Dosani A; Currie G

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.

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]
  
  
    LPIs    have limited physiological reserves to respond to stress [39].
    Because of physiologic instability,    LPIs have more difficulty maintaining temperature, have greater delays in    bilirubin excretion, increased vulnerability to infection, and more    respiratory instability than the term infant [35,36]
    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 airway for breathing, shallow short breaths instead of a series of deep    breaths, bradycardia, apnea); uncoupling of swallowing and breathing (loss of    bolus control orally or drooling; gulping, gurgling sounds in the pharynx,    multiple swallows to clear bolus, coughing and/or choking) [36,37,40,41,42]
       
      Teach parents and caregivers how to    recognize the early signs of stress 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]
  
  
    During the last    6 weeks of gestation, fetal muscle tone increases [5,40]
    LPIs ability to feed in terms of    maintain oral motor control is dependent on their ability to maintain muscle    tone and control throughout their bodies [6]
    Teach parents and caregivers that very    subtle changes in oropharyngeal movements may be the first sign that the    infant is losing control [41]
  
   
   
  
    LPIs are at risk    for general low muscle tone, weak muscle tone around the mouth, decreased    tongue strength, and inability to generate a strong suck and maintain strong    vacuum pressure at the breast. LPIs muscle tone may be adequate at the start    of a feeding but they cannot sustain the necessary tone to feed as required
       [5,6,40,43]
    Decreased muscle strength including    poor oral motor tone of LPIs may lead to difficulties in latching, sucking,    and swallowing [44]
      LPIs appear to go through the motions    of feeding, moving their jaw up and down but the poor vacuum results in    minimal milk transfer, due to decreased suckling strength [5,6]
    Teach parents and caregivers that    LPIs interest in feeding, the length of time they are able to maintain muscle    control and sucking and swallowing skills may vary from feed to feed [6]
      Explain to parents and caregivers    that LPIs may require multiple feeding methods on their journey to exclusive    breastfeeding
       1,35,45]
  
  
    LPIs may have    difficulties feeding since the muscles that are implicated in sucking,    swallowing, and breathing develop at different points in time [46]
    The inability to maintain suction    pressure could lead to ineffective feeding, poor growth, dehydration, and    jaundice 
      [22,44,47]
    Teach parents and caregivers that    when an infant is feeding well, the following is typically observed: smooth,    regular respirations (or significant increase in respiratory effort than what    was observed before the feeding); infant’s hands are actively near the face,    strong and consistent postural control throughout body; the infant’s color    has not changed significantly from what was observed before the feeding; 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 of arousal which is not well established    until the infant reaches 37 weeks gestation [48]
    LPIs tire easily, sleep more    frequently, and have shorter periods of time when they are awake [5,6]
    Teach parents and caregivers that    they need to wake their LPI for feedings [6]



Table 1: Physical Development and Feeding.

Table 2: Neurological Development and Feeding.




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



Table 2: Neurological Development and Feeding.

Table 3: Gastrointestinal System and Feeding.




  
    What is    Happening 
    Significance to    Feeding 
    How PHNs can    Respond 
  
  
    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]
    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]
    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]
  
   
   
  
    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
    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]

  
  
    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]
  
  
    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]
  
   
   
  
    LPIs have    immature mucosal immune systems. They therefore require an external source of    immunosuppression to augment their developing system and to protect from    harmful pathogens[66]
    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 carbohydrates (glycans) which has the ability to inhibit    colonization of pathogens [67,68]
      Human milk has protective and    immunomodulatory functions that are not present in artificial formulas. 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].
  
