BREASTFEEDING MEDICINE

Volume 17, Number 10, 2022 Reviews

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2022.0118

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Interventions to Improve Breastfeeding Outcomes

in Late Preterm and Early Term Infants
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Sarah Dib,1 Kulnipa Kittisakmontri,1,2 Jonathan C. Wells,1 and Mary Fewtrell1

Abstract

Background: Late preterm infants (LPIs; born at 340/7 to 366/7 gestational weeks) and early term infants (ETIs;
370/7 to 386/7 gestational weeks) are at higher risk of morbidity and mortality compared with more mature
infants. Breastfeeding can reduce these risks, but feeding difficulties are common among these infants and
breastfeeding rates are low. We conducted a systematic review to identify the interventions available to improve
any breastfeeding, exclusive breastfeeding, or breast milk yield.
Methods: A literature search was performed up to February 23, 2022, using MEDLINE, CINAHL, Embase, and
Google Scholar, and nine articles were included. Only one article was a randomized controlled trial, and only
one included ETIs. The remaining articles were quasi-experimental and included only LPIs. Outcomes included
breastfeeding duration, breastfeeding exclusivity, and/or breast milk production (volume) before 6 months
actual age.
Results: Professional support significantly improved exclusive breastfeeding rates. A breastfeeding education
program delivered at the hospital with weekly telephone follow-up postdischarge significantly increased
breastfeeding rates. Neither cup feeding nor early discharge (with in-home lactation support) improved
breastfeeding rates, whereas rooming-in (versus direct admission to the neonatal intensive care unit) worsened
exclusive breastfeeding rates.
Discussion: This is the first systematic review to identify interventions available for both LPIs and ETIs.
Overall, there are limited studies that investigate interventions promoting breastfeeding in these populations.
However, breastfeeding support delivered by health care professionals seems to improve breastfeeding rates.
The main limitations are the lack of randomization, blinding, and adjustment for confounding variables.
Experimental studies with robust methodological design are needed.

Keywords: late preterm infants, early term infants, breastfeeding, interventions, systematic review, breast-
feeding promotion

Background It was suggested that preterm birth rates have primarily

increased overall due to the dramatic rise in late preterm
ore than 1 in 10 babies are born preterm worldwide,1 births (340/7 and 366/7 gestational weeks),3 which constitute
M and this rate is rising in almost all countries. Pre-
maturity is the leading cause of death in children under the age
74% of all preterm births.4 Previously, not enough attention
has been paid to late preterm infants (LPIs) due to the in-
of 5 years in nearly all high- and middle-income countries and correct assumption that these infants may be physiologically
is associated with a higher risk of health complications, such and metabolically as mature as term infants, as they may
as chronic respiratory problems, diabetes, and hypertension.2 appear of appropriate size at birth. However, LPIs have a

1
Department of Population, Policy, and Practice, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.
2
Division of Nutrition, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.

781
 782 DIB ET AL.

