Open Access

Austin Pediatrics
Research Article

Supporting Public Health Nurses with Breastfeeding
Interventions for Late Preterm Infants
Dosani A*1, 2 and Currie G1
School of Nursing and Midwifery, Mount Royal
University, Calgary, Alberta, Canada
2
O’Brien Institute of Public Health, University of Calgary,
Calgary, Alberta, Canada

Abstract

1

*Corresponding author: Dosani A, School of Nursing
and Midwifery, Mount Royal University, Calgary, Alberta,
Canada
Received: May 15, 2017; Accepted: June 19, 2017;
Published: June 26, 2017

Late preterm infants often experience feeding difficulty post discharge
from hospital. While breast milk is especially important for late preterm infants,
they have lower exclusive breastfeeding rates than full term infants. This is
because mothers of late preterm infants often do not receive sufficient amount
of breastfeeding support in the postpartum period. Furthermore, in the Canadian
context, guidelines do not exist for health care providers to use to assist them
in providing breastfeeding support for mother’s of late preterm infant in the
community setting. We used a modified Delphi approach to begin to fill this gap.
We present information relating to physiological development in systems, its
significance to feeding, and potential interventions for public health nurses. This
information will assist PHNs in their clinical reasoning and decision-making when
supporting mothers and their LPIs to exclusively breastfeed in the community.
Keywords: Public Health Nurses; Late Preterm Infants; Breastfeeding

Abbreviations
LPI – Late Preterm Infant; PHN – Public Health Nurses

Introduction
Late preterm infants (LPIs), born between 34 0/7 weeks and
36 6/7 weeks gestational age, comprise approximately 75% of all
preterm births [1-3]. While the average rate of preterm birth in
Canada is 7.9%, Alberta (2015-2016) has the highest rate of preterm
birth (8.6%) among the provinces, with Calgary averaging 8.9% [4].
Historically, various health care providers have managed the care of
LPIs similar to that of term infants because of their comparatively
large size and seemingly mature appearance [3,5,6]. The Canadian
Paediatric Society (CPS) supports the early discharge of LPIs if
it is safe to do so, as early discharge promotes infant feeding [2].
However, when compared with full term infants, LPIs are at higher
risk of experiencing feeding difficulties, which may, in turn, result
in excessive weight loss, hypoglycemia, hyperbilirubinemia, and the
associated neurologic sequelae [7-13]. Because these medical issues
may persist after discharge from hospital, LPIs have a higher rate
of emergency room visits and hospital readmission within the first
two weeks of life for issues related to feeding, including jaundice and
dehydration [14-17].
While LPIs may benefit significantly from breastmilk, they
have lower exclusive breastfeeding rates due to mothers receiving
inadequate breastfeeding support after birth [18]. Kair and colleagues
[19] found that mothers receive inadequate breastfeeding support
post discharge. Dosani and colleagues [20] found that not only
did mothers have various difficulties with breastfeeding, public
health nurses (PHNs) also found it challenging to guide mothers in
breastfeeding and provide anticipatory guidance. There are many
reasons for this, including limited training received in undergraduate
programs [21]. In addition, there are limited guidelines, models of
care, and evidence informed standards of community care for LPIs.

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PHNs in Alberta therefore must adapt guidelines for term infants to
care for LPIs in the community setting, where follow up of the mother
infant dyad is provided upon discharge from acute care [22]. As a
result, PHNs in Alberta often rely on their empirical knowledge, and
perhaps prior experience of caring for term and extremely preterm
infants when considering care practices for LPIs [19]. This result in
significant variability in the care offered to LPIs in the community
setting [23]. Therefore, PHNs require support in caring for LPIs in
the community setting in the form of best practice guidelines. We
begin to fill this gap by presenting a systems-based breastfeeding
framework for LPIs. The information presented in this article will
assist PHNs in their clinical reasoning and decision-making when
supporting mothers and their LPIs to exclusively breastfeed in the
community setting.

Methods
We conducted a literature search to gather information about
medical issues of LPIs and related implications on growth and
development and feeding. GC and a research assistant gathered and
collated information available in the literature. We used a modified
Delphi approach to define the issues and important concepts related
to LPIs and feeding, order issues by importance, determine priorities,
and identify best practices [24]. This method is commonly used to
“obtain the most reliable consensus of opinion of a group of experts”
[25]. Ethical approval was received from Mount Royal University
Health Research Ethics Board on March 16, 2016. Data were collected
between April 2016 – March 2017. Managers of the postpartum
community sites sent out an e-mail script inviting the eligible PHNs
to participate in the study on behalf of the AD and GC with a date
of the first Delphi meeting. GC and a research assistant, aided in
the recruitment of eligible PHNs by using the snowball technique.
The snowball technique is used to identify interest from people
who know people who know participants who are informationrich [26]. Fourteen PHNs with 15-35 years of experience working

Citation: Dosani A and Currie G. Supporting Public Health Nurses with Breastfeeding Interventions for Late
Preterm Infants. Austin Pediatr. 2017; 4(2): 1057.

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Table 1: Physical Development and Feeding.
What is Happening

Significance to Feeding

How PHNs can Respond

LPIs often look like term infants due to their
respective size (they often weigh between 4.5
and 7 pounds) but they are physiologically and
metabolically immature. [3,5,6]

Because of their immaturity, LPIs are
often sleepier, have less stamina, and
have more difficulty with latch, suck,
and swallow than a full-term infant
[35,36]
Infants’ physiologic stability alters the
drive to suck and remain alert [37]

Teach parents and caregivers that skin-to-skin contact promotes
physiologic stability [38]