  
    Infant can only    handle small milk volumes initially and this is often inadequate for growth    and development [5,6,46,49]
    Weight loss of more than 7% within    the first 48 hours puts the LPI at risk for dehydration
      [36,49]
      LPIs are at an increases risk for    excessive weight loss, slow weight gain, failure to thrive, prolonged formula    supplementation, exaggerated jaundice, dehydration, breastfeeding failure,    and rehospitalization [16,35,36].
    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 an environment that is warm enough    for the LPI to be unclothed [49,69]. Inform parents and caregivers where they    may access an infant weight scale in the community.
      Teach parents and caregivers that the    LPI should be weighed weekly until 40 weeks postconceptual age to ensure that    consistent weight gain is evident. Weight gain should average 20 – 30 grams    per day [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]
  
  
    Efforts to    increase the volume of intake, when the LPI is not ready, may result in    stressful feeding experiences [37]
    The experience of stress during    feeding could modify sensory-motor pathways in the brain that result in    changes in the infant’s ability to feed and alter the infants desire to feed [37]
    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    cues will increase the oral intake of the infant because less energy is    expended trying to alert the parent or caregiver to hunger [6,72]
      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]
  
  
    Coordination of    infant suck and swallow is only well established about 34 weeks or later [63]
    LPIs take a longer time to achieve    normal feeding patterns [3]
    Teach parents and caregivers that    LPIs have weak and subtle feeding cues due to their immaturity. Work with    parents and caregivers to identify the infant’s strengths. Use positive    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]
    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
  
  
    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 3: Gastrointestinal System and Feeding.

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 temperatureinstability.
      Review normal temperature range with    parents and caregivers as 36.5�C – 37.4�C. [8]
  
  
    LPIs are at risk    for developing cold stress because they have less subcutaneous fat for    insulation, an immature
      epidermis (or    thin skin) that serves as a poor barrier to heat loss. LPIs have a high    metabolic rate, but not enough brown adipose tissue (fat) that is required to    generate heat. They therefore have difficulties regulating their temperature [40,52]
    Cold stress can lead to alterations    in glucose metabolism, decreases in plasma glucose concentration, respiratory    stability, including pulmonary hypertension, and could potentially lead to    sepsis [3,8,39,54]
    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 even    [12]
  
  
    It is during the    last 6 weeks of gestation, subcutaneous tissue and brown fat are deposited    and glycogen stores increase in the liver [5]
    Hypoglycemia may develop secondary to    hypothermia because glucose is used to stimulate brown fat metabolism [40,45,76]
    Explain to parents and caregivers    that maintaining normal temperature helps LPIs to regulate their energy use    and glucose metabolism [52]
  
  
    The term infant    produces heat by the oxidative metabolism of brown fat which results in    non-shivering thermogenesis. LPIs are unable to produce heat this way because    their sympathetic nervous system is underdeveloped [54]
    Hypothermia in LPIs increases the    energy demands required to respond to decreased temperature. LPIs have    limited glycogen stores which will deplete quickly when the glycogen is used    to help regulate temperature. This will result in hypoglycemia [40]
    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 an over-covering [52]
      Discuss with parents and caregivers    what appropriate room temperature is for LPIs and how to dress the LPI infant    appropriately. Consider exposure to environmental conditions and dress    appropriately in layers; include 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 produce heat from brown adipose tissue [1]
      LPIs are also at    risk for losing heat more quickly because they have a larger surface area to    weight ratio, are smaller in size than term infants and have a higher body    water content than term infants [1,40]
    Cold stress causes tachypnea, pallor    due to peripheral vasoconstriction, potential for metabolic acidosis, and    elevated axillary temperatures due to metabolism of brown fat [8,39]
    Discuss with parents and caregivers    that skin-to-skin contact stabilizes their infant’s temperature, breathing,    and heart rate. Skin-to- skin contact reduces infant crying, promotes    bonding, and improves breastfeeding [52]



Table 4: Temperature Regulation and Breastfeeding.

Table 5: Cardio respiratory System and Breastfeeding.




  
    What    is Happening 
    Significance    to Feeding 
    How    PHNs can Respond 
  
  
    LPIs    can experience stress when feeding. They respond to this stress by indicating    their ability to cope with that stress with their heart and respiratory    rates, how hard they work to breathe, their oxygen saturations, and their    suck-swallow-breathe synchrony [37,42]
     
       
       
       
       
       
       
       
       
       
       
