Supporting Public Health Nurses with Breastfeeding Interventions for Late Preterm Infants

Research Article

Austin Pediatr. 2017; 4(2): 1057.

Supporting Public Health Nurses with Breastfeeding Interventions for Late Preterm Infants

Dosani A*1,2 and Currie G1

¹School of Nursing and Midwifery, Mount Royal University, Calgary, Alberta, Canada

²O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada

*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

Abstract

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 mother’s 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 safeto 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 having 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. PHNs in Alberta therefore must adapt guidelines for term infants to care for LPIs in the communitysetting, 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 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.

Results and Discussion

Pertinent information relating to growth and development related to various systems and otherfactors, why this is relevant to feeding, and how the PHN can respond in practice to promote breastfeeding success, are presented in Tables 1 - 9.