Date of Award

2017

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College

College of Nursing

First Advisor

Susan D. Newman

Second Advisor

Martina Mueller

Third Advisor

Jill R. Demirci

Abstract

Purpose: The purpose of this dissertation was to modify an existing breastfeeding intervention for the late preterm infant providing maternal guidance for timing of direct breastfeeding or pumping and bottle-feeding, as well as progression to direct breastfeeding alone. Initially, a scoping review was performed to examine current existing literature for antecedents during the prenatal period associated with late preterm birth, as well as neonatal and childhood health consequences of birth. An integrative review was then performed to identify and evaluate existing breastfeeding interventions that promote breastfeeding exclusivity and duration in the late preterm. Once this data was collected, a mixed-methods study was performed to tailor an existing breastfeeding intervention to transition late preterm infants to direct at breast feeds. Problem: Late preterm infants represent one of the largest segments of the preterm population (Mally, Hendricks-Munoz, & Bailey, 2013). Because of their unique physical immaturities, they present with significant morbidities including respiratory distress syndrome, jaundice, hypoglycemia, poor feeding and failure to thrive (Engle, Tomashek, & Wallman, 2007; Harris, Weston, & Harding, 2012; Sahni & Polin, 2013; Santos et al., 2009). These specific morbidities lead to prolonged hospital stays, as well as an increased rate of readmissions when compared to term infants (Young, Korgenski & Buchi, 2013). Many of these morbidities are related to the inability of the breastfeeding late preterm infant to feed adequately and require the mother to use alternative strategies to feed her infant such as the “triple feeding” method (Meier, Patel, Wright, & Engstrom, 2013). With this method, feedings become demanding and time consuming leading to frustration and possible early cessation. The development of a feasible breastfeeding intervention is needed to provide a structured plan to transition to direct breast feeding and increase breastfeeding exclusivity and duration. Specific aims of this dissertation are: • Aim 1: To examine current existing literature for antecedents during the prenatal period associated with late preterm birth (34-36/67 weeks gestation), as well as neonatal and childhood health consequences of birth during this window. • Aim 2: To identify and evaluate the different breastfeeding interventions that promote breastfeeding exclusivity and duration in the late preterm infant, and to synthesize findings from the published empirical literature on late preterm infant breastfeeding interventions. • Aim 3: To tailor an existing breastfeeding intervention to transition late preterm infants to direct at-breast feeds. Design: The dissertation includes a scoping review to examine the existing literature regarding the antecedents and consequences of late preterm birth, an integrative review to examine existing breastfeeding interventions for the late preterm infant, and a two phase, mixed methods study to guide modification and future implementation of a breastfeeding intervention for late preterm infants. The original late preterm breastfeeding intervention by Meier (2010) was designed to replace triple feedings. Mothers were encouraged to delineate consistent “breastfeeding times” during the day from “pumping and bottle-feeding times” during the nighttime. The late preterm mother was encouraged to pump at least 4 to 5 times the first week at home during a 24-hour period with at least 2 to 3 of these during the stretch of “breastfeeding times”. The plan provides instruction on breastfeeding the late preterm infant including identification of hunger signs, when to change clothing or diaper, appropriate position at the breast, use of nipple shields, and provision of practices to keep the late preterm infant awake. At nighttime, the original plan discusses the use of a helper to bottle feed while the mother pumps to promote a quick return to sleep. Mothers were encouraged to adapt the plan to their baby and situation and to decrease the number of bottle feedings if the infant is drinking at least half of the daily amount of milk from the breast or increase if the infant is drinking less than a quarter of daily amount of milk from the breast (Meier, 2010). Phase I of the study included a qualitative descriptive design utilizing the Breastfeeding Self-Efficacy Theory which informed modifications to the original intervention, from the perspective of both mothers and lactation consultants. Phase II was a convergent parallel mixed methods design guided by the Theoretical Domain Framework to identify potential barriers and enablers to future implementation of the modified intervention from the perspective of lactation consultants. Findings: Several antecedents and consequences related to late preterm birth were identified in the scoping review. Preeclampsia and elective cesarean sections were the most common maternal risk factors associated with a late preterm birth. Consequences of late preterm delivery in the neonatal period included respiratory distress syndrome and poor feeding in the infant as significant consequences of late preterm birth. In addition, as a late preterm infant reaches childhood, there is the potential for failure to thrive, hospital readmission and altered developmental outcomes. Because of the poor feeding, breastfeeding challenges, and the risk of significant consequences post birth hospitalization associated with late preterm birth, an integrative review was performed in order to examine literature regarding existing breastfeeding interventions for this infant population that promote exclusivity and duration. The integrative review established skin to skin care, patient educational interventions and rooming to be effective strategies in promoting breastfeeding exclusivity and duration in the late preterm infant. Finally, during the mixed methods study, five themes emerged within the late preterm mothers’ focus group that informed modification of the breastfeeding intervention. These included: Altered sleep/wake cycle leading to prolonged feedings, feeding challenges led to maternal anxiety, need for information on what is normal, step by step guide would be helpful, and need for ways to decrease isolation. A second focus group with board certified lactation consultants highlighted needed changes in the number of pumpings and breastfeedings during the daytime, as well as, identifying additional outcome measures: bilirubin levels, weight, voids and stools. After the modification of the intervention, the second phase with lactation consultants revealed that workload, interruptions, and staff support were significant barriers to implementation of the intervention. Merging of the two types of data revealed these barriers correlated with the domains of the environmental context, knowledge, social roles, and the skills and beliefs about consequences relative to the lactation consultants within the Theoretical Domains Framework. Conclusions: Poor feeding was identified as a consequence of late preterm birth and that breastfeeding interventions promoted exclusivity and duration of breastfeeding in this population. Participants in the modification and theoretical evaluation of this breastfeeding intervention felt the plan would provide better guidance to the mother in breastfeeding a late preterm infant. With modification of the existing breastfeeding intervention using stakeholder input, potential barriers and enablers to implementation were recognized, which will provide guidance for future implementation of the intervention.

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