Physiologic instability may impact the outcome of each feeding. Teach
parents and caregivers to recognize the signs of physiologic instability
and stress that include: change in state of alertness; change in postural
control or tone and movement patterns; change in cardiorespiratory
behavior (change in baseline color to pallor or cyanosis, respiratory
fatigue, tachypnea – greater than 60 breaths per minute, nasal flaring
and or blanching, chin tugging – a movement in which the infant
extends his/her neck and pulls the chin up in an attempt to open the
Because of physiologic instability,
airway for breathing, shallow short breaths instead of a series of deep
LPIs have more difficulty maintaining breaths, bradycardia, apnea); uncoupling of swallowing and breathing
temperature, have greater delays
(loss of bolus control orally or drooling; gulping, gurgling sounds in the
LPIs have limited physiological reserves to
in bilirubin excretion, increased
pharynx, multiple swallows to clear bolus, coughing and/or choking)
respond to stress [39].
vulnerability to infection, and more
[36,37,40,41,42]
respiratory instability than the term Teach parents and caregivers how to recognize the early signs of stress
infant [35,36]
and promote conservation of energy. This may set parents and LPIs up
for successful feeding experiences [39]
Assist parents and caregivers to think critically about what they are
observing and respond accordingly. For example, if they are observing
a color change that may be related to shallow breathing, the parent may
provide a break during the feed to provide time and space for the LPI to
breathe deeply. If the color change is related to poor milk control, then
the parent may think about whether the flow rate of milk is appropriate
and potentially investigate swallowing problems [41]
LPIs ability to feed in terms of
maintain oral motor control is
Teach parents and caregivers that very subtle changes in
During the last 6 weeks of gestation, fetal muscle
dependent on their ability to maintain oropharyngeal movements may be the first sign that the infant is losing
tone increases [5,40]
muscle tone and control throughout
control [41]
their bodies [6]
Decreased muscle strength including
LPIs are at risk for general low muscle tone,
poor oral motor tone of LPIs may lead
weak muscle tone around the mouth, decreased
Teach parents and caregivers that LPIs interest in feeding, the length
to difficulties in latching, sucking, and
tongue strength, and inability to generate a strong
of time they are able to maintain muscle control and sucking and
swallowing [44]
suck and maintain strong vacuum pressure at
swallowing skills may vary from feed to feed [6]
LPIs appear to go through the motions
the breast. LPIs muscle tone may be adequate at
Explain to parents and caregivers that LPIs may require multiple feeding
of feeding, moving their jaw up and
the start of a feeding but they cannot sustain the
methods on their journey to exclusive breastfeeding
down but the poor vacuum results
necessary tone to feed as required
[1,35,45]
in minimal milk transfer, due to
[5,6,40,43]
decreased suckling strength [5,6]
Teach parents and caregivers that when an infant is feeding well,
the following is typically observed: smooth, regular respirations (or
The inability to maintain suction
LPIs may have difficulties feeding since
significant increase in respiratory effort than what was observed
pressure could lead to ineffective
the muscles that are implicated in sucking,
before the feeding); infant’s hands are actively near the face, strong
feeding, poor growth, dehydration,
swallowing, and breathing develop at different
and consistent postural control throughout body; the infant’s color has
and jaundice
points in time [46]
not changed significantly from what was observed before the feeding;
[22,44,47]
the infant is organized and calm with good coordination of sucking,
swallowing, and breathing; the infant is focused and alert [41]
Infants are not able to organize the management LPIs tire easily, sleep more frequently,
Teach parents and caregivers that they need to wake their LPI for
of arousal which is not well established until the and have shorter periods of time when
feedings [6]
infant reaches 37 weeks gestation [48]
they are awake [5,6]
Table 2: Neurological Development and Feeding.
Significance to Feeding

How PHNs can Respond

Neurodevelopmental maturation, to a large extent, is
responsible for feeding behaviors. Feeding experience and
learned behaviors may have a lesser role to play [49]

Implement simple teaching approaches to educate
parents and caregivers about brain development that
takes place from 34 to 40 weeks gestation: the brain
of an LPI at 34 weeks only weighs 65% of a brain of a
term infant; there is a five-fold increase in white matter
between 35 and 41 weeks gestation; from 34 – 37
weeks gestation, the brain is undergoing significant
development; during the last 10 weeks of gestation, the
grey matter increases four - fold [50,51]

What is Happening

The brain and the respiratory system are
the last systems to mature [5]

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There is a crucial period late in gestation
that is essential to the development of
various structures and pathways in the
brain [3]

LPIs’ ability to coordinate eating and breathing reflects
the neurological development and maturation of the brain
[3,40,48]

Neurons in the brain mature and develop
in a hierarchical method from primitive
brain stem to advanced cortical cognitive
functions that continue to develop after the
neonatal period [53,54]

It is especially important for LPIs to receive breastmilk as
it provides a rich source of components that assist in brain
growth [49,55]

Teach parents and caregivers the importance of skinto-skin contact as this accelerates brain development in
premature infants [38,52]
If the LPI is swaddled during feeds, teach the parents
and caregivers to place infant’s hands towards the
midline and not down at the sides. This positioning
supports neurobehavioral principles and helps the infant
to self-quiet and remain alert which supports swallowing
actions [6]
Teach parents and caregivers who are bottle feeding
with artificial breast milk that LPIs may require the
artificial breast milk to be fortified with
docosahexaenoic acid (DHA) and arachidonic acid as
this improves visual acuity and cognitive development
[56]

During 34 – 36 weeks gestation, the
brain tissues develop rapidly and this is
Teach parents and caregivers that the lactose present
the timeframe that peak synaptogenesis
Breast milk contains the appropriate amounts of lactose
in breast milk supplies the infant with glactocerebrosides
occurs in the medulla. The central nervous
(galactose + glucose) that ensure ample amounts of
that are required for myelinization of the brain. Infants
system also matures between 35 and 38
galactocerebrosides that are necessary for myelinization of
that are fed soy-based formulas or lactose free cow’s
weeks gestation when the coordination
the brain [5]
milk formulas lack the nutrients needed for brain growth
to the functions necessary to nipple feed
[5,6]
improve [46,57]
Many eating behaviors develop in
As LPIs grow and mature, they are better able to manage the Because infants need to coordinate sucking, swallowing,
a sequence from basic to complex
flow of milk and demonstrate alternating patterns of sucking and breathing, teach the parents and caregivers not to
movement patterns and that this
and breathing. They may begin by sucking for a burst of
move the artificial nipple (if bottlefeeding) in the mouth
progression in neurodevelopment
3 to 5 sucks and then take a breath while demonstrating
as a way to remind the infant to suck.Teach parents and
establishes the foundation for postnatal
tachypnea. The sucking bursts may be longer and the infant
caregivers that when infants pause, they require this
suckling and swallowing skills [58]
may experience oxygen desaturation. The infant will then
break and the artificial nipple should be allowed to rest
In preterm infants, oral-motor skills develop recover during tachypneic breathing. The infant will be able in the infant’s mouth until he/she is ready to suck again
between 30 – 45 weeks gestational age.
to better manage sucking, swallowing, and breathing as the
[43]
Effective feeding skills require suction and
sucking bursts and tachypneic catch-up will be shorter in
When breastfeeding, teach mothers to minimize the
compression, and the ability to move milk duration. Eventually, the infant will be able to fully coordinate
initial milk flow by expressing some breastmilk just
back into the pharyngeal area and into the
sucking, swallowing, and breathing, as demonstrated by
before the feeding. This will help the infant establish
esophagus for swallowing [48]
sucking bursts of 20-30 sucks [48]
suck-swallow-breath coordination [59]
Severe hypoglycemia can cause neuronal cell death and can
result in adverse neurodevelopment [12,61]
LPIs’ brains are not mature enough
Hypoglycemia in the neonatal period is associated with both
Teach parents and caregivers the significance of
and therefore do not have established
grey matter injuries and white matter injuries [12]
establishing regular feeding early on to prevent
mechanisms in place to be able to protect
If neonatal hypoglycemia causes injury to the occipital region
neurological injury [12,13]
the brain from hypoglycemic injury [12,60]
in the brain, infants may be at risk for long-term disability,
epilepsy, and visual impairment [12]
Teach parents and caregivers that in order for LPIs’
neurological system development, they need to
experience touch, massage, gentle rocking, vibration,
singing, and they need to hear and see their parents and
caregivers. However, they need to be exposed to one
activity at a time to prevent sensory overload [52]
The success of the feed may also depend
Teach parents and caregivers that LPIs are frequently
on the feeding environment. Some LPIs
Most infants that are born prematurely are not able to
overstimulated and may shut down before consuming
may not be able to stay focused and
simultaneously manage all of the neurodevelopmental
amounts of breastmilk that are adequate for growth and
organized in environments that are loud,
sensory inputs in order to achieve effective feeding [48]
development [5]
bright, and busy [6]
Encourage parents and caregivers to reduce multiple
stimuli during feeding, including distractions from other
children, phone conversations, and television [6, 52]
Teach parents and caregivers that negative feeding
experiences may lead to feeding aversions as neurons
are being mapped in the brain very quickly [48,62]
To eat effectively, infants must be able to
Teach parents and caregivers to watch for the infant’s
sense and react to many inputs comprising
readiness to feed in terms of attaining and maintaining
tactile, kinesthetic, proprioceptive,
LPIs need remain alert in addition to managing the amount,
a quiet state of arousal, a flexed body posture with
olfactory, auditory and visual. In addition
duration, and timing of sensory input that is demanded of
sufficient muscle tone, the ability to search for the nipple
to this, infants need to coordinate sucking,
them during any given feeding [48]
when it is presented, and organize body posture to
swallowing, and breathing all at the same
midline with arms coming forward to assist [43]
time [48]