significantly higher risk of morbidity and mortality compared period overlapping 370/7 and 386/7 gestational weeks by at
with term infants.5 least 1 week (37 or 38 weeks) were also eligible. If the sample
Another category of infants that has gained more attention included more than just LPIs or ETIs, data needed to be
in recent years is early term infants (ETIs), who are infants presented separately for these categories.
born between 370/7 and 386/7 gestational weeks and account
for 23% of all live births.6 The categorization was developed Interventions and comparators. Studies investigating
to highlight the higher risk of morbidity and mortality of ETIs any type of intervention or combination of interventions
compared with those born at 39–41 weeks.7 Despite the provided with the aim of promoting breastfeeding or breast
complications they experience,8 like LPIs, most ETIs are of milk provision, in any setting but starting within 1 month of
healthy weight at birth and have normal Apgar scores, which birth were eligible. Comparators could be other interventions
might lead to false reassurance among health professionals. but must also include some type of control, including usual
Both groups are at higher risk of breastfeeding complica- care, placebo, or no treatment.
tions compared with infants born later.9–11 This could be due
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to infant-related barriers associated with earlier birth, such as Outcomes. The outcomes of the interventions included
rapid fatigue during feeding, lower stamina, fewer awake breastfeeding duration, breastfeeding exclusivity, and/or
periods, and reduced effort to stimulate and empty the breast milk production (volume) at a time point before 6
breast.12 It could also be due to maternal-related barriers months actual age.
associated with preterm delivery, such as cesarean delivery,
obesity, multiple births, smoking status, or maternal psy- Study design. Only randomized controlled trials (RCTs)
chological distress.8,9,11–13 Additionally, since ETIs are still or quasi-experimental (QE) studies (nonrandomized interven-
within the broad full-term categorization, they might not be tional studies) were eligible for inclusion. Observational stud-
receiving special attention to overcome the challenges asso- ies were excluded due to their inability to establish causation.
ciated with an earlier birth.
Reduced breastfeeding rates in these two groups is an Searches
important issue to tackle as all infants benefit from breast-
feeding, but especially those born earlier. Due to their de- 1. The following databases were searched in February
velopmental immaturity and increased susceptibility to 2022: MEDLINE, CINAHL, Embase, and Google
inflammation, oxidative stress, and infections, breast milk Scholar, without time or language restrictions. The
and the constituents of breast milk such as antibodies, growth search terms included: breastfeeding, breast milk, pre-
factors, bacteria, lipids, and enzymes (which are variable mature infants, ETIs, 37–38 weeks, 37–38 gestation,
with gestational age) are particularly beneficial.14 term birth and similar words (Table 1). The full search
Given both the benefits of breast milk for LPIs and ETIs, and screening protocol was registered in PROSPERO
and the breastfeeding difficulties often experienced by their (CRD42020187000).
mothers, it is important to understand what interventions may 2. RCTs and non-RCTs (QE studies) were extracted from
successfully promote breastfeeding in these populations. the search.
Two previous systematic reviews have investigated breast- 3. Other relevant articles were sought by backward ref-
feeding promotion interventions for LPIs (one also included erence searching of the included articles.
moderately preterm infants).15,16 To our knowledge, no re-
view was previously undertaken on available breastfeeding Study selection
promotion interventions for ETIs.
We conducted a systematic review with the aim of ex- The search results were imported to EndNote X9 where
amining the available interventions for LPIs and ETIs that duplicates were removed. An initial screening of the titles and
target breastfeeding outcomes. The outcomes included abstracts against inclusion criteria was conducted by two
