RESEARCH

1 57
2 58
3
4
Administration of Fortifier by Finger 59
60
5
6 Feeder During Breastfeeding in Preterm 61
62
7 63
8
9
Infants 64
65
10 Margarita Thanhaeuser, Alexandra Kreissl, Claudia Lindtner, Sophia Brandstetter, Angelika Berger, Q8 66
11 and Nadja Haiden 67
12 68
13 69
14 Correspondence ABSTRACT 70
15 Nadja Haiden, MD, MSc, 71
Department of Pediatrics, Objective: To evaluate the acceptance, adherence, and feasibility of fortifier administration by finger feeder during
16 72
Division of Neonatology, breastfeeding and to determine weight, length, and head circumference gains after discharge for preterm infants.
17 Pediatric Intensive Care and 73
Design: Observational pilot study.
18 Neuropediatrics, Medical 74
19 University of Vienna, Setting: A Level III NICU and its outpatient clinic in Vienna, Austria. 75
20 Waehringer Guertel 18-20,
Participants: Infants born at younger than 34 weeks gestation were included. 76
A-1090 Vienna, Austria.
21 nadja.haiden@meduniwien. Methods: Mothers were screened in a tertiary NICU and trained by certified lactation consultants to administer fortifier 77
22 ac.at with a finger feeder during breastfeeding. Data on finger feeder use at home were collected by self-reported feeding 78
23 diaries and questionnaires. 79
Keywords
24 80
breastfeeding Results: In total, data from 24 mother–infant dyads were analyzed. The acceptance rate was 67%. In 41.7%, more
25 finger feeder 81
than 50% of meals were fortified. Mothers did not report problems in preparation, but 33% of the infants stopped
26 fortifier
latching on or drooled milk during finger feeder use. 82
27 growth
83
preterm infant Conclusion: Use of a finger feeder to administer fortifier to preterm infants enabled mothers to exclusively breastfeed
28 84
their infants and meet their nutritional needs. The development of further methods to augment preterm infant nutrition
29 85
that do not interfere with breastfeeding is of great interest.
30 86
31 JOGNN, -, -–-; 2017. http://dx.doi.org/10.1016/j.jogn.2017.05.005
87
32 Accepted May 2017
88
33 89
34 90
35 91
36 92
B reast milk is the recommended source of source and contain additional calories, vitamins,
Margarita Thanhaeuser,
37 MD, is a fellow in the nutrition for preterm infants (American and electrolytes. However, it is still unclear how 93
Department of Pediatrics,
38 Academy of Pediatrics, 2012). Many positive long breast milk fortification should be continued 94
Division of Neonatology,
39 Pediatric Intensive Care and short-term health effects such as prevention of to be beneficial for preterm infants. 95
40 Neuropediatrics, Medical necrotizing enterocolitis, improved gut develop- 96
41 University of Vienna,
ment, and strengthening of the immune system The European Society for Pediatric Gastroenter- 97
Vienna, Austria.