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Table 3: Gastrointestinal System and Feeding.
What is Happening

Significance to Feeding

How PHNs can Respond

LPIs thrive with short frequent feeds at the breast or
bottle of combined feeds of around 30 minutes total
feeding time [36]

Help parents and caregivers recognize and interpret infant
feeding behavior and develop competence and confidence in
reading their infants cues [41,48,62]
Teach parents and caregivers to differentiate between nutritive
and non-nutritive sucking. Non-nutritive sucking is usually 2
sucks per second whereas nutritive sucking (and coordination
of swallowing and breathing) is one suck per second [48]
Help parents and caregivers to nurture the feeding relationship
by responding to the LPIs communication about the feeding
experience [41,42]

LPIs swallowing functions, peristaltic
functions, and sphincter control in the
esophagus, stomach, and intestines are
likely to be less mature [3]

LPIs take longer to feed than term infants and
this longer time frame may result in difficulties
coordinating sucking and swallowing [3,63]

LPIs experience transient relaxation of the
lower esophageal sphincter [64]
Motility and gastric emptying is often
delayed in LPIs [3]

Late preterm infants may ­­experience
gastroesophageal
reflux[63]. Severe gastroesophageal reflux may lead
to prolonged apnea and bradycardia [54]
The symptoms of reflux, including frequent spitting
up, vomiting, and apnea may compromise feeding
interactions and feeding outcomes [22]

Teach parents and caregivers that the goal of each feeding
session should be an alert infant who allows for adequate
intake without disorganized behaviours such as loss of milk
from the sides of the mouth and pooling of milk in the mouth.
Teach parents and caregivers to be able to identify signals of
stress including, skin pallor, arching, limb extension or turning
away from the breast or bottle [6]

The nutritive sucking pathway comprises
two connected mechanisms: suck/
pharyngeal swallow/respiration that is
related to safety and suck/pharyngeal
swallow/esophageal activity
that is about efficiency [46]

Teach parents and caregivers to decrease flow of milk by
adjusting the sucking burst length and respond to milk spilling
out of lips with a period of rest. This will allow for the infant to
reorganize swallowing function [41,62]

LPIs’ anatomy of oral and pharyngeal
structures are not developed well-enough
to facilitate successful breastfeeding. LPIs’
mandible is disproportionately small when
compared to the skull [57]

The tongue of the LPI fills the oral cavity and is in
contact with all areas of the mouth that leaves very
little space for variation in tongue movements [57]

Teach parents and caregivers that if the infant does not open
his or her mouth spontaneously or the mouth does not open
wide enough, they may exert gentle downward pressure on the
infant’s chin with their index finger as the infant approaches the
breast [5]
Teach parents and caregivers to be aware of smacking sounds
at the breast as this signals loss of contact between the infant’s
tongue and the breast. Instruct the mother that she may apply
sublingual pressure and place her index finger directly behind
and under the tip of the infant’s chin where the tongue attaches
to limit the extent of the downward movement of the infant’s
jaw [5]

LPIs are at increased risk for experiencing
oxidative stress. Necrotizing enterocolitis
is associated with oxidative stress if
the damage that has occurred is in the
digestive tract [5,65]

Breastmilk has been shown to have a higher
antioxidative capacity than infant formula and helps
neutralize oxidative stress [65]

Encourage parents and support them to achieve breastfeeding
success [35]

Infants who are fed human milk have a lower risk of
necrotizing enterocolitis because human milk has
direct immunomodulation effects. Human milk also
has a prebiotic effect of its indigestible complex
LPIs have immature mucosal immune
carbohydrates (glycans) which has the ability to
systems. They therefore require an external
inhibit colonization of pathogens [67,68]
source of immunosuppression to augment
Human milk has protective and immunomodulatory
their developing system and to protect from
functions that are not present in artificial formulas.
harmful pathogens[66]
Human milk contains products of the adaptive
immune system of the mother, primarily sIgA, and
products of an innate
immune system of human milk [66,68]

Explain to parents and caregivers that the components of
human milk interact with each other and components of the
infant intestinal tract. Explain to parents and caregivers that
some of the components of human milk are only effective at
certain times, locations, and sometimes only in specific types
of individuals. This makes human milk even more powerful in
protecting LPIs against pathogens [66].

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Infant can only handle small milk volumes
initially and this is often inadequate for
growth and development [5,6,46,49]

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Teach parents and caregivers how to assess their infant for
signs of dehydration: sunken fontanels, dry mucus membranes,
and lack of urine output [40,49]
Teach parents and caregivers when the LPI experiences
excessive weight loss, it may be appropriate to weigh the
LPI daily (before and after feeds with an infant weight scale).
Weighing should be done when the infant is unclothed and in
Weight loss of more than 7% within the first 48 hours an environment that is warm enough for the LPI to be unclothed
puts the LPI at risk for dehydration
[49,69]. Inform parents and caregivers where they may access
[36,49]
an infant weight scale in the community.
LPIs are at an increases risk for excessive
Teach parents and caregivers that the LPI should be weighed
weight loss, slow weight gain, failure to thrive,
weekly until 40 weeks postconceptual age to ensure that
prolonged formula supplementation, exaggerated
consistent weight gain is evident. Weight gain should average
jaundice, dehydration, breastfeeding failure, and
20 – 30 grams per day [36]
rehospitalization [16,35,36].
If poor weight gain is identified, the feeding practice and
feeding behaviours should be observed every 2-4 days after
each adjustment. Interventions should be implemented as
appropriate [6,36,70]
Explain to parents and caregivers the importance of monitoring
voids and stools to determine if feeding intake is adequate: 1
void and 1-2 stools by day 1; 2-3 voids and at least 1 stool by
days 2 and 3; 6 voids and 4 stools by day 4 [36,71]

