Breastfeeding Preterm Infants:

An Educational Program to
Continuing Support Mothers of Preterm
Nursing
Education Infants in Cairo, Egypt
Series
Azza H. Ahmed

Purpose: To develop, implement, and examine the effect of a breastfeeding educational program on breast-
feeding knowledge and practices of Egyptian mothers of preterm infants.
Methods: An experimental design was used with a convenience sample of 60 mothers and their preterm
infants who were born before 37 weeks of gestation. They were randomly assigned to intervention and con-
trol groups. Data collection instruments included breastfeeding knowledge questionnaire, observational
checklist of mother’s breastfeeding practices, breastfeeding diary, infant’s and mother’s profile form, and
demographic information. A five-session breastfeeding educational program based on Bandura’s Social
Cognitive Theory was implemented with the intervention group during the infant’s hospitalization and after
discharge. Both groups were followed up to 3 months after discharge. Descriptive statistics, ANOVA, Chi-
square, and regression were used to analyze the data.
Findings: Mother’s knowledge significantly increased for the intervention group but not the control group
(p = 0.041). The intervention group showed gradual improvement in breastfeeding practices, i.e., started
breast milk expression earlier and had more breast milk expression frequency than the control group. Of
the intervention group, 80% were discharged on exclusive breastfeeding compared to 40% among the con-
trol group, and breastfeeding problems were less among the intervention group.
Conclusions: The breastfeeding educational program was effective in improving breastfeeding knowledge
and practices among mothers of preterm infants.

reast milk is a dynamic body eral studies indicate that providing for preterm infants as it consists of

B fluid that changes in its com-

position to meet the nutrition-
al requirements of the
neonate, provides protection from
infectious disease, and promotes neu-
rodevelopment (American Academy
of Pediatrics, 2005). The health bene-
fits of mother’s milk are especially sig-
nificant for the immunocompromized
preterm infant; however, mothers of
those infants experience documented
physiological and emotional barriers
to the initiation and maintenance of
lactation (Hurst & Meier, 2005; Meier,
2001). In addition, findings from sev-
Azza H. Ahmed, DNS, RN, IBCLC, PNPc,
is Visiting Associate Professor, Purdue
University School of Nursing, West
Lafayette, IN, and Lecturer, Faculty of
Nursing, University of Cairo, Cairo, Egypt.
Objectives and the
CNE Posttest can be
found on pages 139-140.
milk for infant feeding helps a mother
cope with emotional stress by giving
her the opportunity to participate in
caring for her preterm infant
(Kavanaugh, Meier, Zimmermann,
and Mead, 1997).
Framework and Background
Social Cognitive Theory (SCT)
provides a framework for analyzing
human motivation, thought, and
action from a social cognitive per-
spective (Bandura, 1977a, 1978).
Bandura’s SCT has been selected as a
framework for the current study
because it explains the process of
acquisition of new behavior patterns
and change in behavior as well as how
behavior is regulated and maintained.
Bandura’s SCT also provides effective
educational strategies (e.g., modeling,
rehearsal, reinforcement, and self-
monitoring) that can be used in imple-
menting an educational program.
Such educational strategies were
effective to influence behavior either
through direct action or through influ-
ence on self-efficacy or outcome
expectations (Bandura 1977b, 1986).
Breast milk is the optimal nutrition
unique amounts and types of proteins,
enzymes, micronutrients, lipids, and
particularly long-chain polyunsaturat-
ed fatty acids, which are critical for
growth and development (Heird,
2001; Koletzko et al., 2001; Larque,
Demmelmair, & Koletzko, 2002).
Breast milk also protects the vulnera-
ble premature infant by reducing the
risk of infection and improving gas-
trointestinal function and the absorp-
tion of nutrients (Boersma & Lanting,
2000; Schanler, Hurst, & Lau, 1999).
In addition, breast milk is significantly
associated with higher scores of cog-
nitive ability, teacher rating, standard-
ized achievement tests, and increased
high school success later on (Bier,
Oliver, Ferguson, & Vohr, 2002;
Feldman, & Eidelman 2003; Horwood,
Darlow, & Mogridgi, 2001). Schanler
(2001) explained that the use of forti-
fied human milk provides the preterm
infant adequate growth, nutrient reten-
tion, and biochemical indices of nutri-
tional status.
While recent studies and literature
confirm the importance of preterm
milk for preterm infants, several stud-
ies demonstrated that breastfeeding