42 are associated with breastfeeding (Castellote ology, Hepatology and Nutrition (ESPGHAN) 98
43 Alexandra Kreissl, MSc, et al., 2011; Gartner et al., 2005; Sisk, Lovelady, recommends fortification of breast milk in accor- 99
PhD, is a nutritionist in the
44 Dillard, Gruber, & O’Shea, 2007). Furthermore, dance with the postnatal growth pattern of the 100
Department of Pediatrics,
45 Division of Neonatology, positive effects on neurodevelopmental out- preterm infant. If weight gain continues to be 101
46 Pediatric Intensive Care and comes are reported (Koo, Tank, Martin, & Shi, above the 10th percentile, breast milk should be 102
47 Neuropediatrics, Medical
2014; Vohr et al., 2007). fortified until term gestational age. In the case of 103
University of Vienna,
48 Vienna, Austria. growth restriction, which is defined as weight gain 104
49 The composition of breast milk meets the below the 10th percentile, breast milk should be 105
50 nutritional demands of term infants. Because fortified up to 52 weeks postconceptional age 106
51 preterm infants have enhanced nutritional (Aggett et al., 2006). 107
(Continued)
52 requirements, multicomponent fortifiers are 108
53 added to breast milk to support adequate growth Data from the Vermont Oxford Network and our 109
54 and neurodevelopment (Young, Embleton, department indicated that most very-low-birth- 110
The authors report no con-
55 flict of interest or relevant McCormick, & McGuire, 2013). These fortifiers weight infants are discharged at approximately 111
56 financial relationships. are based on a bovine or human milk protein 36 weeks gestational age. According to the 112

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113 Infants with impairment of sucking–swallowing 169

114 We tested a new method to administer fortifier with a finger coordination due to esophageal or other 170
115 feeder during breastfeeding to optimize fortification anatomic anomalies and infants with neurologic 171
116 management in preterm infants after hospital discharge. impairments were excluded from the study. 172
117 Furthermore, mothers with anatomic anomalies of 173
118 the breast and mothers with psychiatric disorders 174
ESPGHAN recommendations, breast milk should
119 were excluded. 175
be fortified after the infant has been discharged
120 176
from the hospital. Usually, fortifiers are mixed with
121 Study Objectives 177
expressed breast milk and fed via bottle. This
122 The primary objective of the study was to 178
significantly interferes with breastfeeding and
123 determine acceptance of this new method. 179
may have a negative effect on overall duration of
124 Acceptance was defined as any reported 180
breastfeeding (Howard et al., 2003). Breastfeed-
125 successful use of the finger feeder to administer 181
ing has been shown to be beneficial for the infant;
126 fortifier during breastfeeding. Acceptance was 182
for example, some researchers reported that
127 measured via a self-report feeding diary 183
infants had more stable oxygen saturation and
128 completed by the infant’s mother. Secondary 184
heart rate during breastfeeding compared with
129 objectives were to determine adherence to and 185
bottle-feeding (Chen, Wang, Chang, & Chi, 2000;
130 feasibility of the method. Adherence was defined 186
Lucas & Smith, 2015).
131 as fortification of more than 50% of the breast- 187
132 feeding meals per day at home, also measured 188
To optimize fortification management after
133 via a self-report feeding diary completed by each 189
discharge, we tested a new method of feeding
134 infant’s mother. Feasibility of this new method was 190
fortifier with a finger feeder during breastfeeding.
135 determined by evaluating problems in prepara- 191
We investigated the effect of this new method on
136 tion, simultaneous administration of medication, 192
acceptance and adherence. Further aims of this
137 feeding, and cleaning of syringes and finger 193
study were to evaluate the feasibility of prepara-
138 feeders using an investigator-created question- 194
tion and the weight, length, and head circumfer-
139 naire completed by the mothers. In addition, 195
ence gains of infants after discharge.
140 weight, length, and head circumference gains of 196
141 infants after discharge were documented. 197
142 Claudia Lindtner, MD, is a 198
143 fellow in the Department of Methods Fortification via Finger Feeder 199
144 Pediatrics, Division of Study Design and Participant Eligibility Participating mothers were trained to administer 200
Neonatology, Pediatric
145 Intensive Care and This was an observational pilot study to investi- fortifier by international board-certified lactation 201
146 Neuropediatrics, Medical gate a new method for fortifier administration consultants during the hospital stays of their 202
147 University of Vienna, during breastfeeding. The finger feeder device infants. The procedure is explained in Figure 1. 203
148 Vienna, Austria. 204
used in our study was already in use in infants Training was especially helpful for non-native
149 Sophia Brandstetter, MD, is with feeding problems such as sucking weakness German–speaking mothers. Participants were 205
150 an associate professor in the or poor latch and for administration of medication, advised to fortify all meals except the night meals, 206
Department of Pediatrics,
151 Division of Neonatology, so this was not an off-label use. All mothers of for which exclusive breastfeeding was recom- 207
152 Pediatric Intensive Care and exclusively breastfed preterm infants born at our mended. Therefore, a minimum of 50% of the 208
153 Neuropediatrics, Medical hospital between January 2013 and May 2014 daily meals were fortified. At our department, 209
154 University of Vienna, 210
with gestational ages less than 34 weeks were Aptamil FMS fortifier (Milupa, Austria) in a dosage
Vienna, Austria.