Teach parents and caregivers that feeding experiences need to
be positive and that increases in intake with respect to volume
will be the outcome of feeding experiences that are positive
[37,62]
Teach parents and caregivers that feeding is not only about
nutritional intake, but also has social implications in infancy that
may last throughout the life span [62]
Teach parents and caregivers to recognize hunger cues and
interest in sucking: crying, mouthing, rooting, hands to mouth
and sucking movements. Recognizing and responding to subtle
The experience of stress during feeding could modify
cues will increase the oral intake of the infant because less
Efforts to increase the volume of intake,
sensory-motor pathways in the brain that result in
energy is expended trying to alert the parent or caregiver to
when the LPI is not ready, may result in
changes in the infant’s ability to feed and alter the
hunger [6,72]
stressful feeding experiences [37]
infants desire to feed [37]
Teach parents and caregivers that an infant who is not ready
to feed will not open his or her mouth when the lips are stroked
[43]
Teach parents and caregivers to recognize satiation cues:
arching of back, pushing away [72]
Teach parents and caregivers to be able to identify signs of
feeding disengagement including: coming off breast; pushing
the artificial nipple out of mouth, pulling off the nipple, lack of
active rooting or sucking, arching the back, inability to remain
alert, and using a weak suck to signal the preference to return
to non-nutritive sucking [42,62]
Teach parents and caregivers that LPIs have weak and subtle
Coordination of infant suck and swallow is
feeding cues due to their immaturity. Work with parents and
LPIs take a longer time to achieve normal feeding
only well established about 34 weeks or
caregivers to identify the infant’s strengths. Use positive
patterns [3]
later [63]
reinforcement with parents when they are able to identify their
LPI’s subtle feeding cues [6]

Sucking, swallowing, and breathing
coordination is not well established until the
infant is 37 weeks old [48,73]

When oral feeding is initiated early, LPIs have
increased opportunities to improve their oral motor
skills and gain experience in coordinating sucking,
swallowing, and breathing [74]

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Teach parents and caregivers that the rhythm and ratio of one
suck, one swallow, and one breath does not normally occur
until the infant is 37 weeks gestation [73]
Teach parents and caregivers to expect pauses during feeding.
Infants use these pauses to breath and for coordinating
swallowing. Teach parents that infants need to rest just as
children pause between bites during a meal [6]
Teach parents and caregivers to learn their infant’s
communication which will indicate the timing, frequency, and
length of the pause required [42]
Teach parents and caregivers to listen for the sound of
swallowing in relation to breathing sounds. Swallowing that is
quiet and effective will protect the infant from potential choking
incidents and allow for breathing in between swallowing efforts
to preserve physiologic stability [43]
Teach the parents and caregivers to burp infant half way
through feeding
Teach parents and caregivers to observe infant's face while
burping in case of cyanosis, or regurgitation

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LPIs gastrointestinal tract is not yet
colonized with bacteria that convert
conjugated bilirubin to urobilinogen [70]

LPIs are at increased risk for developing jaundice
[49,70,75]

Teach parents and caregivers that LPIs who are breastfed are
fed 10-12 times within a 24-hour period. Teach parents and
caregivers that LPIs who are bottle fed are fed 8-10 times within
a 24-hour period [40]

Table 4: Temperature Regulation and Breastfeeding.
What is Happening

Significance to Feeding

How PHNs can Respond

LPIs have difficulties regulating temperature
because of because of immature epidermal barrier,
high ratio of surface area compared with birth
weight, and the difference between the temperature
of the environment and LPIs’ temperature in the first
few days of life [8]

LPIs have reduced glycogen stores, which may
be depleted quickly, and therefore their ability to
produce and conserve heat is limited [76]

Discuss with parents and caregivers the reasons behind
infant’s risk for temperature instability.
Review normal temperature range with parents and
caregivers as 36.5°C – 37.4°C. [8]

Teach parents and caregivers to monitor their LPI’s
temperature. Neonatal hypothermia occurs when the
axillary temperature reads below 36.5°C. [8,77]
Teach parents and caregivers that during the first
few days of life, a normal body temperature (37°C)
may not be enough to determine whether the thermal
environment is optimal for LPIs. Clinical signs of cold
stress, including peripheral
vasoconstriction may be observed [12]
It is during the last 6 weeks of gestation,
Hypoglycemia may develop secondary to
Explain to parents and caregivers that maintaining
subcutaneous tissue and brown fat are deposited
hypothermia because glucose is used to stimulate normal temperature helps LPIs to regulate their energy
and glycogen stores increase in the liver [5]
brown fat metabolism [40,45,76]
use and glucose metabolism [52]
Teach parents and caregivers how to appropriately
implement skin-to-skin contact: placing an infant wearing
only a diaper on a parent’s or caregiver’s bare skin with
Hypothermia in LPIs increases the energy
The term infant produces heat by the oxidative
an over-covering [52]
demands required to respond to decreased
metabolism of brown fat which results in nonDiscuss with parents and caregivers what appropriate
temperature. LPIs have limited glycogen stores
shivering thermogenesis. LPIs are unable to produce
room temperature is for LPIs and how to dress the LPI
which will deplete quickly when the glycogen is
heat this way because their sympathetic nervous
infant appropriately. Consider exposure to environmental
used to help regulate temperature. This will result in
system is underdeveloped [54]
conditions and dress appropriately in layers; include
hypoglycemia [40]
socks and head cover when outside
Teach parents and caregivers to anticipate and
recognize the signs and symptoms of hypoglycemia [60]
LPIs have less white adipose tissue to insulate
themselves with and they have a limited ability to
Discuss with parents and caregivers that skin-to-skin
Cold stress causes tachypnea, pallor due to
produce heat from brown adipose tissue [1]
contact stabilizes their infant’s temperature, breathing,
peripheral vasoconstriction, potential for metabolic
LPIs are also at risk for losing heat more quickly
and heart rate. Skin-to- skin contact reduces infant
acidosis, and elevated axillary temperatures due to
because they have a larger surface area to weight
crying, promotes bonding, and improves breastfeeding
metabolism of brown fat [8,39]
ratio, are smaller in size than term infants and have
[52]
a higher body water content than term infants [1,40]
LPIs are at risk for developing cold stress because
they have less subcutaneous fat for insulation, an
Cold stress can lead to alterations in glucose
immature
metabolism, decreases in plasma glucose
epidermis (or thin skin) that serves as a poor barrier
concentration, respiratory stability, including
to heat loss. LPIs have a high metabolic rate, but not
pulmonary hypertension, and could potentially lead
enough brown adipose tissue (fat) that is required
to sepsis [3,8,39,54]
to generate heat. They therefore have difficulties
regulating their temperature [40,52]

