pumping. Some cited an improper nipple shield fit and were simply not properly educated on how to alleviate that problem. Others were unable to bear the p ain of breast engorgement or felt a general pain or discomfort while pumping. There were a few women who decided they did not want to continue pumping for various other reasons. Among those reasons were a desire to return to smoking, a feeling that the sch edule was too difficult, or a decision that there was not a need to provide breast milk when a baby was doing well on formula. In the other reasons cited for discontinuing lactation two women were ordered to stop by doctors due to the development of masti tis. Two other mothers had returned to taking pre pregnancy medications that they attributed to caloric intake than the mother could supply; another baby developed an adverse reaction to the dairy milk ; and, finally, one woman felt too embarrassed to pump. DISCUSSION Mothers of VLBW infants cease lactating for a variety of reasons, with the most commo n being insufficient production. Results of this study set the framework for further investigation on the etiology of lactation cessation in mothers of VLBW infants and the implications of that focus on increasing the lactat ion duration in this population. The majority of mothe rs reported more than one factor contributing to her cessation. This finding indicates a possible interplay between multiple challenges mothers of this population face while lactating. Information regarding why mothers of VLBW infants cease lactation is cr itical to determine strategies to facilitate a longer lactation in this
L ACATION C ESSATION A MONG M OTHERS OF V ERY L OW B IRTH W EIGHT I NFANTS University of Florida | Journal of Undergradua te Research | Volume 19, Issue 2 | Spring 201 8 3 population and to therefore to increase consumption of breast milk by these vulnerable infants. Many of the problems encountered by the mothers are non modifiable. For instance, the need to pump every 2 3 hours is based on research demonstrating this is the most effective method for consistent milk production, especially in a population vulnerable to insufficient supply. However, addressed. In some instances, there was simply a knowledge Pumping should be a painless experience when done properly. Mothers who felt pain from engorgement could be taught to pump sooner to avoid becoming overfilled. Pain resulting from improper nipple shield fit can be avoided through consultation with a lactation specialist to identify the appropriately sized nipple sh ield. Furthermore, education on the benefits of breast milk should begin earlier in pregnancy. Many women were not taught about breast milk until they had given birth. Their understanding of the cruciality of the components of breast milk for their infant was very shallow; although, they did ultimately grasp that it Early education in the prenatal period would potentially encourage more successful lactation and therefore would improve health outcomes of both infants and mothers. Additionally, several issues arise from the baby being in the NICU. Much of the stress involved in the pumping process can be traced back to the difficulty of having a baby bound to the hospital. One way this issue can be address ed would be for hospitals to start adapting to the needs of both the mother and child, viewing them as symbiotic rather than focusing only on the needs of the infant. If the hospital were able to provide a more relaxed environment for pumping, offer suppor t during the lactation process, and potentially provide sleeping accommodations for the mother on the unit, it could lessen the burden of the hospital stay and the mother could care. Oftentimes mothers felt detac hed from her infant or discouraged by the hospital staff and/or environment. By eliminating this unnecessary burden, more women could achieve better lactation success. The importance of breast milk to VLBW infants is insurmountable. Through its significan t reductions in risks associated with life threatening complications of prematurity, breast milk enables survival for infants that otherwise lack basic defenses. This study investigated potentially modifiable barriers faced by women in supplying this essen tial nutrient to their infant. Using this information and further research on the subject, we will be able to direct interventions towards promoting optimal health outcomes of both the mother and her vulnerable infant. REFERENCES Bertino, E., Di Nicola, P. Giuliani, F., Peila, C., Cester, E., Vassia, C., feeding. Journal of Pediatric and Neonatal Individualized Medicine (JPNIM) 1 (1), 19 24. Callen, J., & Pinelli, J. (2005). A review of the li terature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants. Advances in Neonatal Care 5 (2), 72 88. Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O'Hare, D., Schanler, R. J., & Eid elman, A. I. (2005). Breastfeeding and the use of human milk. Pediatrics 115 (2), 496 506. Gatti, L. (2008). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of Nursing Scholarship 40 (4), 355 363. Schanler, R. J. (2011, February) Outcomes of human milk fed premature infants. In Seminars in perinatology (Vol. 35, No. 1, pp. 29 33). WB Saunders. Sisk, P. M., Lovelady, C. A., Dillard, R. G., Gruber, K. J., & O'shea, T. M. (2007). Early human milk feeding is associated with a lower r isk of necrotizing enterocolitis in very low birth weight infants. Journal of Perinatology 27 (7), 428 433. Vennemann, M. M., Bajanowski, T., Brinkmann, B., Jorch, G., Ycesan, K., Sauerland, C., & Mitchell, E. A. (2009). Does breastfeeding reduce the risk of sudden in fant death syndrome?. Pediatrics 123 (3), e406 e410.