PEDIATRIC NURSING/March-April 2008/Vol. 34/No. 2 125

preterm infants results in better suck-
ing ability, less ventilatory disruption
and warmer skin temperature in com-
parison with bottle-feeding (Hurst &
Meier, 2005). Another study by Bier et
al. (1993) tested the ability of very low
birth weight (VLBW) infants to breast-
feed at the same postnatal age at
which bottle-feeding is initiated.
Results demonstrated that VLBW
infants can tolerate both breast and
bottle-feeding at the same postnatal
age, and those infants were less likely
to have oxygen desaturation (to less
than 90%) during breastfeeding.
Bier et al. (1993) concluded that
mothers of VLBW infants need lacta-
tion counseling and support. Meier
and Mangurten (1993) also reported
that mothers of preterm infants
receive conflicting advice from profes-
sionals and friends. Hill, Hanson, and
Mefford (1994) found that insufficient
milk supply and breastfeeding difficul-
ties were the main concern of the
mothers of low birth weight (LBW)
preterm infants who stopped breast-
feeding 8 weeks after birth.
In Egypt, 12% of live neonates are
low birth weight and it is estimated
that about one third of such infants are
preterm (UNICEF, 2001). In a study
that Campbell et al. (2004) conducted
in Egypt, the neonatal mortality rate
was estimated to be 25 per 1000 live
births. In Egypt, UNICEF (1993)
reported that prematurity was a main
reason for premature breastfeeding
cessation. They found that 27.3% of
mothers in Upper Egypt, 27.4% in
Lower Egypt, and 16.4% in Cairo
stopped breastfeeding due to prema-
turity.
Although the Egyptian culture sup-
ports breastfeeding for a long time
period of 12-18 months, lately formu-
la feeding has started to increase,
which affects the incidence of breast-
feeding. The main reasons were imi-
tating Western countries, increase in
the number of working mothers, lack
of breastfeeding support, and receiv-
ing incorrect information from family
members and relatives. Mothers of
preterm infants are more likely to
have a problem in establishing breast-
feeding and more likely to quit breast-
feeding earlier without professional
breastfeeding support. Several studies
indicated that a single phone call or a
single home visit is not enough sup-
port for breastfeeding continuation for
term infants, so preterm infants need
more frequent support. Constant sup-
port is needed to reinforce education
and ensure longer duration of breast-
feeding.
The purpose of this study was to
126
develop, implement and examine the
effect of a breastfeeding program on
breastfeeding practices among moth-
ers of preterm infants. It was expected
that the breastfeeding program for
mothers of preterm infants would
improve the mothers’ knowledge
about breastfeeding their preterm
infants and would improve their
breastfeeding practices for their
preterm infants.
Methods
Participants. The participants were
a convenience sample of 60 mothers
and their preterm infants who were
born before 37 weeks of gestation and
who were able and willing to breastfeed
their preterm infants. The sample was
collected from the neonatal intensive
care units (NICU) of three governmen-
tal and university hospitals in Cairo.
The sample was randomly assigned to
intervention (30 mother-infant pairs)
and control (30 mother-infants pairs).
Instruments. Five instruments were
used in this study. After substantive lit-
erature review, the researcher devel-
oped the Breastfeeding Knowledge
Questionnaire (BFK) to measure a
mothers’ knowledge about (a) preterm
infants, (b) benefits of breastfeeding
and breast milk for mother and infant,
(c) physiology of breast milk formation
and secretion, technique of breast mas-
sage and breast milk expression, (d)
breastfeeding technique in preterm
infants, and (e) common breastfeeding
problems in preterm infants. Content
validity was considered through
reviewing by a group of expert nurses
and neonatologists using a content
validity form. Split half reliability
reported a value of 0.95.
Observational checklist of mother’s
breastfeeding practices was developed
by the researcher to evaluate a moth-
er’s skills in breast massage, hand
expression, and breastfeeding tech-
nique in preterm infants. Content valid-
ity was considered by the expert panel
of nurses and neonatologists, and inter-
nal consistency reported alpha of 0.91
values. The observational checklist
was used three successive times to
accurately evaluate the mothers’ skills.
The researcher developed a demo-
graphic and mother’s profile question-
naire to gather information about
mother’s age, education, occupation,
parity, past obstetrical history, high-risk
problems during pregnancy, past
breastfeeding experience, and method
of delivery. Content validity was tested
by the expert panel and internal consis-
tency reported alpha of 0.85 values.
The Infant’s Profile Form, an 18-item
information and follow-up form was
PEDIATRIC NURSING/March-April 2008/Vol. 34/No. 2
developed by the researcher to gather
information about the infant’s gesta-
tional age, birth weight, Apgar scores,
type and method of first feeding, age of
the infant at first breast milk feeding,
and type and method of feeding on dis-
charge. The form also included follow-
up information about the infant’s
breastfeeding pattern and problems for
3 months after discharge. Content