155 approached before discharge from the hospital. of 4.4% (4.4 g fortifier þ 100 ml breast milk) is 211
156 Angelika Berger, MD, Every participating mother gave informed used for all preterm infants by default and was 212
MBA, is a professor in the
157 Department of Pediatrics, consent after a detailed explanation of the pro- used during the study period. 213
158 Division of Neonatology, cedures. The study was approved by the local 214
159 Pediatric Intensive Care and ethical committee (EK-Nr: 1866/2012). Fortifier Feeding Diary 215
160 Neuropediatrics, Medical 216
To survey acceptance of and adherence to the
University of Vienna,
161 Vienna, Austria. Infants with a weight at discharge above the 10th finger feeder method, a self-report feeding diary 217
162 percentile received fortified breast milk until the was developed: the fortifier feeding diary (FFD). 218
Nadja Haiden, MD, MSc, is
163 an associate professor in the estimated date of birth, according to the The FFD included information on the number of 219
164 Department of Pediatrics, ESPGHAN guidelines (Aggett et al., 2006). breastfeeding meals during 24 hours, the number 220
165 Division of Neonatology, Infants with a discharge weight below the 10th of fortified meals administered with the finger 221
166 Pediatric Intensive Care and 222
percentile were fed fortified breast milk until the feeder, and the amount of fortifier administered to
Neuropediatrics, Medical
167 University of Vienna, 52nd week postconceptional age, corrected for the infant each time the finger feeder was used. 223
168 Vienna, Austria. prematurity (Aggett et al., 2006). Mothers received the FFD at time of discharge. 224

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225 281
226 282
227 283
228 284
229 285
230 286
231 287
232 288
233 289
234 290
235 291
236 292
237 293
238 294
239 295
240 296
241 297
242 298
243 299
244 300
245 301
246 302
247 303
248 304
249 Figure 1. Illustrated instructions given to participants before discharge.
305
250 306
251 307
252 They were asked to complete it on three precisely after each question (qualitative data). 308
253 consecutive days before the first routine follow-up Participants received the FQ at time of discharge. 309
254 appointment at the neonatal outpatient clinic. The They were asked to complete it before the first 310
255 first visit was scheduled 2 to 3 weeks after routine follow-up appointment at the neonatal 311
256 Q1 discharge or at the originally estimated due date, outpatient clinic and return it to the study team 312
257 whichever came first. along with the FFD. Samples of the FQ and FFD 313
258 (Supplemental Appendixes S1 and S2) are 314
259 Feedback Questionnaire included online as supplements to this article. 315
260 To survey feasibility of the new fortification Data on weight, length, and head circumference 316
261 method, we used a self-report feedback ques- of the infants were collected by the study team at 317
262 tionnaire (FQ). The questionnaire included the birth, discharge, and the first follow-up visit at the 318
263 following questions (quantitative data): outpatient clinic. 319
264 320
265  Were you able to administer the total amount Analysis 321
266 of fortifier (5 ml)? (Yes/No) Descriptive methods were used to analyze data 322
267  Did you have any problems with prepara- on weight, length, and head circumference gains. 323
268 tion? (Yes/No) Quantitative analysis of questionnaires, qualita- 324
269  Did you administer any medication simulta- tive data provided by the participants, and nutri- 325
270 neously? (Yes/No) tion protocols are presented via descriptive 326
271  Did you have any problems in administration methods. Data were analyzed using SPSS 327
272 of medication? (Yes/No) version 21. 328
273  Did you have any problems with breast- 329
274 feeding during finger feeder use? (Yes/No) 330
275  Did you have problems with follow up pro- Results 331
276 cessing, cleaning of the finger feeder or During a 17-month study period (January 2013 332
277 syringes? (Yes/No) through May 2014), a total of 264 infants were 333
278 born with a gestational age younger than 334
279 Q2 If there were any yes answers, participants were 34 weeks. Of these infants, 14% (37/264) were 335
280 able to specify their problems or concerns more exclusively breastfed at the time of hospital 336

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337 Results of the qualitative evaluation of the FQ are 393

338 Nutritional fortification via finger feeder during as follows. Participants reported breastfeeding 394
339 breastfeeding is a safe alternative to bottle-feeding but is problems during simultaneous administration of 395
340 not feasible for all mothers. fortifier. One third of the participants (n ¼ 8/24) 396
341 observed drooling of milk as soon as the finger 397
342 feeder was in the corner of their infants’ mouths; 398
discharge. Three mothers declined to participate
343 some even reported interruption in or stoppage of 399
because of the associated effort.