Table 5: Cardio respiratory System and Breastfeeding.
What is Happening
Significance to Feeding

How PHNs can Respond
Explain to parents and caregivers that feeding is the infant’saerobic exercise
and similar to how adults respond to exercise, infants also need to match
oxygen requirements to activity. This includes the rate and depth of breathing,
any changes in heart rate, any changes that occur in the rate and depth of
breathing, and the shape of the airway. It is these changes in respiratory effort
that can significantly impact their energy levels and endurance which will lead
to lack of coordination of sucking, swallowing, and breathing [41]
Instruct parents and caregivers to watch for signs of stress including apnea
(a pause in breathing lasting longer than 20 seconds), decreased heart rate
Cardiorespiratory instability can affect
(less than 80 beats per minute), rapid breathing, nasal flaring or blanching,
LPIs can experience stress when
control of the larynx, pharynx, and
chin tugging, eyebrow lifting, shallow short breaths instead of a series of deep
feeding. They respond to this stress by
esophagus. It is possible for the infant
breaths, changes in skin color, loss of state arousal, loss of postural control,
indicating their ability to cope with that
to experience laryngeal penetration or
tone, or movement patterns [37,43,49]
stress with their heart and respiratory
aspiration, as a result [37,42]
Teach parents and caregivers that when infants experience stress, parents
rates, how hard they work to breathe,
When an infant has trouble coordinating will observe a loss of coordination between swallowing and breathing that will
their oxygen saturations, and their suckswallowing and breathing, he/she may
present as drooling, gulping, curgling sounds on the pharynx, high pitched
swallow-breathe synchrony [37,42]
stop sucking even though they are awake
crowing sounds, multiple attempts to swallow the milk that is in the infant’s
and hungry [42]
mouth, coughing, and choking [37,41,43]
Teach parents and caregivers the importance of supporting feeding success
by employing the infant’s cues to guide their decision-making and actions
about how to progress with the feeding. Parents and caregivers can respond
to their infant’s cues of stress by offering a side-lying position, swaddling their
infant in a way that supports and optimizes postural stability, offering pacing
during the feeding to ensure that swallowing and breathing is coordinated,
and employing gentle techniques to calm the infant or re-arouse the infant [37]
Encourage early skin-to-skin contact as this increases cardiorespiratory
stability in LPIs [78]

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The same reflexes that are responsible
Brainstem development and neural
for clearing oral and nasal secretions, and
control of respiration are less developed
respiration, need to work together in order
in LPIs [54]
for a feeing to be successful [54]
Late preterm infants have a greater risk
for developing respiratory distress. This
may be related to transient tachypnea
of the newborn, surfactant deficiency,
pneumonia, pulmonary hypertension,
and experiencing extreme hypoxic
events [10,13,79,80].
Due to their relatively mature
appearance, their birth weight and a
misleading clinical picture, the severity
of respiratory disease in LPIs is often
underestimated [13]
LPIs are at risk for difficulties clearing
amniotic fluid from their lungs and
producing surfactant, and may have
difficulties with expanding alveoli and
lung perfusion [3,13,52]. Respiratory
issues could also result from a
deficiency in surfactant [3]
Due to the immature respiratory control
centre (maturity of airway and chemical
control of breathing) and/or immature
respiratory reflexes, LPIs may develop
apnea [40,76]

LPIs often experience bradycardia
and apnea during feeding since the
neurological and anatomical structures
in the upper airway are common for both
respiration and feeding [54]

Teach parents and caregivers to avoid prodding the infant. This includes
pulling the artificial nipple in and out, twisting or turning the nipple, jiggling
the nipple, rhythmically squeezing the infant’s cheeks, or manually moving
the infant’s jaw up and down as these actions make the coordination of
swallowing and breathing more difficult [37,43]

Discuss with parents and caregivers the importance of monitoring the infant’s
physical efforts during and immediately following feeding, including burping,
such as work of breathing, skin color, and behavior

LPIs are at risk for developing coEmphasize to parents and caregivers that the feeding experience is a journey;
morbidities including transient tachypnea
oral-motor skills develop in an organized, observable progression for the
of the newborn, pulmonary hypertension, healthy preterm infant, but are negatively influenced by medical comorbidities
and respiratory failure [3,10]
[48]
The immature respiratory control centre
and immature respiratory reflexes lead
to uncoordinated suck, swallow, and
breathing patterns in LPIs [76]

Teach parents and caregivers that their LPI may be fussy due to inability to
protect his/her airway [41]

When LPIs do not receive an adequate
Teach parents and caregivers to recognize that when an infant is experiencing
level of oxygen in their bodies, this
LPIs require sufficient oxygenation
trouble breathing, sucking patterns may change, jaw and tongue movements
contributes to fatigue that is experienced
as this provides the energy for the
may be limited to reduce the amount of milk entering the mouth, the nipple
during feeding. The end result of
physiologic work of effective feeding [43]
may be pushed out of the mouth and sucking may stop, or, the infant may fall
inadequate oxygenation is shorter
asleep [37]
feedings, and decreased caloric intake [43]
Infants who become drowsy or fall
asleep during feeding may be exhibiting
respiratory fatigue related to feeding
too fast, inadequate oxygenation, or
excessive respiratory effort [41]

LPIs look misleadingly exuberant at
feeding times but can quickly lose state
organization and energy to finish eating
[35,41,48]

Teach parents and caregivers the signs of sleepiness/fatigue: not cueing for
feeds by 3 hours, not easily awakened, falling asleep before sufficient milk
volume has been taken, requiring more frequent breaks [52]
Teach parents and caregivers that increasing fussiness displayed by their
infant may be a sign of inadequate oxygenation in response to the increased
demands of feeding [41]

LPIs have higher energy demands and
Teach parents and caregivers that LPIs need to be fed at least every 3 hours.
therefore require more rest and short
Teach parents and caregivers to wake the infant for feedings if they do not
frequent feeds [52]
wake themselves [52]
LPIs have less stamina to latch on to the
Teach parents and caregivers to identify signs of decreased endurance
Due to less energy stores, LPIs may
breast [48]
including decreased arousal, fatigue, and disinterest in feeding, not rooting/
fatigue quickly and show signs of falling
Infants who do not appear to have
closed lips, poor sucking, turning away from breast, pushing nipple out of
asleep or shutting down during a feed
sufficient energy to feed are more
mouth, not actively sucking, closing mouth, and sleeping. Teach parents to
[52]
vulnerable to physiologic stress and are at
provide frequent breaks as appropriate [6,43]
risk for aspiration because they are less
Teach parents and caregivers that use of a nipple shield may facilitate longer
able to cue their caregiver that assistance
sucking bursts and longer periods of wakefulness [81]
is required [6]
Table 6: Hepatic System and Feeding.
Significance to Feeding