validity was reviewed by expert panel
and internal consistency reliability
reported a value of 0.85.
Mothers recorded the frequency of
breastfeeding both day and night and
the type and methods of any other fluid
or formula given to the infant through
the 3-month follow-up period. This
data was recorded in a Breast-feeding
Diary, which was given to each mother
in the study.
Procedures. Formal permission
from the directors of the three hospitals
and the heads of the postpartum unit
and NICU were received to conduct the
study. Informed consent from the
mothers and assent from their hus-
bands was obtained from those who
agreed to participate in the study.
Information about the mother’s demo-
graphic data and infant’s profile were
obtained from medical records on
admission. Both the control and inter-
vention groups were psychologically
and emotionally supported after
preterm delivery by answering their
questions and giving information about
their preterm infant and his/her prog-
nosis.
To assess a mother’s knowledge
regarding breastfeeding, the BFK ques-
tionnaire was given to both the inter-
vention and control groups. A five-ses-
sion breast feeding educational pro-
gram in the form of individual instruc-
tion sessions was given to the interven-
tion group, while the control group fol-
lowed the routine care of the unit,
which did not provide all the breast-
feeding education and support that was
provided to the intervention group. The
frequency of the sessions depended
upon the mother’s condition but the
first four sessions finished before the
infant’s discharge from the NICU. The
BFK questionnaire repeated 1 month
after the infant’s discharge for both
groups to assess the improvement in
their knowledge. The observational
checklist was used to evaluate the
mother’s breastfeeding practices in
breast massage, hand pumping, and
breastfeeding technique for three suc-
cessive sessions during hospitalization
and in the follow-up clinic in the NICU
every week. The Breastfeeding Diary
was used to evaluate the mother’s
breastfeeding practices during the first
weeks after discharge. It also helped in
determining the pattern of breastfeed-
ing. Both control and intervention
groups were followed up to 3 months to
assess their breastfeeding patterns, the
breastfeeding problems they confront-
ed, and how they resolved those prob-
lems.
Process of program development.
McKenzie and Smeltzer (1996) stated
that health education programs should
be based on well-developed model and
theory. Models provide structure, direc-
tion and organization to the program-
ming process, while theory provides
direction of the type of interventions
and assures congruence between the
planned interventions and expected
outcomes. The five-session breastfeed-
ing educational program designed
using the PRECEDE (Predisposing,
Reinforcing, Enabling Constructs in
Educational Diagnosis and Evaluation)
model includes: (a) needs assessment
based on the results of previous studies
and surveys, literature review and clin-
ical observation; (b) specification of
program goals, (c) formulation of
behavioral and learning objectives for
each goal; (d) selection of intervention
methods; (e) specification of time
needed to achieve each learning objec-
tive; (f) selecting suitable educational
strategies based on Bandura’s SCT;
and (g) program evaluation.
Phases of program implementa-
tion. Program implementation com-
prised four phases:
1. Pre-training Phase: This phase
started with psychological and emo-
tional support for the mothers by
answering their questions about their
preterm infant’s condition, explaining
the difference between preterm and
full-term infants, and discussing the
problems of preterm infants and the
benefits of breast milk and breastfeed-
ing for themselves and their infants.
2. Training Phase: This phase
included teaching and training on basic
breastfeeding skills starting with breast
massage and going through milk
expression using hand expression to
correct breastfeeding technique.
Several educational methods and
strategies from Bandura’s SCT were
used during this phase. Modeling in the
form of demonstration, discussion, and
written materials in the form of a book-
let in Arabic summarized the program.
3. Initial testing phase (posttrain-
ing): Once the skill was learned, the
mother was encouraged to practice the
skill with the assistance of the
researcher (participant modeling). The
mother started to practice breast mas-
sage first, then milk expression to
maintain milk secretion until the infant
PEDIATRIC NURSING/March-April 2008/Vol. 34/No. 2
was in stable condition (e.g., physio-
logical stability and gaining weight)
then started direct breast feeding with
special techniques for preterm infants
(e.g., chin support, dancer hand posi-
tion).
4. Continued performance phase
and follow up (3 months): During this
phase mothers were given a self-mon-
itoring form (breastfeeding diary) and
encouraged to monitor their breast-
feeding behavior. The fifth session was
included during this phase to help the
mothers deal with and overcome
common breastfeeding problems in
preterm infants. Poor coordination of
sucking and swallowing, easily
fatigued infant, state disorganization,
weak arrhythmical sucking, frequent
choking, and nipple confusion were
the most common problems that were