       
      Cardiorespiratory    instability can affect control of the larynx, pharynx, and esophagus. It is    possible for the infant to experience laryngeal penetration or aspiration, as    a result [37,42]
      When    an infant has trouble coordinating swallowing and breathing, he/she may stop    sucking even though they are awake and hungry [42]
    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 (less than    80 beats per minute), rapid breathing, nasal flaring or blanching, chin    tugging, eyebrow lifting, shallow short breaths instead of a series of deep    breaths, changes in skin color, loss of state arousal, loss of postural    control, tone, or movement patterns [37,43,49]
      Teach    parents and caregivers that when infants experience stress, parents will    observe a loss of coordination between swallowing and breathing that will    present as drooling, gulping, curgling sounds on the pharynx, high pitched    crowing sounds, multiple attempts to swallow the milk that is in the infant’s    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]
  
  
    
  
  
    
  
  
    
  
  
    
  
  
    
  
  
    
  
  
    Brainstem    development and neural control of respiration are less developed in LPIs [54]
    The    same reflexes that are responsible for clearing oral and nasal secretions,    and respiration, need to work together in order for a feeing to be successful    [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]
  
  
    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    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]
    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 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]
    LPIs    are at risk for developing co-morbidities including transient tachypnea of    the newborn, pulmonary hypertension, and respiratory failure [3,10]
    Emphasize    to parents and caregivers that the feeding experience is a journey;    oral-motor skills develop in an organized, observable progression for the    healthy preterm infant, but are negatively influenced by medical    comorbidities [48]
  
  
    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]
    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]
  
   
   
  
    LPIs    require sufficient oxygenation as this provides the energy for the    physiologic work of effective feeding [43]
    When    LPIs do not receive an adequate level of oxygen in their bodies, this    contributes to fatigue that is experienced during feeding. The end result of    inadequate oxygenation is shorter feedings, and decreased caloric intake [43]
    Teach    parents and caregivers to recognize that when an infant is experiencing    trouble breathing, sucking patterns may change, jaw and tongue movements may    be limited to reduce the amount of milk entering the mouth, the nipple may be    pushed out of the mouth and sucking may stop, or, the infant may fall asleep [37]
  
   
   
  
    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]
  
  
    Due    to less energy stores, LPIs may fatigue quickly and show signs of falling    asleep or shutting down during a feed [52]
    LPIs    have higher energy demands and therefore require more rest and short frequent    feeds [52]
      LPIs    have less stamina to latch on to the breast [48]
      Infants    who do not appear to have sufficient energy to feed are more vulnerable to    physiologic stress and are at risk for aspiration because they are less able    to cue their caregiver that assistance is required [6]
    Teach    parents and caregivers that LPIs need to be fed at least every 3 hours. Teach    parents and caregivers to wake the infant for feedings if they do not wake    themselves [52]
      Teach    parents and caregivers to identify signs of decreased endurance including    decreased arousal, fatigue, and disinterest in feeding, not rooting/closed    lips, poor sucking, turning away from breast, pushing nipple out of mouth,    not actively sucking, closing mouth, and sleeping. Teach parents to provide    frequent breaks as appropriate [6,43]
      Teach    parents and caregivers that use of a nipple shield may facilitate longer    sucking bursts and longer periods of wakefulness [81]



Table 5: Cardio respiratory System and Breastfeeding.

Table 6: Hepatic System and Feeding.




  
    What is    Happening 
    Significance to    Feeding 
    How PHNs can    Respond 
  
  
    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]
    Any visible jaundice within the first 24 hours of life requires    further investigation because this is an indication of an underlying    pathologic process [85] 
      Jaundice is the leading cause of rehospitalisation in the late preterm    infant [70,86] 
    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 to identify    jaundice, the Registered Nurse applies pressure with a finger over a bony    area (e.g. nose or forehead) for several seconds to empty all of the    capillaries of blood in that area. If jaundice is present, the blanched area    will look yellow, before the capillaries refill with blood [85]. Use a    transcutaneous monitor to measure bilirubin level if available in your    facilitysince 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].
  