What is Happening
LPIs have immature hepatic
functions that place them at
increased risk for developing
significantly elevated serum
bilirubin levels [1, 13, 16, 70,82,
83, 84]
LPIs have an increased bilirubin
load on the hepatocyte. This is due
to decreased erythrocyte survival,
increased erythrocyte volume, and
increased enterohepatic
circulation of bilirubin. LPIs also
experience decreased hepatic
uptake of bilirubin from plasma and
have defective bilirubin conjugation
mechanisms [70]

How PHNs can Respond

Teach parents and caregivers how to identify hyperbilirubinemia.
Jaundice is usually first noticed in the head, especially the sclera
and mucous membranes, and then progresses to the thorax,
abdomen and then to the extremities [85]; the higher the serum
bilirubin, the greater the surface area of the skin that is yellow
[87]. Every newborn needs to be assessed for jaundice. In order
Any visible jaundice within the first 24 hours of life requires to identify jaundice, the Registered Nurse applies pressure with
further investigation because this is an indication of an
a finger over a bony area (e.g. nose or forehead) for several
underlying pathologic process [85]
seconds to empty all of the capillaries of blood in that area. If
Jaundice is the leading cause of rehospitalisation in the late
jaundice is present, the blanched area will look yellow, before
preterm infant [70,86]
the capillaries refill with blood [85]. Use a transcutaneous
monitor to measure bilirubin level if available in your facility since
transcutaneous protocols developed for full term infants are valid
for LPIs in the first 3 days of life [88].
Check that a total serum bilirubin has been drawn prior to
discharge. Total serum bilirubin levels are the gold standard for
evaluating hyperbilirubinemia [84,87].

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LPIs have decreased serum
bilirubin binding capacity because
they have: lower
serum albumin levels,
enhanced permeability of the
Timely outpatient follow-up for LPIs is essential to prevent severe
blood– brain barrier to
Severe hyperbilirubinemia is a medical emergency
jaundice [44]
unconjugated bilirubin influx, and
requiring immediate treatment [84,90]. Severe jaundice
The ultimate goal of identifying and treating jaundice is the
immaturity of
is accompanied by the following signs and symptoms:
prevention of kernicterus, defined as permanent brain cell
neuronal protective mechanism
persistent sleeping, difficulty rousing for feedings, a lack
damage caused by elevated bilirubin levels [11]
[3,75]
of interest in feedings, decreased muscle tone, a sunken
Teach parents and caregivers who have LPIs with additional risk
LPIs are at higher risk of developing anterior fontanel (soft spot) indicative of dehydration, and factors (use of instrumentation during delivery, male sex, born to
kernicterus and its related
decreased urine and fecal output [90]
a mother who was older than 25 years of age) to be more vigilant
neurologic sequalae [13,75,89].
in watching for jaundice [91,92]
This is because LPIs demonstrate
signs of bilirubin neurotoxicity at an
earlier postnatal age than infants
who are born at term [70,75]
Significant elevation of serum
bilirubin is caused by an imbalance
between bilirubin production and
Typically, hyperbilirubinemia is treated by correcting the
bilirubin elimination [84]
Inadequate feeding, and the resulting dehydration, can lead
dehydration, encouraging increased frequency of feedings to
Neonates with high bilirubin
to increased bilirubin in the blood by increasing bilirubin
promote fecal excretion of bilirubin, phototherapy, and rarely,
production may not develop high
reabsorption in the intestines
exchange transfusion [70,87,90].
serum levels if fecal excretion is
[3,40,70,75]
Instruct parents and caregivers to feed up to 12 times per 24
not impaired; conversely, neonates
hours in their first few days of life in order to prevent jaundice [93]
with low bilirubin production may
develop high serum levels if fecal
excretion is impaired [84]
LPIs who are fed breast milk, either through breastfeeding
or expressed breast milk, are at increased risk for severe
Explain to parents and caregivers that the benefits of breast
LPIs present with greater severity
hyperbilirubinemia [70]
milk feeding (versus formula feeding) outweigh the risks of
of jaundice and more protracted Breast milk-induced jaundice occurs in infants who consume
hyperbilirubinemia [70]
jaundice than term infants [10,70]
sufficient amounts of breast milk but it is unclear how the
Provide close follow-up and lactation support within the first 48
components of breastmilk contribute to hyperbilirubinemia
hours of discharge [49,70]
[94]
Glucose-6-phosphatase is an enzyme that hydrolyzes
Due to hepatic immaturity, LPIs
glucose-6-phosphate into phosphate and glucose and
Teach parents and caregivers to recognize the signs and
may have a delay in hepatic
therefore plays a key role in the homeostatic regulation
symptoms of hypoglycemia which include changes in level of
glucose-6-phosphatase activity [3]
of blood glucose level as this is the primary biochemical
consciousness (irritability, excessive crying, lethargy or stupor);
LPIs have lower accumulation of
response to hypoglycemia [3]
apnea and cyanosis; poor feeding; tachypnea, tachycardia,
glycogen reserves in the hepatic
The LPI is at risk for developing hypoglycemia [35]
grunting; hypothermia; hypotonia – limpness; tremor-seizures,
system which are depleted very
LPIs experience a greater decrease in postnatal plasma
and jitteriness [12]
quickly after birth [12]
glucose concentrations than term infants [12]

with breastfeeding mothers were recruited from three postpartum
community sites (North, South, and East) in Calgary, Alberta,
Canada. Ten of the 14 PHNs were certified lactation consultants.
Informed consent was verbally discussed with potential
participants on the day of the Delphi meetings. Written consent was
obtained. Participants were informed that they may withdraw from
the study at any time. Due to the nature of the Delphi technique,
that comments are used to build consensus, study participants were
informed that if they chose to withdraw from the study, data cannot
be removed. We employed a “real-time” Delphi, in which multiple
rounds were compressed to occur over several meetings [24]. We used
three rounds of questioning. In the first round, called the exploration
phase [27], PHNs explored the challenges they experienced when
working with breastfeeding LPIs using broad open-ended questions.
Each subsequent round then became part of an “evaluation phase”
[27], where the results of the previous round were used to frame
another set of questions. Each round provided an opportunity for
the experts to respond to and revise their answer in light of other
group members’ previous responses. Over multiple rounds, the
process gradually led to consensus or near-consensus [24]. After the
Delphi rounds AD ensured all current literature was included until
saturation was reached and critically synthesized the information
according to systems and important concepts.
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Results and Discussion
Pertinent information relating to growth and development
connected to various systems and other factors, why this is relevant
to feeding, and how the PHN can respond in practice to promote
breastfeeding success, are presented in Tables 1 - 9.
As demonstrated in Tables 1 - 9, LPIs experience significant
feeding challenges that are related to systems development and
other factors including positioning and maternal physiology. It is
imperative that all health care providers who work with LPIs and their
families understand the significant feeding challenges experienced by
LPIs and how this relates back to physiological systems maturation.
It is especially important for PHNs to be aware of the myriad of
factors that could potentially contribute to feeding difficulties in
the LPI population, given the continuing trend of early discharge of
neonates after birth, including LPIs [2]. Parental anxiety and feeling
overwhelmed, fatigued, and stressed are very common with parents
caring for LPIs and, as a result, parents require adequate community
health care supports at home, particularly with regards to feeding
challenges [28]. PHNs are well-positioned to provide information
and education, support, and anticipatory guidance, and this has the
potential to have a lasting impact on parents and newborns [29].
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Table 7: Transition to Exclusive Breastfeeding.
What is Happening