breastfeeding duration and exclusivity, but also breast milk reviewers independently (S.D. and K.K.). This was followed
production since many mothers might be dependent (partially by a screening of the full texts of relevant articles. Dis-
or fully) on milk expression in the early postnatal period. In crepancies were resolved by discussion and by consulting a
contrast to one of the previous reviews,16 we only included third reviewer (M.F.).
experimental studies, and specified no language or time
restrictions. Data extraction
The research question that this review addressed follows
The guidelines from the Center for Reviews and Dis-
the PICOS (participants, interventions, comparators, out-
semination17 were followed to generate the data extraction
comes, study design) model: What is the evidence on the forms. For this review, guidelines of the Preferred Reporting
effect of interventions available for LPIs and ETIs on
Items of Systematic reviews Meta-Analysis (PRISMA) were
breastfeeding duration/exclusivity or breast milk production?
followed. Details of methodological quality, study design,
sample, and intervention were abstracted. For each outcome,
Methods the time point, the numeric results, the statistic used, and the
Inclusion criteria p-value were abstracted.
Participants. Studies that included LPIs or infants born in
Quality assessment
a period overlapping 340/7 to 366/7 gestational weeks by at
least 2 weeks (34–35 weeks or 35–36 weeks) were eligible for Two reviewers (S.D. and K.K.) independently assessed the
inclusion. Studies that included ETIs or infants born in a risk of bias based on the Cochrane group methods for
 BREASTFEEDING LATE PRETERM AND EARLY TERM INFANTS 783

Table 1. Keywords and Map Term to Subject Heading Used in Literature Search
and Search Strategy Used
No. Search strategy MeSH Keywords
1 MeSH OR Keywords Breast feeding Breastfeeding or Breast Feeding or Human Milk or
for Breastfeeding Breast milk or breast milk or lactation
2 MeSH OR Keywords Infant, premature Late preterm infant* or late preterm newborn*
for Late Preterm or Late premature infant* or late premature
newborn* or near term
3 MeSH OR Keywords – Early term infant* or early term newborn*
for Early Term
4 2 OR 3 (Infant, Premature/or Late preterm infant* or late preterm newborn*
or Late premature infant* or late premature newborn*
or near term) OR (Early term infant* or early term newborn*)
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5 1 AND 4 (Breastfeeding or Breast Feeding or Human Milk or Breast milk or

Breast milk or Lactation) AND ([Infant, Premature/or Late preterm infant*
or late preterm newborn* or Late premature infant* or late premature
newborn* or near term] OR [Early term infant* or
early term newborn*])
MeSH, map term to subject heading.

systematic reviews (details provided in Supplementary Results

Data). Discrepancies were resolved by discussion with in-
volvement of a third review author (M.F.) where necessary. Based on the search strategy, 2,408 records were
The level of risk of bias in each of these domains was pre- identified from the four databases. As shown in Figure 1,
sented separately for each study. after duplicates were removed, 1,556 titles were screened
after which 372 abstracts were assessed for eligibility.
After 63 full texts were screened, nine articles were in-
Data synthesis
cluded for this review (Table 2). Two studies reported
Included studies were too diverse (various interventions, outcomes related to ‘‘exclusive breastfeeding’’ only,18,19
targeting different age groups, outcomes at different time two related to ‘‘any breastfeeding’’ only,20,21 and the
points) for a quantitative synthesis. Therefore, a narrative other five related to both ‘‘any breastfeeding’’ and ‘‘ex-
synthesis was undertaken. Results were classified according to clusive breastfeeding.’’22–26 None of the studies reported
the outcome: breastfeeding duration, breastfeeding exclusiv- on breast milk volume. Only one study was an RCT,18
ity, or breast milk production. They were further grouped the rest were QE (nonrandomized). Only one study in-
according to the target population (LPIs versus ETIs). cluded infants of 37 weeks’ gestation,18 the rest included