344 sucking. Furthermore, 33% of the participants 400
345 (n ¼ 8/24) reported a slightly bitter flavor of the 401
Thirty-four mothers of these breastfed infants
346 fortifier–water mixture, which also led to discon- 402
were included in this study, and written informed
347 tinuation of breastfeeding; 25% (n ¼ 6/24) com- 403
consent was obtained. One mother–infant pair
348 plained about the additional effort of this method; 404
was excluded because time to follow-up was
349 and 8% (n ¼ 2/24) had problems with positioning 405
insufficient. Nine mothers were lost during follow-
350 the infant, breastfeeding, and administering the 406
up and were therefore excluded. In total, data
351 fortifier all at once. 407
from 24 mother–infant dyads were analyzed, and
352 408
these 24 dyads made up the final sample
353 409
(see Figure 2). Weight, Length, and Head Circumference
354 410
Gains
355 Parameters of Acceptance and 411
Data on the weight, length, and head circumfer-
356 Adherence: FFD 412
ence of the infants at birth, discharge, and the
357 In total, 62.5% (n ¼ 15/24) of the participants 413
follow-up visit including percentiles are given in
358 returned the FFD. One third (n ¼ 8/24) did not 414
Table 2. Infants were born at a median of
359 use the finger feeder at all at home, corre- 415
28 weeks, 0 days gestation with a median birth
360 sponding to an acceptance rate of 67%. Adher- 416
weight of 917.5 g, a length of 35 cm, and a head
361 ence was 41.7%, because fortifier was 417
circumference of 25 cm. At discharge, infants
362 418
administered in more than 50% of the meals for were at a median postconceptional age of 37 þ 1 Q3
363 10 out of 24 infants. On average, fortifier was 419
weeks with a median weight of 2,721 g, a length
364 used 3 to 4 times a day (range ¼ 1–5 times/day), 420
of 46 cm, and a head circumference of 32 cm.
365 and 46% (n ¼ 11/24) of the participants used the 421
Median time to the follow-up visit was 18 days.
366 finger feeder more than three times a day. On 422
At the follow-up visit, infants were at a median
367 423
average, infants were breastfed a median of six postconceptional age of 40 þ 2 weeks with a
368 times a day (range ¼ 4–10 times/day). Almost 424
median weight of 3,395 g, length of 50 cm, and
369 half of the participants (n ¼ 11/24) were able to 425
head circumference of 35.15 cm.