discussed with the mothers.
Statistical methods: All the items
and responses to the items listed in
the questionnaires and the observa-
tional checklist were coded, entered
into a personal computer, and ana-
lyzed using the Statistical Package for
the Social Science (SPSS) for
Personal Computers. Measures of reli-
ability and internal consistency of the
questionnaires and forms were identi-
fied using Cronbach’s alpha. Descrip-
tive statistics such as means, percent-
ages, and standard deviation were
used to describe the demographic
data about the mother and to classify
preterm infants according to their ges-
tational age and weight. Inferential
statistics such as ANOVA and Chi-
square were used to test the research
hypothesis. Alpha was set at .05.
Results
A total of 60 mothers in both the
control and experimental groups
between the ages of 20 and 29 with a
mean age of 24.5 ± 7.86 completed
Table 1
Summary of Mother and Infant Demographics
Intervention
M SD
Mother age 24.90
Mother education (yr) 8.50
GA 32.90
Birth weight (g) 2085
APGAR 1 min. 6.50
APGAR 2 min. 8.50
Days in hospital 12.50
Time of starting BF 14.00
the study. The majorities of the moth-
ers in both the intervention and control
groups were not working outside the
home and had an average of 9 years
education. Forty percent of the moth-
ers in the intervention group were
primiparas while 30% of the control
group were multiparas. Caesarian
section was the common method of
delivery among mothers of both
groups. Forty percent of the interven-
tion group had no past breastfeeding
experience compared to 30% in the
control group.
The mean gestational age among
infants of both groups was 32.2 ± 6.33
weeks with a mean birth weight of
2085 ± 838 grams among infants in
the intervention group and 1900.5 ±
1.8 grams among infants of the con-
trol group. The majorities of the
infants in both groups were
Appropriate for Gestational Age
(AGA) and had Apgar scores ranging
from 0-8 in the first minutes and 5-10
at 5 minutes and stayed in the NICU
an average of 12 days with a range of
3 to 42 days. More than one feeding
method was used in the first feeding
for infants in both groups. Nasogastric
tube feeding was the most common
feeding method among infants in both
groups during the first enteral feeding.
Twenty three infants (76.6%) among
the intervention group started direct
breastfeeding within 2 weeks com-
pared to 60% among infants in the
control group. There were no signifi-
cant differences among both groups
regarding mother and infant demo-
graphics (see Table 1).
Effect of the program on mother’s
breastfeeding knowledge. No statisti-
cally significant difference was found
in the pretest scores between the
intervention and control groups.
Although knowledge of both groups
significantly improved in the posttest,
Control
P
M SD
7.10 24.20 7.60 N.S.
2.50 9.10 2.30 N.S.
6.33 32.80 6.30 N.S.
838.8 1900.30 760.80 N.S.
2.30 5.00 1.50 N.S.
1.88 8.23 1.90 N.S.
5.45 12.59 6.59 N.S.
3.00 15.00 3.50 N.S.
127
 Table 2 the improvement was highly signifi-
Comparison of the Total Mean of Knowledge Scores of cant among the intervention group (F
Pre- and Post-tests Among the Intervention and Control Groups = 3.48, p = .011) (see Table 2). A pos-
itive relationship between mothers’
Item Intervention Control p past breastfeeding experience and
their preknowledge scores was found
Pre-test 28.87 ± 12.19 24.47 ± 4.79 .031 (r = .388, p = .034 for intervention and
Post-test 68.73 ± 8.80 40.00 ± 6.667 .041 r = .539, p = .002 for control).
Effect of the program on mothers’
P .00*** .00** breastfeeding practices. Statistically
significant differences were evident in
the mean scores among the three suc-
Figure 1 cessive sessions of breast massage,
Time of Starting Milk Expression hand expression, and breastfeeding
technique (see Table 3). As seen in
Table 3, there was progress in the
mean scores of the mothers of the
60 intervention group.
More than 50% of the intervention
50 group started breast massage and
40 milk expression from the second day
compared to 10% among the control
% 30 group (see Figure 1). In addition, they
Intervention
20 Control had more breast milk expression fre-
quency than the control group. Fifty
10 percent in the intervention group
0 expressed their milk from 5 - 6
1st day 2nd day 3rd day more times/day during the infant’s hospital-
ization, while 66.7% of the control
Time
group expressed their milk just up to 2
times/day (see Figure 2). Statistically
significant differences were found
between the two groups concerning
Figure 2 the time of starting milk expression
(χ2 = 26.8, p < .000) and frequency of
Frequency of Milk Expression
milk expression (χ2 = 12.4, p =
0.297).
Eighty percent of the intervention
70 group was discharged from the hospi-
tal on exclusive breastfeeding com-
60 pared to 40% among the control
50 group. Another 30% from the inter-
40 vention group were on partial breast-
% feeding. At the end of the second
30 Intervention
month, 66.7% of the intervention
20 Control group was still on exclusive breast-
10 feeding compared to 30% in the con-
0 trol group. By the end of the third
0-2 3 to 4 5 to 6 7 to 8 month, exclusive breastfeeding was
still higher among the intervention
Times/day group (40%) compared to the control
group (13%). A statistical difference
was found between both groups con-