FIG. 1. PRISMA flow dia-

gram.
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Table 2. Data Extraction of Included Studies

Author, year, Study
location design Population Intervention & comparators Outcomes Time point Main resulta
McKeever et al RCT 101 Term infants Standard hospital care with early discharge EBF (feeding by At discharge The intervention had no effect
(2002),18 and home support from nurses who were breast only) on EBF (OR = 1.4; 95%
Canada 37 LPIs (35–37) lactation consultants versus standard Exclusive breast 5–12 Days CI = 0.3–7.2)
hospital care and standard length of milk feeds postpartum
hospitalization (feeding only
breast milk by
breast or bottle)
Maastrup et al QE 110/421 Control LPIs Standard care (preintervention) versus EBF (feeding by At discharge The intervention had 1.3
(2021),19 (350/7 to 366/7) neonatal nurse training program (with breast only) times the odds of EBF at
Denmark 142/494 Intervention focus on early breast milk expression, discharge (95% CI = 0.8–
LPIs (350/7 to 366/7) skin-to-skin contact, rooming-in, use of 2.3) in infants born at 35–
test-weighing and minimizing use of 36 weeks (study is not
pacifiers) powered to detect
subgestational group
differences)
Jang and Ju QE 27 Control LPIs Standard care versus four-session LPI Breastfeeding At discharge OR of 3.9 (95% CI = 1.2–
(2020),20 (340/7 to 366/7) education program (characteristics of (newborn received 12.6) of breastfeeding at
Korea 26 Intervention LPIs LPIs, breastfeeding for LPIs, any breast milk) 1 Month 1 month postdischarge in

784
(340/7 to 366/7) postdischarge management of LPIs, postdischarge the experimental group
emotional support)
Jang and Ko QE 19 Control LPIs Control group (four home visits with Breastfeeding At discharge The interaction effect
(2021),21 (340/7 to 366/7) counseling related to nurturing LPIs) (feeding by breast, First week between treatment and time
Korea versus breastfeeding coaching program or bottle-feeding Second week had an OR of 1.2 (95%
21 Intervention LPIs (web-based breastfeeding education pumped milk Third week CI = 0.6–2.5), 1.3 (0.5–
(340/7 to 366/7) program involving four home visits, and/or small Fourth week 3.12), 2.4 (0.6–9.3), and 3.7
practical breastfeeding support based on amounts of (1.0–14.2) for the first,
infant’s and mother’s needs, and formula once or second, third, and fourth
encouragement and advice to express milk twice a day) week, respectively
regularly)
Jang and Hong QE 20 Control LPIs Control group (four home visits with EBF (feeding by At discharge OR of 5.2 (95% CI = 1.1–
(2020),22 (340/7 to 366/7) counseling related to nurturing LPIs) breast only) First week 16.7) of EBF overall and
Korea versus breastfeeding support program Second week 7.1 (95% CI = 1.7–29.9),
20 Intervention LPIs (web-based breastfeeding education Mixed feeding Third week 12.0 (95% CI = 2.7–52.9),
(340/7 to 366/7) program involving four home visits, (feeding breast Fourth week and 15.2 (95% CI = 3.3–
practical breastfeeding support based on milk by breast or 69.2) the odds of EBF at 2,
infant’s and mother’s needs, and bottle, and 3, and 4 weeks,
encouragement and advice to express milk supplemented respectively
regularly) with formula
milk)
(continued)
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Table 2. (Continued)
Author, year, Study
location design Population Intervention & comparators Outcomes Time point Main resulta
Estalella et al QE 212 Control LPIs Standard care (recommendations provided on EBF (newborn At discharge The intervention group had
(2020),23 (340/7 to 366/7) a sheet, breastfeeding evaluated verbally, received breast twice the odds of EBF
Spain visits conducted separately by pediatrician milk) (OR = 2.1; 95% CI = 1.4–
161 Intervention LPIs and nurse, phototherapy at NICU) versus Breastfeeding 3.2)
(340/7 to 366/7) intervention (postnatal booklet provided, (newborn received
breastfeeding evaluated by chart, visits breast milk and
conducted together, phototherapy at human milk
bedside) substitute)
Abouelfettoh QE 30 Control LPIs Control group (bottle feeding all oral feeds at EBF (feeding breast Weeks 1, 2, 3, 4, 5, The intervention did not
et al (2008),24 (340/7 to 366/7) the NICU) versus intervention group (cup milk only) and 6 increase exclusive
Egypt 30 Intervention LPIs feeding all oral feeds at the NICU) postdischarge breastfeeding at 1 week
(340/7 to 366/7) postdischarge (OR = 1.8;
95% CI = 0.6–5.0)
Jang (2020),25 QE 19 Control LPIs Control group (four home visits with Breastfeeding At discharge OR for breastfeeding
Korea (340/7 to 366/7) counselling related to nurturing LPIs) (feeding by breast First week (adjusted for length of
versus breastfeeding coaching program or bottle-feeding Second week hospital stay and newborn