370 administer the whole amount of fortifier (5 ml). 426
371 One mother had problems with the administration 427
372 of the total amount of fortifier, and three other Discussion 428
373 participants had problems with feeding their In a prospective observational pilot study, we 429
374 infants using the finger feeder, which resulted in determined the effects of a new method of fortifier 430
375 discontinued use of the finger feeder after a short administration via finger feeder during breast- 431
376 trial period. feeding with regard to acceptance, adherence, 432
377 and feasibility. Furthermore, data on weight, 433
378 Data on Feasibility: FQ length, and head circumference gains were 434
379 In total, 87.5% (n ¼ 21/24) of the participants collected. 435
380 returned the FQ at the follow-up visit. The quan- 436
381 titative evaluation results of the FQ, such as At hospital discharge, exclusive breastfeeding 437
382 problems with preparation, simultaneous admin- directly from the breast is often possible. The 438
383 istration of medication, or problems with feeding, coordination of sucking–swallowing–breathing 439
384 are reported in Table 1. None of the participants matures significantly between 33 and 36 weeks 440
385 reported problems with preparation of the fortifier postconceptional age but conflicts with fortifier 441
386 water mixture or cleaning of the finger feeder after administration (Lucas & Smith, 2015; Mizuno & 442
387 use. One mother reported failure to mix the Ueda, 2003). The procedure of fortifying 443
388 water–fortifier solution. Medication (i.e., vitamins, expressed breast milk is tedious: breast milk has 444
389 iron supplementation, other medication needed) to be expressed with an electric breast milk 445
390 was administered simultaneously via finger pump, reheated, mixed with the fortifier, and fed 446
391 feeder and was tolerated very well. No problems to the infant via a bottle. This additional effort 447
392 in administration of medication were noticed. decreases the acceptance of breast milk 448

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449 fortification, especially for women who want to 505

450 exclusively breastfeed their infants. Furthermore, Further research to improve fortifier administration without 506
451 the need for fortification might cause mothers to interference to breastfeeding is necessary. 507
452 Q4 be concerned about breast milk as proper nutri- 508
453 tion for their infants, possibly resulting in early 509
Median time to the first visit was 18 days, indi-
454 discontinuation of breastfeeding (Young et al., 510
cating that our participants had enough time to
455 2013). 511
practice the new feeding technique and report on
456 512
Use of our new method enables breastfeeding advantages and problems. Only two participants
457 513
and fortifier administration simultaneously. Medi- reported problems with preparation of the fortifier.
458 514
cations such as multivitamin or iron supplements, No problems with follow-up processing or cleaning
459 515
among others, can also be administered simul- of the finger feeder and syringes were mentioned.
460 516
461 taneously with the finger feeder, which was 517
tolerated very well. The method appears to be Still, even though participants received training
462 518
cost effective, because finger feeders and during their infants’ hospital stays on proper use of
463 519
syringes are reusable products. the finger feeder, some described the procedure
464 520
465 521
466 522
467 523
468 <34 weeks of gestaon 524
469 n = 264 525
470 526
471 527
472 Transfer to another hospital before 528
473 discharge: 529
474 On parenteral nutrion: n = 20 530
475 Breast milk: n = 38 531
476 Formula: n = 9 532
477 Breast milk and formula: n = 25 533
478 534
479 535
480 Infants discharged: n = 174 536
481 Formula: n = 46 537
482 Breast milk and formula: n = 53 538
483 Breast milk only, but not exclusively 539
484 breased: n = 36 540
485 541
486 Exclusively breased: n = 37 542
487 543
488 544
489 545
490
No wrien consent given: n = 3 546
491 547
492 Mother-infant pairs 548
493 included: 549
494 n = 34 550
495 551
496 552
No feedback given: n = 9
497 553
Follow Up Problems: n = 1
498 554
499 555
500 Mother-infant pairs 556
501 analyzed: 557
502 n = 24 558
503 559
Figure 2. Participation flow chart.
