CONSIDERACIONES DE ORDEN PRÁCTICO PARA LA APLICACIÓN DE LOS PROGRAMAS DE AUDITORÍA

The theoretical model indicates that interventions to improve late preterm breastfeeding success should commence early (prior to onset of the negative management cascade) and focus on modifiable factors influencing breastfeeding management, including detrimental hospital policies and practices, lack of provider and maternal breastfeeding knowledge (particularly among primiparas), and misguided expectations among healthcare providers and mothers alike regarding LPI breastfeeding behavior. Mothers of LPIs and health care providers should be educated on basic breastfeeding interventions and qualified breastfeeding support resources.

Additionally, the connection between infant behavior, physiological immaturity, and the high likelihood for problems compromising milk supply should be repeatedly emphasized to mothers of LPIs. Early breastfeeding interventions to assist with latching and milk transfer (e.g., supplemental nursing systems, nipple shields, supplementation via bottle) should be strongly considered, given the likelihood for decreased energy reserves and insufficient suction pressures common among LPIs (Medoff-Cooper, McGrath, & Bilker, 2000; Meier, Furman, &

Degenhardt, 2007). However, caution should also be exercised with regard to the risk-benefit ratio of formula supplementation, the increased probability for “nipple confusion” when alternating between at-breast and bottle feeds within the LPI population, and the balance between work and worth. For example, mothers who are extremely committed to breastfeeding may be amenable to more intensive interventions.

Future research building on study findings might include an examination of LPI breastfeeding beyond 6-8 weeks postpartum, inclusion of “early term” (37-38 weeks gestation) infants, who are also likely to experience breastfeeding issues related to neurologic immaturity (Kinney, 2006), and participant recruitment in areas known to be more ethnically diverse.

Considering the complexity of events, external factors, individual variations, management decisions, and consequences found to impact the LPI breastfeeding trajectory, a systems-based analysis would add significantly to the science. This might take the form of a mixed-methods examination of hospital policies and practices, follow-up support, and perceptions or experiences of other “players” (e.g., pediatricians, home-visiting nurses, family members). Alternatively, intervention studies at this juncture might include an examination of the effectiveness of the following: 1) LPI peer breastfeeding support groups, as prior breastfeeding experience was perceived to significantly impact breastfeeding success; 2) provision of early, in-person breastfeeding management education, as participants repeatedly emphasized their desire to be

“shown,” rather than told, how to manage breastfeeding; and 3) early introduction of breastfeeding interventions, such as breast pumps and nipple shields. Outcomes might be measured in terms of breastfeeding continuation and exclusivity, breastfeeding-associated morbidities and re-hospitalizations, volume of milk output, and/or maternal satisfaction, confidence, or anxiety related to breastfeeding. Methodologically, delivering part of the

intervention electronically (e.g., an iPhone “app”) may be a cost-effective alternative to exclusive in-person meetings and a preferable communication medium for some participants.

2.7 REFERENCES

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The Academy of Breastfeeding Medicine. (2011). ABM clinical protocol #10: breastfeeding the late preterm infant (34 /07 to 36 6/7 weeks gestation). Breastfeeding Medicine, 6(3), 151-156.

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3.0 MANUSCRIPT #1: THE PARADOX OF BREASTFEEDING-ASSOCIATED