785
(web-based breastfeeding education pumped milk) disease) was 13.7 (95%
21 Intervention LPIs program involving four home visits, Mixed feeding Third week CI = 1.2–157.0) and 20.6
(340/7 to 366/7) practical breastfeeding support based on (feeding breast Fourth week (95% CI = 2.0–214.4) at the
infant’s and mother’s needs, and milk by breast or third and fourth weeks,
encouragement and advice to express milk bottle, and respectively
regularly) supplemented
with formula
milk)
Dani et al QE 190 Control LPIs Standard care at hospital 1 (LPIs directly EBF (newborn fed At discharge The intervention reduced the
(2022),26 (350/7 to 366/7) admitted to SCU/NICU) versus rooming- only breast milk, odds of EBF (OR = 0.2;
Italy in assistance at hospital 2 (followed by including human 95% CI = 0.1–0.4) in
admission to SCU/NICU if needed) donor milk and/or infants born at hospital 2
expressed breast (rooming-in), but the odds
milk) were nil when adjusting for
240 Intervention LPIs Mixed (any differences in infants’
(350/7 to 366/7) breastfeeding characteristics
mixed with
formula feeding)
a
OR and 95% CI were calculated if not available in articles.
CI, confidence interval; EBF, exclusive breastfeeding; LPI, late preterm infant; NICU, neonatal intensive care unit; OD, odds ratio; QE, quasi-experimental; RCT, randomized controlled trial; SCU,
special care unit.
 786 DIB ET AL.

LPIs exclusively. The studies included 1,325 infants of Any breastfeeding

which 20 were of 37 weeks’ gestation (ETIs) and the rest Estalella et al23 also investigated breastfeeding at dis-
were late preterm. charge as an outcome. Breastfeeding rate was lower in the
intervention group (25.9%) compared with the control group
Interventions
(37.8%), a reflection of the significantly higher exclusive
All the interventions in the included studies involved breastfeeding rate in the intervention group rather than more
breastfeeding support delivered by health professionals. formula feeding. Jang and Hong22 showed that there was a
McKeever et al18 investigated early hospital discharge cou- small increase in breastfeeding rate in the experimental group
pled with breastfeeding support delivered at home by lacta- compared with the control group, but the lack of the large
tion consultants. Maastrup et al19 investigated a neonatal increase is again a reflection of the noticeable increase in
nurse training program that focused on improving certain exclusive breastfeeding. Similarly, another QE study re-
hospital practices such as early breast milk expression, skin- vealed that the intervention group who received a four-
to-skin contact, and rooming-in. Estalella et al23 targeted session education program had 3.9 times the odds (95%
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hospital practices that could improve breastfeeding such as CI = 1.2–12.6) of breastfeeding at 1 month postdischarge
bedside phototherapy and more detailed evaluation of compared with the control group.20 Conversely, three
breastfeeding. Similarly, Dani et al26 explored rooming-in studies21,25,26 did not find any significant differences in
assistance in comparison to direct admission to neonatal breastfeeding rates between the intervention and control
intensive care unit (NICU). Abouelfettoh et al24 studied the groups.
influence of cup feeding for LPIs admitted to a NICU,
compared with bottle feeding. The remaining studies were Breast milk volume
education-based interventions designed specifically for LPIs.
The first involved a four-session/intervention education None of the included studies reported breast milk volume
program, which covered topics such as the characteristics of as an outcome.
LPIs, breastfeeding the LPIs, and postdischarge management
delivered face-to-face at the hospital before discharge.20 Quality of the studies
Mothers were also followed up on a weekly basis, for a
The quality of each study was assessed according to six
month postdischarge, through telephone to offer them emo-
domains. Only one RCT was included in this review, in
tional support and to allow them to ask questions. The other
which the method of randomization sequence generation was
three studies covered education on late preterm topics over
not mentioned.18 While the researchers collecting the data
four home visits but also offered individualized practical
were originally blinded to the group status, the participants
breastfeeding support and advice to express breast milk
were not blinded to the intervention due to its nature (early
regularly.21,22,25
discharge, home support) and later revealed their status
during the interviews.
Exclusive breastfeeding
The other eight studies were of QE design, where the re-
McKeever et al,18 who conducted the only RCT included, searchers and the participants were aware of the group alloca-
showed that home lactation support compared with hospital tion. Six of the studies collected data at different periods for the
support did not improve breastfeeding exclusivity at 5–12 days control and experimental groups (*1-year gap),19–21,23,25,26
postpartum in LPIs and EPIs (37 weeks). Dani et al26 found that one of which was also carried out at different hospitals for each
rooming-in assistance rather than direct admission to NICU re- group,26 which might have introduced a bias in the character-
sulted in lower exclusive breastfeeding rates. Conversely, one istics of the sample. However, Estalella et al23 and Maastrup
QE study reported twice the odds of exclusive breastfeeding at et al19 reported no significant differences in the baseline char-
discharge in LPIs whose mothers received an intervention de- acteristics between the control and experimental group (there
signed to promote breastfeeding in this population.23 Two other were fewer extremely preterm infants in the Maastrup et al19
studies showed that a breastfeeding support intervention deliv- but this is not relevant to this review). Similarly, Jang and
ered over 4 weeks increased exclusive breastfeeding at the sec- Hong,22 Jang and Ko,21 and Jang and Ju20 reported no signifi-
ond, third, and fourth week postdelivery (odds ratio [OR] = 7.1, cant differences at baseline, but there were some notable dif-
95% confidence interval [CI] = 1.7–29.9; OR = 12.0, 95% ferences in infant characteristics, which might have contributed
CI = 2.7–52.9; and OR = 15.2, 95% CI = 3.3–69.2)22 or at to the findings. On the other hand, the remaining three QE
4 weeks postdelivery (OR = 4.0, 95% CI = 1.2–12.6),25 com- studies found significant differences in baseline characteris-
pared with the control group. tics.24–26 Both Dani et al26 and Jang25 provided an adjustment
Maastrup et al19 also found that the intervention (nurse for the differences in infant characteristics, whereas Abouel-
training program) resulted in higher odds of exclusive fettoh et al24 did not account for the significantly higher
breastfeeding at discharge (OR = 1.3; 95% CI = 0.8–2.3) in birthweight in the cup feeding group.
infants born at 35–36 weeks. Lastly, Abouelfettoh et al24 Other study quality concerns are evident. For example,
showed that the proportion of feedings that were breast milk there was a high number of attrition in Abouelfettoh’s
(direct or expressed) at 1 week postdischarge was signifi- study,24 where only 13/30 participants in the intervention
cantly higher in the cup feeding (80.2%; 95% CI = 70.6–89.8) group but 25/30 in the control group maintained participation
group than in the bottle feeding group (64.4%; 95% by 6 weeks. The differences in characteristics between par-
CI = 53.4–75.4), although there were no significant differ- ticipants included and lost to follow-up were not investigated,
ences in the proportion who were exclusive breastfeeding and the results of the first week only were reported despite the
between the two groups. intention to investigate breastfeeding practices at 1–6 weeks
 BREASTFEEDING LATE PRETERM AND EARLY TERM INFANTS 787

