Management of Breastfeeding During and After the Maternity Hospitalization for Late Preterm Infants

Human milk reduces the risk of short- and long- term morbidities in recipient infants through a combination of nutritional, anti-infective, anti-inflammatory, anti-oxidative, epigenetic and gut colonizing substances. [1–6] These substances function synergistically to downregulate inflammatory and oxidative stress processes that manifest in lifelong health problems, including infections, atopic disease, neurocognitive and neurodevelopmental delay, and many chronic diseases. [1, 7–9] Late and moderately preterm infants, and even those infants delivered early term, are born prior to the maturation of many body organs and systems, [10–16] and are especially protected by the bioactive components in human milk. In contrast, several lines of inquiry indicate that the components in commercial formulas may be separately detrimental in that they upregulate inflammatory and oxidative stress processes by a variety of mechanisms, including increased intestinal permeability and toxicity to immature gut epithelial cells. [17–26] Thus, while human milk is important for all infants, it is especially important for infants who are born early and have a compromised immunomodulatory response, and with immature organs, including the brain, that are susceptible to inflammatory injury and oxidative stress. Among the infants born moderately and late preterm or early term, the greatest challenge for breastfeeding management is the late preterm infant (LPI) who is cared for with the mother in the maternity setting. [27] The lack of management strategies is underscored by the fact that exclusive breastfeeding at the time of hospital discharge is a major risk factor for rehospitalization in LPIs due to dehydration, hyperbilirubinemia, and suspected sepsis. [27–31] In less severe situations, LPIs who are exclusively breastfed tend to gain weight slowly and have protracted jaundice. These and other complications can be termed “lactation-associated morbidities”, in that human milk does not cause the morbidity, but inadequate milk intake during breastfeeding contributes to its severity. [27] It is well documented that LPIs demonstrate ineffective breastfeeding behaviors such sleepiness and slipping off the mother's nipple during feeding that translate into compromised milk transfer during breastfeeding. [27, 32] Whether or not rehospitalization is required, common outcomes in this population include routine formula supplementation and early cessation of breastfeeding. [27, 32] Although breastfeeding for LPIs and their mothers is commonly managed according to practices designed for healthy term infants, LPIs are much more like premature infants being discharged from the NICU with respect to consuming an adequate volume of milk during feedings at the breast. [27] However, unlike mothers of NICU infants who have used a breast pump to establish their milk supply by the time of NICU discharge, mothers of LPIs must rely on the sucking stimulation of the infant to establish the milk supply. Furthermore, delayed onset of lactation is especially common among mothers of LPIs, meaning that despite an effective sucking stimulus from the breast pump or the infant, little milk is available for several days post-birth. [27, 33–37] As a consequence, breastfeeding failure among LPIs and their mothers is high and clinicians need evidence-based strategies to protect infant hydration and growth and maternal milk supply until complete feeding at breast can be established. This articlewill review the evidence for lactation and breastfeeding risk in LPIs and their mothers, and describe strategies for managing these immaturity-related feeding problems. Application to moderate preterm infants (MPIs) and early term infants (ETIs) will be made throughout.