Significance to Feeding

How PHNs can Respond

LPIs have immature and inconsistent
feeding behaviours (e.g. feeding cues,
number of sucks, duration of sucking bursts,
and sucking pressure) which may make
it challenging for mothers to breastfeed
effectively and establish and sustain an
adequate milk supply [31,45]

LPIs are at an increased risk for experiencing
breastfeeding difficulties and often require
breastfeeding assistance after discharge from
hospital [9]

Planned feeding follow-up is imperative for the LPI [36,48]

Discuss feeding goals with mother [36,69]. Teach parents and caregivers
that skin-to-skin contact is associated with an earlier establishment of
exclusive breastfeeding [38]. Review feeding plan with parents and
caregivers including specifics regarding frequency, approximate duration
of feedings, and how baby is being fed (e.g., at the breast, use of a
nipple shield, expressed breast milk with supplemental device such as
supplemental nursing system, finger feeds, cup or bottle [36]. Some LPIs
LPIs who are discharged within 48 hours of birth are
may require increased caloric intake for a period of time under the guidance
at increased risk of breastfeeding difficulties [49]
LPIs may be discharged home after
of a registered dietitian. It may be necessary to implement individualized
Supplementation may be required if the infant
successful transfer to the extrauterine
feeding plans that are based on the LPIs growth, quality of growth, and the
cannot obtain an adequate amount of colostrums/
environment, but before lactogenesis II is
potential for nutrient deficiencies [44]. Discuss with parents and caregivers
milk directly from the breast, with the use of frequent
completely developed, before problems with
the type of nipple and flow rate to purchase. Artificial nipples with too high
cue - based feeds. This includes circumstances in
latch and milk transfer are identified, and
a flow-rate increase the likelihood that infant will lose control of the bolus
which the mother has tried breast massage and
adequately addressed [36]
of liquid in his mouth [41]. Slower flow rates, gives infants time to organize
compression, use of a nipple shield, and use of
suck, swallow, and breathe [47]. Explain to parents and caregivers to treat
incentives at the breast [5]
the bottle like the breast: improved physiological stability (measured in
heart rate and oxygen saturation) may be promoted in LPIs using elevated
side lying position to feed [95]. Teach parents and caregivers to offer
and wait for infant to invite nipple into their mouth [6]. Teach parents and
caregivers to wait for the wide gape before putting artificial nipple in to infant
mouth. Teach parents and caregivers to minimize pacifier use for earlier
establishment of exclusive breastfeeding [96]
Teach parents and caregivers that the appropriate amount of colostrum
to be offered to the infant every 2 -3 hours within the first few days of life
generally are: 5–10 ml on day one, 10–20 ml on day 2, and 20–30 ml
on day 3 [52]. Teach the mother that she may massage her breast and
LPIs may require supplementation via tube feeding
compress her breast when the infant is pausing between sucking bursts.
devices at the breast, cups, finger feeding, droppers,
Some LPIs may be unable to latch
This will compensate for a weak vacuum and will increase milk transfer to
syringes, or bottles [5]
independently because they may lack the
the infant. This technique will also improve the pressure gradient between
The use of artificial nipples during bottle feeding
strength required to draw the breast into
the breast and the infant’s mouth [5]. Teach parents and caregivers that
is a completely different feeding method than
their mouths and/or generate the sucking
the benefit of using cup feeding during supplementation is that it allows the
breastfeeding and this method may weaken the
pressure required to sustain the vacuum that
infant to use the masseter and temporalis muscles which is similar to their
sucking of an infant who may already demonstrate
is required for milk transfer [5,97]
muscle functioning while breastfeeding [99]. Teach parents and caregivers
the inability to generate a strong vacuum at the
that finger feeding with a tube device necessitates the infant to generate
breast [98]
and sustain a vacuum to remove the milk [5]. Explain to parents and
caregivers that bottle feeding is different from, and not necessarily easier
than, breastfeeding. During breastfeeding, it is the infant that paces the
feeding and is an active participant [59]
Provide lactation support when required [3]. A referral to a lactation
consultant should be viewed with the same medical urgency as any other
acute medical urgency [35,36]. Teach parents and caregivers that cup
feeding (versus bottle feeding) significantly increased the likelihood that
LPIs will be exclusively breastfed at 3 months and 6 months [100]. If the LPI
is unable to cup feed, teach parents and caregivers how to assist the infant
to latch with a milk–filled dropper or a syringe or tube feeding device. These
LPIs may require multiple sessions with lactation
devices may be filled with colostrums or breast milk and placed at the side
consultants or experienced PHNs before they are
of the infant’s mouth as they latch on. As the infant is about to latch, a few
Some infants may engage in rapid side-toable to establish nutritive breastfeeding. They will
drops of colostrums or milk is delivered from the dropper/syringe/tube that
side head movements that make latching
often require supplementation with expressed
instigates a swallow. When the infant’s mouth comes into contact with the
difficult and/or painful [5]
breast milk or formula until nutritive breastfeeding is device, it eliminates the side-to-side head movements and orients the infant
established [35]
to the breast. The initial drops of colostrum or milk encourages the infant to
swallow, followed by a nutritive suck [5]. If the above latching techniques
are unsuccessful, teach the mother how to use a nipple shield. Teach
mothers that they may hand express (or use a syringe to pre-fill) colostrum/
milk into the nipple shield tunnel to give the infant an immediate sucking
reward [5]. Provide regular follow-up, and access to lactation support
when required, to ensure that successful exclusive breastfeeding can be
accomplished [3,35,70]
Teach mothers how to use a nipple shield because the use of nipple shields
Preterm infants have significantly lower
will help the infant maintain suction pressures necessary to remove milk
LPIs may have difficulty maintaining a sustained
suction pressures than term infants
from the breast and increase breast milk transfer [59,81]
latch to the maternal breast [59]
[59,81,101]
Teach parents and caregivers that the use of a nipple shield will ensure the
infant does not slip off the breast during pauses of sucking bursts [46,81]

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Table 8: Physical Positioning and Feeding.
What is Happening