postdischarge. In three other studies, it is unclear how the (for 1 month) after discharge. The results showed that at 1-
decision to allocate infants to each group was made, which month postdischarge breastfeeding rates and parenting con-
might produce a high risk of bias.21,22,25 Additionally, it is fidence were significantly higher in the experimental group
uncertain how the intervention investigated by Jang25 and compared with the control group. However, there are several
Jang and Ko21 was modified from the one developed by Jang limitations to the study, such as the QE design, the 1-year gap
and Hong.22 Lastly, it also unclear why the breastfeeding/ in data collection, and higher proportion of infants of 34
mixed-feeding rates were reported differently in Jang25 and weeks’ gestation and lower proportion of infants of 36 weeks’
Jang and Ko21 despite involving the same sample Table 3. gestation in the control group versus intervention group at
baseline. Other observational studies have also analyzed the
Discussion association between hospital practices and support on
breastfeeding in LPIs. A study, including 579 LPIs from the
The findings from this review are inconclusive but might
UK 2010 Infant Feeding Survey, showed that mothers who
indicate that breastfeeding support interventions delivered by
reported that they did not receive enough support with breast-
health professionals in the early postnatal period (birth-4
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feeding at the hospital were less likely to be breastfeeding at 10

weeks) can be beneficial at improving exclusive breastfeed-
days.33 Another showed that high levels of professional support
ing duration in LPIs.
at the hospital was associated with an increased likelihood of
any breastfeeding in LPIs, ETIs, and term infants.10
Professional breastfeeding support
Jang and Hong,22 Jang,25 and Jang and Ko21 evaluated a
and hospital practices
breastfeeding education/coaching/support program delivered
McKeever et al18 found that in-home lactation support did at discharge and over four home visits after (once per week).
not increase exclusive breastfeeding. While the authors In the initial period, the intervention encouraged mothers to
aimed to investigate early discharge of infants of 35–37 express breast milk to increase production, then later pro-
weeks’ gestation with the additional in-home lactation sup- vided practical instruction on latching and positioning. The
port, there were no significant differences in the length of results suggested an improvement in exclusive breastfeeding
hospital stay between groups (45 versus 48 hours). This was rates, however, there were some differences in infant char-
because they did not meet the early discharge criteria and acteristics at baseline as well as other study quality concerns.
because of the already existing practice of early discharge for Similarly, an RCT has shown that a program involving 11
LPIs. Several studies have shown that LPIs who were dis- one-hour sessions pre- and postdischarge, aiming to educate
charged early were more likely to be readmitted.27–29 Simi- parents on their infant’s characteristics and improve re-
larly, a recent study showed that early discharge (<48 hours) sponsiveness to cues and interaction, increased breastfeeding
of healthy LPIs was not associated with cost savings, prob- duration in mothers of moderately preterm infants and LPIs at
ably due to the higher risk of rehospitalization after early 6, 9, and 12 months postdischarge, although the effects were
discharge.30 In all these studies, the most common reason for only significant at 9 months.34
rehospitalization was jaundice. Therefore, it is possible that Another RCT, which included mainly moderately preterm
early discharge for LPIs does not allow for enough time to infants and LPIs (n = 414; 84%) from six NICUs in Sweden
support breastfeeding practices and establish adequate breast found no significant differences in exclusive breastfeeding at
milk supply. Nevertheless, other similar studies have also 8 weeks between the proactive telephone support group (re-
shown no significant differences in exclusive breastfeeding ceived daily telephone calls from day 1 to day 14 post-
rates between the two groups.31,32 discharge from a member of the breastfeeding support team)
Estalella et al23 delivered an intervention where hospital and the reactive telephone support group (given the option to
practices were changed with the aim of promoting parents’ call a member from the team if they face any breastfeeding
education and involvement, avoiding separation from the problems).35 However, mothers in the proactive telephone
infant (when phototherapy is provided), and creating a mul- support group reported less parental stress at 8 weeks post-
tidisciplinary approach to support breastfeeding. The results discharge. This might indicate the importance of face-to-face
showed that the intervention group had higher exclusive support for practical breastfeeding difficulties, whereas
breastfeeding rate at discharge. This could be partially ex- telephone support might be beneficial for emotional support.
plained by the significantly higher proportion of mothers in Dani et al26 compared direct admission to the NICU in one
the intervention group expressing breast milk after some or hospital with providing rooming-in assistance and only ad-
all of the feeds. The results should be interpreted with caution mitting to NICU if necessary, in another hospital. The odds of
due to the QE design and the 1-year gap in data collection, exclusive breastfeeding were lower in the hospital that pro-
however, no significant differences were found in the base- vided rooming-in assistance (OR = 0.17; 95% CI = 0.07–0.4).
line characteristics and the sample size was relatively large This could be explained by the differences in infant charac-
with only a few exclusions. Additionally, Maastrup et al19 teristics between the two hospitals. It might also be possible
investigated another intervention that aimed at improving that infants admitted to the NICU are recognized to be more
hospital practices supportive of breastfeeding such as skin-to- vulnerable and thus their parents might be provided with
skin contact, rooming-in, and early breast milk expression. more support to breastfeed and with more encouragement to
The findings also revealed an increase in exclusive breast- express breast milk.
feeding rates in the intervention group. As with Estallela
et al,23 the study involved a large sample with low risk of bias.
Early breast milk expression and supplementation
Jang and Ju20 designed a within-hospital breastfeeding
education intervention for mothers of LPIs admitted to the The abovementioned studies provide further evidence that
NICU, but this was followed by weekly phone call checkups breast milk expression might be a crucial factor that increases
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Table 3. Data Quality Assessment of Included Studies Based on the Cochrane Group Methods for Systematic Reviews
Selective
Treatment allocation Completeness of outcome outcome
Article Sequence concealment Blinding data reporting Other sources of bias
McKeever Not Interviewers were originally Did not mention blinding No differences between those No Restricted inclusion criteria make the
et al18 mentioned blinded to group status, but during analysis but who declined to participate results less generalizable to LPIs:
mothers later revealed their personnel assessing and those who completed. Not experienced c-sections or
status. Baseline outcomes were not Exclusions discussed but postpartum complications
measurements were taken adequately blinded did not discuss if there Babies at least 35 weeks gestation, no
before randomization. throughout. were differences in those morbidities, including
who were lost to follow-up hyperbilirubinemia
compared with included. Included sample are mainly White,
middle class
Maastrup Not No concealment. Control Did not mention blinding High percentage of missing No QE design that was conducted in
et al19 applicable group data were collected during analysis but staff data. Consent was obtained different periods.
between October 2016 and assessing outcomes were for 72% and 65% of
July 2017 (preintervention) not blinded due to study eligible participants and
and intervention data design. information on
between February 2018 and breastfeeding outcome was
December 2018 collected for 53% and 48%
(postintervention). of participants in the
control and intervention