  
    LPIs have    decreased serum bilirubin binding capacity because they have: lower
      serum albumin    levels,
      enhanced    permeability of the blood– brain barrier to
      unconjugated    bilirubin influx, and immaturity of
      neuronal    protective mechanism [3,75]
      LPIs are at    higher risk of developing kernicterus and its related neurologic sequalae [13,75,89].    This is because LPIs demonstrate signs of bilirubin neurotoxicity at an    earlier postnatal age than infants who are born at term [70,75]
    Severe hyperbilirubinemia is a    medical emergency requiring immediate treatment [84,90]. Severe jaundice is    accompanied by the following signs and symptoms: persistent sleeping,    difficulty rousing for feedings, a lack of interest in feedings, decreased    muscle tone, a sunken anterior fontanel (soft spot) indicative of    dehydration, and decreased urine and fecal output [90]
    Timely outpatient follow-up for LPIs    is essential to prevent severe jaundice [44]
      The ultimate goal of identifying and    treating jaundice is the prevention of kernicterus, defined as permanent    brain cell damage caused by elevated bilirubin levels [11]
      Teach parents and caregivers who have    LPIs with additional risk factors (use of instrumentation during delivery,    male sex, born to a mother who was older than 25 years of age) to be more    vigilant in watching for jaundice [91,92]
  
  
    Significant elevation of serum bilirubin is caused by an imbalance    between bilirubin production and bilirubin elimination [84] 
      Neonates with high bilirubin production may not develop high serum    levels if fecal excretion is not impaired; conversely, neonates with low    bilirubin production may develop high serum levels if fecal excretion is    impaired [84] 
    Inadequate feeding, and the resulting dehydration, can lead to    increased bilirubin in the blood by increasing bilirubin reabsorption in the    intestines 
      [3,40,70,75] 
    Typically, hyperbilirubinemia is    treated by correcting the dehydration, encouraging increased frequency of    feedings to promote fecal excretion of bilirubin, phototherapy, and rarely,    exchange transfusion [70,87,90].
      Instruct parents and caregivers to feed up to 12 times per 24 hours in    their first few days of life in order to prevent jaundice [93] 
  
  
    LPIs present    with greater severity of jaundice and more protracted jaundice than term    infants [10,70]
    LPIs who are fed breast milk, either through breastfeeding or    expressed breast milk, are at increased risk for severe hyperbilirubinemia    [70] 
      Breast milk-induced jaundice occurs in infants who consume sufficient    amounts of breast milk but it is unclear how the components of breastmilk    contribute to hyperbilirubinemia [94] 
    Explain to parents and caregivers    that the benefits of breast milk feeding (versus formula feeding) outweigh    the risks of hyperbilirubinemia [70]
      Provide close follow-up and lactation    support within the first 48 hours of discharge [49,70]
  
  
    Due to hepatic    immaturity, LPIs may have a delay in hepatic glucose-6-phosphatase activity [3]
      LPIs have lower    accumulation of glycogen reserves in the hepatic system which are depleted    very quickly after birth [12]
    Glucose-6-phosphatase is an enzyme    that hydrolyzes glucose-6-phosphate into phosphate and glucose and therefore    plays a key role in the homeostatic regulation of blood glucose level as this    is the primary biochemical response to hypoglycemia [3]
      The LPI is at risk for developing    hypoglycemia [35]
      LPIs experience a greater decrease in postnatal plasma    glucose concentrations than term infants [12]
    Teach parents and caregivers to    recognize the signs and symptoms of hypoglycemia which include changes in    level of consciousness (irritability, excessive crying, lethargy or stupor);    apnea and cyanosis; poor feeding; tachypnea, tachycardia, grunting;    hypothermia; hypotonia – limpness; tremor-seizures, and jitteriness [12]



Table 6: Hepatic System and Feeding.

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]
  
   
  
    LPIs may be    discharged home after successful transfer to the extrauterine environment,    but before lactogenesis II is completely developed, before problems with    latch and milk transfer are identified, and adequately addressed [36]
    LPIs who are discharged within 48    hours of birth are at increased risk of breastfeeding difficulties [49]
      Supplementation may be required if    the infant cannot obtain an adequate amount of colostrums/milk directly from    the breast, with the use of frequent cue - based feeds. This includes    circumstances in which the mother has tried breast massage and compression,    use of a nipple shield, and use of incentives at the breast [5]
    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 breastmilk with supplemental device such as supplemental nursing    system, finger feeds, cup or bottle [36]
      Some LPIs may require increased    caloric intake for a period of time under the guidance of a registered    dietitian. It may be necessary to implement individualized feeding plans that    are based on the LPIs growth, quality of growth, and the potential for nutrient    deficiencies [44]
      Discuss with parents and caregivers    the type of nipple and flow rate to purchase. Artificial nipples with too    high a flow-rate increase the likelihood that infant will lose control of the    bolus of liquid in his mouth [41]. Slower flow rates, gives infants time to    organize suck, swallow, and breathe [47]
      Explain to parents and caregivers to    treat 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]
  