504 560

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561 In 58.3% of participants, adherence was poor 617

562 Table 1: Results of the Feedback because of the associated effort and the problems 618
563 Questionnaire (FQ) reported. Although fortification of 50% of the 619
564 meals was recommended, fortifier was not used 620
Parameters of Feasibility
565 or was used only once or twice a day in some 621
(Total n ¼ 21) No, n (%) Yes, n (%)
566 families. Despite the problems mentioned, data on Q5 622
567 Total amount of fortifier (5 ml) given? 10 (47.6) 11 (52.4) infant growth indicated appropriate gains. Infant 623
568 Any problems with preparation?a 18 (85.7) 2 (9.5) percentiles for weight, length, and head circum- 624
569 Simultaneous administration of 7 (33.3) 14 (66.6)
ference decreased from birth to discharge but 625
570 increased from discharge to the follow-up visit, 626
medication?
571 indicating sufficient nutrient supplies at home. 627
Problems with administration of 11 (78.6) 3 (21.4)
572 628
573 medication?b Nevertheless, the goal of exploring a new method 629
574 Q6 Problems with feeding?a 10 (47.6) 10 (47.6) of fortifier administration with this pilot study was 630
575 Problems with follow-up processing, 21 (100) 0 (0)
met, but further research is needed. After a long 631
576 period of hospitalization, it is especially important 632
cleaning of finger feeder, and
577 to maintain the relationship between mother and 633
syringes?
578 preterm infant to avoid feeding problems 634
579 Q7 aData for one dyad missing. bOf mothers administering medi- (Tambelli, Odorisio, & Lucarelli, 2014). Therefore, 635
cation (n ¼ 14).
580 more research regarding devices for fortifier 636
581 administration that do not interfere with breast- 637
582 feeding, do not lead to discontinuation of 638
583 as very difficult when used at home. For some breastfeeding, and do not result in vacuum loss 639
584 infants, finger feeder use resulted in loss of correct during sucking is needed. 640
585 latch on the breast and drooling of milk as soon as 641
586 the finger feeder was put in the corner of their It is important to create a device for fortifier 642
587 mouths. Some participants even reported refusal administration to help supply enough calories 643
588 of the breast, an outcome we wanted to avoid with and establish adequate growth in preterm infants 644
589 this method. We assume that this problem might after discharge that does not have a negative 645
590 be related to the hydrolyzed whey protein con- effect on overall time of breastfeeding. The 646
591 tained in FMS fortifier, which tastes bitter if mixed development of ready-to-use devices that are 647
592 with water instead of with breast milk (Pedrosa, more user friendly or already prepared liquid 648
593 Pascual, Larco, & Esteban, 2006). Furthermore, fortifiers is of great interest. To avoid irritation for 649
594 interruption of breastfeeding during fortifier the infant, improvement in the flavor of the fortifier 650
595 administration might have been caused by the would be helpful. Multivitamin supplements, 651
596 loss of vacuum needed to suck from the breast which are often prescribed, have a sweet taste. 652
597 sufficiently, because the finger feeder was inser- Splitting the daily dose of supplements into small 653
598 ted in the corner of the mouth (Geddes, Kent, portions might help sweeten the fortifier solution 654
599 Mitoulas, & Hartmann, 2008). and make it tastier for the infant. Furthermore, 655
600 656
601 657
602 658
Table 2: Weight, length, and head circumference at birth, discharge, and follow-up visit
603 659
604 Discharge, Median Follow-Up Visit, Median 660
605 Parameters (n ¼ 24) Birth, Median (Range) (Range) (Range) 661
606 662
Gestational age, weeks 28 þ 0 (23 þ 4 to 32 þ 5) 37 þ 1 (34 þ 6 to 41 þ 5) 40 þ 2 (37 þ 4 to 44 þ 0)
607 663
608 Weight, g 917.5 (580.0–2,140.0) 2,721 (2,032–3,140) 3,395 (2,340–4,980) 664
609 Weight, percentile 46.5 (5.0–88.0) 36.5 (2.0–73.0) 41.5 (4.0–88.0) 665