788
groups, respectively.
Jang Not No concealment. Control Did not mention blinding Only three participants were No QE design that was conducted in
and Ju20 applicable group data were collected during analysis but lost to follow-up in the different periods (1 year gap).
between 2014 and 2015 researchers assessing control group, unclear if Control group had a higher
and intervention data outcomes were not blinded there were differences in proportion of 34 weekers (48.1%
between 2015 and 2016. due to study design. those who were not versus 23.1%), whereas the
followed up with. experimental group had a higher
proportion of 36 weeks’ gestation
(53.8% versus 29.6%).
Jang Not No concealment. Control Did not mention blinding Data seem to be complete. No QE design that was conducted in
and Ko21 applicable group data were collected during analysis but Not clear if any participants different periods. The rate of
from June to October 2017 researchers assessing were excluded. ventilator used in the experimental
and intervention data from outcomes were not blinded group was higher than in the control,
November 2017 to May due to study design. whereas the mean 1-minute and 5-
2018. Did not mention how minute Apgar scores were lower in
the mothers and infants the experimental group.
were allocated to each
group.
Jang and Not No concealment. Did not Did not mention blinding Data seem to be complete. No Control group had a higher proportion
Hong22 applicable mention how the mothers during analysis but Not clear if any participants of infants with feeding intolerance
and infants were allocated researchers assessing were excluded or if any (25% versus 10%), or an
to each group, or why it outcomes were not blinded data were not collected. illness/complication (65% versus
was not a randomized due to study design. 50%), and who initiated feeding on a
controlled trial. day after the day of birth (25%
versus 10%).
(continued)
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Table 3. (Continued)
Selective
Treatment allocation Completeness of outcome outcome
Article Sequence concealment Blinding data reporting Other sources of bias
Estalella et al23 Not No concealment. Control Did not mention blinding Only six participants were No QE design that was conducted in
applicable group data were collected during analysis but excluded for refusing to different periods. However, baseline
between 2012 and 2013 personnel assessing participate. No attrition but pregnancy and delivery
and intervention data outcomes were not blinded data collected from medical characteristics were not significantly
between 2014 and 2015 due to study design. records so missing values different.
(after implementation of are possible. It was not
intervention). clear which values might
be missing.
Abouelfettoh Not No concealment. Did not Did not mention blinding High risk of bias as only the Yes Birthweight was significantly higher in
et al24 applicable mention how the mothers during analysis but results from the first week the cup feeding group compared
and infants were allocated researchers assessing were reported and the plan with the bottle feeding group at
to each group. outcomes were not blinded was to investigate baseline, which was not accounted
due to study design. breastfeeding practices at for. Unclear if mothers were
1–6 weeks postdischarge. expressing breast milk, and if there
High number of attrition were differences in milk expression
but the differences in between the two groups.
characteristics of

789
participants who remained
and lost to follow-up were
not investigated.
Jang25 Not No concealment. Control Did not mention blinding Data seem to be complete. No QE design that was conducted in
applicable group data were collected during analysis but Not clear if any participants different periods. The length of
from June to October 2017 researchers assessing were excluded. hospital stay was significantly
and intervention data from outcomes were not blinded longer in the experimental group,
November 2017 to May due to study design. and more LPIs in the experimental
2018. Did not mention how group had diseases.
the mothers and infants
were allocated to each
group.
Dani et al26 Not No concealment. Control Did not mention blinding Data seem to be complete. No Study was conducted in different
applicable group data were collected during analysis but periods and settings. Gestational age
from January 2018 to researchers assessing was lower and the need for
December 2020 at hospital outcomes were not blinded respiratory support was higher in
1 and intervention data due to study design. hospital 2 (intervention), whereas in
from July 2019 to hospital 1 (control) there was higher
December 2020 at hospital need of peripheral vascular catheters
2. and higher incidence of gestational
diabetes.
LPI, late preterm infant; QE, quasi-experimental.
 790 DIB ET AL.