Table 3
Mean Scores of Mothers’ Breastfeeding Practices in Three Successive Sessions Among
Mothers of Intervention Group
1st Session 2nd Session 3rd Session
F P
M SD M SD M SD
Breast Massage 0.43 .30 2.03 0.61 3.93 2.50 7.38 0.011
Hand Expression 3.40 1.35 5.87 1.46 8.37 0.61 19.34 .000
BF technique 4.37 0.61 7.87 0.94 11.10 0.99 11.44 .000
Total 8.07 1.44 15.63 1.67 23.37 1.22 14.52 .000

128 PEDIATRIC NURSING/March-April 2008/Vol. 34/No. 2

 Figure 3
Pattern of Breastfeeding on Discharge
80
70
60
50
% 40
30
20
10
0 group, but was still high compared to
Exclusive Partial Minimal
Pattern of breastfeeding
Figure 4
Pattern of Breastfeeding After 3 Months
50
40
30
% Horvat (2000) and Sheehan, Watt,
20
10
0 breastfeeding continuation and long-
Exclusive Partial Minimal
Pattern of breastfeeding
cerning the pattern of breastfeeding at
the end of the third month (χ2 =25.7, p
< 0.000) (see Figures 3 and 4).
Both groups experienced breast-
feeding problems after discharge,
including drowsy and sleepy infants,
easily fatigued infant during feeding,
nipple confusion, weak sucking, and
inadequate milk supply. These prob-
lems decreased gradually among
mothers of both groups, but perceived
inadequate milk supply and nipple
confusion persisted until the end of the
third month among control group.
Perceived inadequate milk supply was
the main reason for stopping breast-
feeding among the control group while
personal reasons were the main rea-
son for stopping breastfeeding among
the intervention group.
PEDIATRIC NURSING/March-April 2008/Vol. 34/No. 2
Intervention
Control
No BF
Intervention
Control
No BF
Discussion
An educational intervention pro-
gram was highly successful in both
promoting breastfeeding and extend-
ing breastfeeding duration among
Egyptian mothers of preterm infant,
even in a cultural climate where bottle
feeding is being promoted.
Results of this study indicated that
breastfeeding education, frequent
support, and follow up with mothers of
preterm infants increased their breast-
feeding rate on discharge, decreased
breastfeeding problems, and con-
tributed to a higher breastfeeding rate
compared to the control group. The
differences between intervention and
control groups suggests that the out-
comes are not solely related to devel-
opmental or demographic factors.
The intervention group showed a
high incidence of exclusive breast-
feeding on discharge (80%) compared
to 40% among the control group. This
result is consistent with Nyqvist
(2002) who conducted a similar study
in Sweden and found that 85% of
preterm twins breastfed during hospi-
talization. In another study in the
United Kingdom, 83% of the sample of
preterm infants received breast milk at
discharge and 75% were feeding at
breast (Warren, Tan, Dixon, & Ghaus,
2000). In this study, the breastfeeding
rate among the control group was sig-
nificantly lower than the experimental
Western countries, which have greater
access to technology that supports
breastfeeding (e.g., electrical pumps).
Such technology is unavailable to
mothers of preterm infants in Egypt.
Also, the current study found that 40%
of the mothers in the intervention
group were still exclusively breast-
feeding and another 50% were partial-
ly breastfeeding by the end of the third
month, which indicates success of
continuous breastfeeding support and
follow-up with the mothers after dis-
charge. Lewallen et al. (2006) found
that most women received help with
breastfeeding in the hospital, but only
slightly more than half received help
after returning home. Hoyer and
Krueger, and Sword (2006) provided
additional evidence for the importance
of postpartum support and its role in
term breastfeeding.
This study found that education
and support resulted in earlier and
more frequent milk expression in
Egyptian mothers of preterm infants.
Fifty seven percent of the women in
the intervention group were effectively
expressing milk by the second day
postpartum with effective breast mas-
sage. Nyqvist (2005) found that early
frequent breast milk expression with
breast massage significantly affects
milk production. She also reported
that initiation of milk expression
beginning before 6 hours postdelivery
and frequent regular milk expression
(seven times per day) has shown sig-
nificant effect on milk production.
Breastfeeding problems such as
drowsy and sleepy infants, easily