  
    Some LPIs may be    unable to latch independently because they may lack the strength required to    draw the breast into their mouths and/or generate the sucking pressure    required to sustain the vacuum that is required for milk transfer [5,97]
    LPIs may require supplementation via    tube feeding devices at the breast, cups, finger feeding, droppers, syringes,    or bottles [5]
      The use of artificial nipples during    bottle feeding is a completely different feeding method than breastfeeding    and this method may weaken the sucking of an infant who may already    demonstrate the inability to generate a strong vacuum at the breast [98]
    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 compress her breast when the infant is pausing between sucking    bursts. This will compensate for a weak vacuum and will increase milk    transfer to the infant. This technique will also improve the pressure    gradient between the breast and the infant’s mouth [5]
      Teach parents and caregivers that the    benefit of using cup feeding during supplementation is that it allows the    infant to use the masseter and temporalis muscles which is similar to their    muscle functioning while breastfeeding [99]
      Teach parents and caregivers that    finger feeding with a tube device necessitates the infant to generate 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]
  
  
    Some infants may    engage in rapid side-to-side head movements that make latching difficult    and/or painful [5]
    LPIs may require multiple sessions    with lactation consultants or experienced PHNs before they are able to    establish nutritive breastfeeding. They will often require supplementation    with expressed breast milk or formula until nutritive breastfeeding is established    [35]
    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 devices may be filled with colostrums or breast milk and placed at the    side of the infant’s mouth as they latch on. As the infant is about to latch,    a few drops of colostrums or milk is delivered from the dropper/syringe/tube    that instigates a swallow. When the infant’s mouth comes into contact with    the device, it eliminates the side-to-side head movements and orients the    infant 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]
  
  
    Preterm infants    have significantly lower suction pressures than term infants [59,81,101]
    LPIs may have difficulty maintaining    a sustained latch to the maternal breast [59]
    Teach mothers how to use a nipple    shield because the use of nipple shields will help the infant maintain    suction pressures necessary to remove milk from the breast and increase    breast milk transfer [59,81]
      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]



Table 7: Transition to Exclusive Breastfeeding.

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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. ISSN:2381-8999

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What is Happening	Significance to Feeding	How PHNs can Respond
If the maternal nipple is too large or flat, the LPI will slip off of the breast completely as the mandible closes [81]	The LPI’s inability to remove milk from the mother’s breast effectively results in delayed lactogenesis II and this may decrease milk volume within the first few days after birth [47]	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] Teach mothers how to massage their breasts to express colostrum (more than 5 times per day in the first 3 days) and how to use hands on pumping to express mature milk [103] Teach mother to increase milk yield by combining manual expression, breast 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, diabetes, pregnancy induced hypertension, prolonged rupture of membranes, chorioamnionitis, oxytocin induction, or a cesarean section delivery [35]	Any one, or a combination, of these conditions places the infant at increased risk for breastfeeding difficulty [35]	Timely evaluation of the LPI after discharge is critical to promote the health of both mother and infant [35]
LPIs may be discharged before effective lactation is established [44]	Mother’s milk supply may not meet infant’s required volumes for age. Infant may require supplementation	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 expression) during the first 48 hours post birth than with the use of an electric pump [103,401] 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
Mothers may experience areolar edema [5] If the mother is experiencing engorgement, expanded circulation and excess of interstitial fluid compete for space as milk volumes increase [105]	Areolar edema and engorgement may result in difficulty latching, delayed milk ejection, poor milk transfer to infant, pain, and nipple damage [105]	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 softening should last between 1-3 minutes. This intervention may be implemented once or more, depending on how severe the edema is. Mothers may implement this reverse positive pressure until engorgement resolves and latching becomes easier [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 [105]