the likelihood of exclusive/any breastfeeding in LPIs.19–22,25 breastfeeding exclusivity at 6 months, compared with con-
A prospective survey in Denmark, including 1,488 preterm trol.40 The discrepancy in the significance might be due to the
infants with a gestational age of 24–36 weeks, 483 of which difference in the duration skin-to-skin was practiced. For
were 35–36 weeks, found that delayed initiation of breast example, Hake-Brooks and Anderson40 reported that partic-
milk expression beyond 6 hours postdelivery had a dose– ipants in the intervention group practiced skin-to-skin for an
response association with failure to exclusively breastfeed average of 4.47 hours per day, whereas Mörelius39 reported 7
(directly at the breast) at discharge.36 Multiple factors in the hours of skin-to-skin per day on average in the control group.
early postnatal period after a late preterm/early term birth Similar evidence was reported in a few observational
might necessitate expressing breast milk. For example, LPIs studies. For example, a cohort study conducted in the United
often have lower stamina and fewer awake periods leading to Kingdom also found that kangaroo mother care increased
reduced effort to stimulate the breast, which might lead to breastfeeding rates at discharge and reduced average length
decreased breast milk production and ejection. As a result, of hospital stay in LPIs, small-for-gestational-age infants,
LPIs are commonly supplemented with infant formula, which and infants of diabetic mothers.41 Likewise, in a QE study
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might further interfere with establishment of breast milk. involving a large sample of LPIs and their mothers, mothers
Therefore, breast milk expression could be beneficial in who chose to provide kangaroo mother care were twice as
maintaining or increasing breast milk supply while simulta- likely to exclusively breastfeed at discharge and at 42 days
neously providing nutrients to less mature infants who might postdelivery compared with mothers who opted not to.42
be unable to feed effectively.
A comparative study that investigated the influence of Alternative and relaxation therapies
formula supplementation in the hospital on breastfeeding
rates in LPIs found that 87% of infants who were exclusively The use of herbal therapies and meditation audio for
breastfed from birth were exclusively breastfed at discharge mothers of LPIs and ETIs with perceived insufficient milk
compared with 24% who were supplemented with formula supply was investigated.43 The study did not report signifi-
regularly from birth.37 The study also showed that 65% of cant differences in breast milk volume or breastfeeding sta-
mothers whose infants were prescribed breast milk substi- tus, however, this is probably due to the small sample size
tutes on a regular basis never used a breast pump, while the (n = 11), which was underpowered to detect differences.
rest took an average of 42 hours before using one. Therefore, Additionally, the study did not include a control comparator,
the low exclusive breastfeeding rates may be partially ex- which is why it was not included in this review. Nevertheless,
plained by the inadequate milk expression to establish the study showed that these two complementary and alter-
breastfeeding, and also due to formula volume exceeding the native therapies are safe and acceptable in this population.
amount of milk the infant would receive at the breast, al- Other relaxation interventions such as music and meditation
though this was not investigated in this study. were shown to be beneficial at increasing breast milk volume
The method by which supplementation, whether breast in mothers of preterm infants44,45 and in full-term infants.46
milk or formula milk, is delivered to LPIs has also been However, their efficacy was not studied in LPIs or ETIs
studied. Abouelfettoh et al24 showed that infants fed by cup specifically, and further investigation is warranted.
had a higher proportion of feedings that were breast milk at 1
week postdischarge compared with infants fed by bottle. Conclusion
Likewise, in another study, including LPIs that was defined in
In summary, professional breastfeeding support and edu-
the study as 32–35 weeks gestation, exclusive breastfeeding
cation programs tailored to LPIs might improve breastfeed-
was significantly higher at discharge, 3, and 6 months, and
ing and/or exclusive breastfeeding rates. Other interventions,
breastfeeding was significantly higher at discharge and 6
such as early breast milk expression, kangaroo mother care,
months in the cup feeding group.38 However, both studies
and relaxation therapies, are promising and warrant more
had several methodological limitations, including the lack of
investigation in this population using robust study design.
information on breast milk expression practices and the high
Overall, there are limited experimental studies that exclu-
level of attrition. Moreover, the analysis was not intention to
sively include LPIs or ETIs, or present the data for these
treat,38 and 85 participants were excluded for noncompli-
groups separately. Additionally, since the experiments are
ance, which introduced bias to the study results.
mainly conducted in single hospitals, which makes random-
izing infants and avoiding cross-contamination difficult, 8/9
Kangaroo mother care studies in this review are QE. This introduces confounding
bias and limits their ability to conclude a causal association,
Mörelius39 and Hake-Brooks and Anderson40 conducted
which is especially true in 6/8 QE studies in this review that
two RCTs that studied kangaroo mother care, but which were
were found to have differences at baseline. Therefore, RCTs
not included in this review because the data were not ana-
that target LPIs and ETIs are needed to improve breastfeed-
lyzed separately for LPIs versus more preterm infants.
ing and health outcomes for these infants. More interventions
Mörelius39 found that in infants (32–36 gestational age)
that are delivered postdischarge are also needed, as many of
admitted to the NICU, breastfeeding rates were higher in the
these infants do not have long hospital stays and thus their
continuous skin-to-skin group compared with infants in the
mothers might require support at home.
standard care group, at discharge (100% versus 84%) and at
1 month (94% versus 74%) and 4 months (77% versus 53%)
Authors’ Contributions
corrected age, although the results were not statistically
significant. In the other study, in infants of 32–36 gestational S.D. and M.F. proposed the idea and concept of this re-
age, kangaroo care significantly increased breastfeeding and view. S.D. conducted the search and screened the titles. S.D.
 BREASTFEEDING LATE PRETERM AND EARLY TERM INFANTS 791

and K.K. screened the abstracts and full-text articles and 12. Kair LR, Colaizy TT. Breastfeeding continuation among
assessed the quality of the studies. S.D. drafted the article, late preterm infants: Barriers, facilitators, and any associ-
and J.W., M.F., and K.K. edited the article and contributed ation with NICU admission? Hosp Pediatr 2016;6(5):261–
critical intellectual input. All authors approved the final ar- 268; doi: 10.1542/hpeds.2015-0172
ticle for submission. 13. Crippa BL, Colombo L, Morniroli D, et al. Do a few weeks
matter? Late preterm infants and breastfeeding issues.
Disclosure Statement Nutrients 2019;11(2):312; doi: 10.3390/nu11020312
14. Andreas NJ, Kampmann B, Le-Doare KM. Human breast
No competing financial interests exist. milk: A review on its composition and bioactivity. Early
Hum Dev 2015; 91(11):629–635; doi: 10.1016/j.earlhumdev.
Funding Information 2015.08.013
15. Carpay NC, Kakaroukas A, Embleton ND, et al. Barriers
No funding was received for this article.
and facilitators to breastfeeding in moderate and late pre-
term infants: A systematic review. Breastfeed Med 2021;
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Supplementary Material 16(5):370–384; doi: 10.1089/bfm.2020.0379

Supplementary Data 16. Cartwright J, Atz T, Newman S, et al. Integrative review of
interventions to promote breastfeeding in the late preterm
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Effects on breast feeding and associated clinical parame- Department of Population, Policy, and Practice
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30(2):174–179; doi: 10.1177/0890334413517940 E-mail: [email protected]