fatigued infants during feeding, poor
lip closure, and weak sucking were
common among both groups during
the first 3 weeks after discharge. By
the end of the second month, a few
mothers of the intervention group
reported their babies still suffering
from fatigue and poor lip closure but
reported no problems by the end of
the third month. Among the control
129
group, mothers were still reporting
infants who easily fatigued, nipple
confusion, and inadequate milk sup-
ply by the end of the second month,
and 73% reported insufficient milk
supply by the end of third month,
which was the main risk factor for dis-
continuing breastfeeding. These
results were consistent with Hill et al.
(1994) and Bell, Geyer, and Jones
(1995), who found that a sleepy
infant, latch-on difficulty, poor suck-
ing, and fussiness after feeding were
the main infant factors that lead to
breastfeeding discontinuation besides
the mother’s perception of inadequate
milky supply. Lewallen et al. (2006)
and Dunn, Davies, McCleary,
Edwards, and Gaboury (2006) also
reported that the perception of insuffi-
cient milk supply was the major rea-
son for premature weaning and
reflected lack of knowledge and lack
of support.
In terms of breastfeeding knowl-
edge, the educational program not
only improved the mothers’ practice
but also improved their knowledge
about benefits of breastfeeding and
preterm infants, which was reflected in
the highly significant difference in
knowledge scores in the posttest
between both groups. These findings
not only reflect the effect of the educa-
tional program but also indicate that
when mothers of preterm infants are
supported by knowledge and encour-
aged to breastfeed their infant, the
result will be satisfactory, as Ekstrom,
Widstrom, and Nissen (2006) found.
These results all support the study
hypothesis regarding the effect of the
breastfeeding education program on
successfully improving a mother’s
knowledge and practices regarding
breastfeeding her preterm infant.
Overall, the program was very
effective in promoting breastfeeding
among preterm infants in Egypt
despite the shortage of supplies and
access to breastfeeding devices such
as hospital-based electric pumps and
digital scales that facilitate breastfeed-
ing preterm infants in Western coun-
tries. The program also developed a
positive attitude among medical and
nursing staff in the NICU who were
enthusiastic to support the breastfeed-
ing of preterm infants.
Weakness and limitations. There
were several limitations for this study
including a small sample size. Around
30 mothers dropped out of the study
during program implementation and
five mothers did not show up for all the
follow-up period because of their long
distance location and transportation
problems. Thus, it is difficult to gener-
130
alize the results of this study. In addi-
tion to the limited breastfeeding sup-
plies such as electric and manual
pumps, breast shields, and digital
scales, there were not enough private
places for teaching mothers in one
hospital; there was no special room for
breastfeeding in the small NICU.
Nursing Implications
Mothers of preterm infants need
immediate support starting immedi-
ately after birth by highly motivated
and knowledgeable health profession-
als such as International Board Certi-
fied Lactation Consultants (IBCLCs).
These professionals should be a part
of the NICU team to help mothers ini-
tiate and maintain their milk supply
and overcome breastfeeding prob-
lems and lack of confidence after
infant discharge. Early and frequent
milk expression was crucial in estab-
lishing and maintaining breastfeeding.
Providing mothers with adequate
information about their preterm
infants and how to breastfeed immedi-
ately after delivery was also an effec-
tive way to encourage breastfeeding.
Individual teaching and the use of
developmental breastfeeding support-
ive care were effective ways to adjust
the care according to the individual
case. Continuous support and follow-
up after discharge are crucial for long-
term breastfeeding.
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Suggested Readings
Feist, N., Berger, D., & Speer, C.P. (2000).
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ing, a complex support system for the
offspring. Pediatrics International, 44,
347-352.

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