Significance to Feeding

How PHNs can Respond

Teach parents and caregivers the importance of
promoting a feeding position that is supportive
LPIs are at risk for experiencing
and developmentally focused. This means that
positional apnea caused by airway
When the mother is semi–reclined during breastfeeding with the infant the infant’s head and neck should be in a neutral
obstruction, bradycardia, and oxygen
paced prone, this positioning stimulates feeding reflexes, improves
position and should align to his or her trunk [6]
desaturation when they are placed in
ventilation, and increases skin-to-skin contact [102]
Instruct mothers to position infants in a cross
positions that create excessive flexion on
cradle, clutch or ventral (prone) position during
the neck and trunk [5]
breastfeeding. Teach parents to avoid the cradle
hold [5]
Positioning in a car seat or other devices that are designed to support
LPIs may not have the neurological
the infant in an upright position may result in apnea, bradycardia,
Teach parents and caregivers never to feed an
maturity to maintain their airway while
or oxygen desaturation [52]. LPIs have are not able to ventilate
LPI while in a car seat. Instruct parents to never
positioned in a properly installed car seat
themselves appropriately in response to hypoxia [54]. Therefore, if leave an LPI unattended in a car seat and should
or other devices that are designed to
feeding if an infant is in a car seat or other devices, or immediately
spend limited time in devices that are meant to
support the infant in an upright position
after removing the LPI from the car seat or other device, they may not
support infants in an upright position [52]
[52]
be ready to feed.
Table 9: Maternal Physiology and Feeding.
What is Happening

Significance to Feeding

How PHNs can Respond

Teach mothers that the use of a nipple shield will correct flat and/or large
nipples which will make it easier for the LPI to maintain a latch and extract
milk and will also increase breast stimulation which, in turn, may contribute
to milk production [81]
The LPI’s inability to remove milk from Teach mothers how to massage their breasts to express colostrum (more
If the maternal nipple is too large or flat, the the mother’s breast effectively results than 5 times per day in the first 3 days) and how to use hands on pumping to
LPI will slip off of the breast completely as the
in delayed lactogenesis II and this
express mature milk [103]
mandible closes [81]
may decrease milk volume within the Teach mother to increase milk yield by combining manual expression, breast
first few days after birth [47]
compression, and use of an electric breast pump [103]
Teach parents that because of the unique qualities of LPIs,
immediate and frequent
pumping is the primary driver of milk supply, not the LPIs suckling at the
breast [49]
Women with the following conditions may be
at risk for delivering a LPI: multiple pregnancy,
Any one, or a combination, of
diabetes, pregnancy induced hypertension,
these conditions places the infant
Timely evaluation of the LPI after discharge is critical to promote the health
prolonged rupture of membranes,
at increased risk for breastfeeding
of both mother and infant [35]
chorioamnionitis, oxytocin induction, or a
difficulty [35]
cesarean section delivery [35]
Encourage mothers to use an electric double pump to pump their breasts
every two to three hours if: they are experiencing a delay in their milk supply,
they notice that their infants have a weak suck, their infant is receiving
supplementation, or are unable to feed due to illness [52]
Teach mothers that early pumping and establishment of maternal milk
supply within the first week will lead to longer breastfeeding duration [49]
Teach mothers that they may express more colostrum manually (hand
Mother’s milk supply may not meet
LPIs may be discharged before effective
expression) during the first 48 hours post birth than with the use of an
infant’s required volumes for age.
lactation is established [44]
electric pump [103,101]
Infant may require supplementation
Encourage parents and caregivers to use expressed breast milk (EBM)
when possible
Teach parents and caregivers about the special handling of expressed
breast milk or formula
Observe interactions between LPI and mother especially if there has been a
separation in hospital
Provide supports for Postpartum Depression as needed
Teach mothers the technique of reverse pressure softening: before each
attempt to latch, hand express, or pump, apply gentle, but firm pressure on
a 1-2 cm radius of the center of the areola, in the place where it connects
with the base of the nipple. Apply the pressure in an inward direction that
is perpendicular to the mother’s chest wall. The act of reverse pressure
Mothers may experience areolar edema [5]
Areolar edema and engorgement may
softening should last between 1-3 minutes. This intervention may be
If the mother is experiencing engorgement,
result in difficulty latching, delayed
implemented once or more, depending on how severe the edema is.
expanded circulation and excess of interstitial
milk ejection, poor milk transfer to
Mothers may implement this reverse positive pressure until engorgement
fluid compete for space as milk volumes
infant, pain, and nipple damage [105]
resolves and latching becomes easier [105]
increase [105]
Teach mothers that reverse pressure softening reduces the resistance of the
subareolar tissue while freeing it temporarily to interact more efficiently with
the infant’s mouth. The reverse pressure softening technique also triggers
the milk ejection reflex [106]

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Mothers are responsive to interventions regarding their
breastfeeding practices delivered in the community setting [30].
We, therefore, offer that the education, support, and anticipatory
guidance that PHNs can provide in the immediate postpartum period
may increase the competence and confidence of mothers, families,
and other caregivers to provide the type of care that is specific to the
LPI population. Mothers’ confidence in caring for LPIs depends on
their ability to understand what is happening in terms of physiologic
and neurologic development and to recognize related infant cues and
appropriately respond to them [31]. Likewise, maternal confidence
is also impacted by infants’ positive responses to the type of care
offered [32]. Maternal confidence is significant because it impacts
breastfeeding duration [33]. Furthermore, breastfeeding the LPI is
a complex and tenuous process that is influenced by many factors
which ultimately determines whether, or not, breastfeeding is
continued [34]. Therefore, appropriate and timely support in the
postnatal period by public health nurses is critical to the health and
wellbeing of LPIs, mothers, and families.

Conclusion
Based on a review of the literature and our previous research
experience [20,23], mothers and families of LPIs require an additional
level of care in terms of information and education, support, and
anticipatory guidance from PHNs with respect to breastfeeding. We
offer a systems-based approach to bridge the information from the
literature and input from PHN stakeholders, using a modified Delphi
approach. This information will help guide PHNs and other health
care professionals, who care for the vulnerable LPI population in the
community setting, with clinical reasoning and decision-making with
respect to breastfeeding.
References
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Engle WA, Tomashek KM, Wallman C. “Late-preterm” infants: a population
at risk. Pediatr. 2007; 120: 1390-1401.

2.

Whyte RK, Canadian Paediatric Society, Fetus and Newborn Committee.
Safe discharge of the late preterm infant [position statement FN 2010-01].
Paediatr Child Health. 2010; 15: 665-660.

3.

Malley PV, Bailey S, Hendricks-Muñoz KD. Clinical issues in the
management of late preterminfants. CurrProblPediatrAdolesc Health Care.
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12. Garg M, Devaskar SU. Glucose metabolism in the late preterm infant.
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Citation: Dosani A and Currie G. Supporting Public Health Nurses with Breastfeeding Interventions for Late
Preterm Infants. Austin Pediatr. 2017; 4(2): 1057.

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