610 666
Length, cm 35.0 (30.0–46.5) 46.0 (40.5–51.0) 50.0 (43.0–55.0)
611 667
Length, percentile 41.5 (1.0–93.0) 16.0 (0.0–90.0) 46.5 (0.0–80.0)
612 668
613 Head circumference, cm 25.00 (22.00–31.40) 32.15 (30.00–34.50) 35.15 (32.50–38.00) 669
614 Head circumference, percentile 42.0 (1.0–94.0) 28.5 (0.0–77.0) 48.5 (1.0–94.0) 670
615 671
616 672

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673 administration of the fortifier before breastfeeding Chen, C. H., Wang, T. M., Chang, H. M., & Chi, C. S. (2000). The 726
effect of breast- and bottle-feeding on oxygen saturation and
674 rather than simultaneously may reduce breast- 727
body temperature in preterm infants. Journal of Human
675 feeding problems. Feasibility could also be 728
Lactation, 16(1), 21–27. http://dx.doi.org/10.1177/0890334
676 increased if less fortifier per day is needed to 40001600105
729
677 provide additional nutrients. Therefore, high- Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O’Hare, D., 730
678 caloric fluids would be of great help. Schanler, R. J., & American Academy of Pediatrics Section on 731
679 Breastfeeding. (2005). Breastfeeding and the use of human 732
A major limitation of our study was the small milk. Pediatrics, 115(2), 496–506.
680 733
Geddes, D. T., Kent, J. C., Mitoulas, L. R., & Hartmann, P. E. (2008).
681 sample size and limited feedback from the par- 734
Tongue movement and intra-oral vacuum in breastfeeding
682 ticipants. In particular, the reasons that led to the 735
infants. Early Human Development, 84(7), 471–477. http://dx.
683
rejection of any use of the finger feeder would doi.org/10.1016/j.earlhumdev.2007.12.008 736
have been of great value. Another limitation of the Howard, C. R., Howard, F. M., Lanphear, B., Eberly, S., deBlieck, E. A.,
684 737
study is the self-reported nature of data collec- Oakes, D., & Lawrence, R. A. (2003). Randomized clinical trial
685 738
tion. Furthermore, macronutrient composition of of pacifier use and bottle-feeding or cupfeeding and their effect
686 on breastfeeding. Pediatrics, 111(3), 511–518. http://dx.doi.org/
739
participants’ milk was not analyzed during the
687 10.1542/peds.111.3.511 740
study period, so no detailed data on protein and
688 Koo, W., Tank, S., Martin, S., & Shi, R. (2014). Human milk and 741
energy intakes are available. neurodevelopment in children with very low birth weight: A
689 742
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690 743
691 Conclusion 10.1186/1475-2891-13-94
Lucas, R. F., & Smith, R. L. (2015). When is it safe to initiate
744
692 In conclusion, fortification via finger feeder during breastfeeding for preterm infants? Advances in Neonatal 745
693 breastfeeding is a safe alternative to bottle- Care, 15(2), 134–141. http://dx.doi.org/10.1097/ANC.000000 746
694 feeding but is not applicable for all mothers. 0000000167 747
695
Further research in optimization of fortifier Mizuno, K., & Ueda, A. (2003). The maturation and coordination of
748
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feeding is needed. The development of new
697 2003.mpd.0312 750
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698 Pedrosa, M., Pascual, C. Y., Larco, J. I., & Esteban, M. M. (2006). 751
prospective studies is necessary. Palatability of hydrolysates and other substitution formulas
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for cow’s milk-allergic children: A comparative study of taste,
700 753
smell, and texture evaluated by healthy volunteers. Journal of
701 Supplementary Material Investigational Allergology and Clinical Immunology, 16(6),
754
702 Note: To access the supplementary material that 351–356. 755
703 accompanies this article, visit the online version Sisk, P. M., Lovelady, C. A., Dillard, R. G., Gruber, K. J., & O’Shea, T. M. 756
704 of the Journal of Obstetric, Gynecologic, & (2007). Early human milk feeding is associated with a lower risk 757
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