The 10 steps that increase breastfeeding among premature babies and can save lives

“In the beginning, it was difficult. Born at 25 weeks, it was hard for him to nurse. But, with the help of the study team and constant and daily dedication, I managed to breastfeed my baby for the first time.”

The account above perfectly summarizes the difficulties of breastfeeding small and very low birth weight premature babies. It comes from one of the mothers of 4,600 babies born before 37 weeks, who participated in a study at the Ribeirão Preto College of Nursing at the University of São Paulo (USP). The project measured the impact of the Baby Friendly Hospital Initiative for neonatal units (Neo-BFHI), implemented in centers in five regions of Brazil. “The goal of the intervention was to increase the early onset and prevalence of exclusive breastfeeding in neonatal intensive care units (UTIs) in order to improve health outcomes of premature infants,” says researcher Carmen Scochi, a doctor in nursing from USP who specializes in neonatal nursing. “We also evaluate the adherence of professionals to these best practices.”

Neo-BFHI, developed by Nordic and Quebec-Canada researchers, brings together the Ten Steps to Successful Breastfeeding, adapted to the needs of neonatal units, the Three Guiding Principles, and the Code of Marketing of Breast-milk Substitutes. The adapted Ten Step include measures for health professionals, such as the “guarantee of education and training of all staff in specific knowledge and skills.” For mothers, the intervention allows “them to remain with their babies 24 hours a day,” and for parents, it is designed to “prepare them to continue breastfeeding and to ensure access to support services/groups after hospital discharge.”

Breastfeeding a premature baby is a task that requires a motivated and trained health team. Due to the immaturity of the whole organism, it is common for premature infants to have some difficulty with sucking, swallowing and breathing, all of which can interfere with breastfeeding, while simultaneously generating feelings of inadequacy in the mother. The lower the baby’s gestational age (at how many weeks of gestation the baby was born), the more difficult it is to feed through the mouth. This may require feeding through tubes and further delay the transition to the breast. When premature babies are not breastfed, they end up needing high-cost commercial formulas that may even aggravate health problems.

For these and other reasons, a Pernambuco study in 2014 with 93 premature infants found that only 22.6% had been breastfed in the first hour of life, an essential factor in establishing a bond between mother and child. In addition, breast milk protects against necrotizing enterocolitis (NEC), intestinal inflammation in which portions of the intestine undergo necrosis, and improves the immune system, ensuring a lower incidence of infections, such as sepsis (generalized infection) and meningitis, as well as re-hospitalizations, which are very common at this stage.

The researchers conducted the study in nine hospitals throughout the five regions of Brazil (north, northeast, central west, southeast and south) – five received Neo-BFHI intervention and four did not (control). The research measured the impacts of implementing the 10 Steps with respect to two indicators: exclusive breastfeeding incidence among premature infants and adherence to these practices by health professionals.

The hospital that received the intervention in the southern region, in Londrina (PR), was the only one that saw significant increases in the rates of exclusive breastfeeding both at hospital discharge (from 29.8% to 84.4%) and during the first month the premature infant was home (from 27.3% to 77.1%). “These results are due to the great commitment of everyone: from leaders to residents,” explains Carmen. In addition to training and engagement, Neo-BFHI feature a number of low-cost, high-impact interventions, including accommodation for the mother to stay beside the baby’s incubator, in the so-called kangaroo care, and skin-to-skin contact between mother and child.

After Londrina, the second largest increase in the adherence to best practices to encourage breastfeeding of premature infants occurred at a hospital in the southeast, in Ribeirão Preto – SP. “The women who participated in the program were more motivated to care for their children and, with this, they obtained greater support from their parents and family,” says Adriana Moraes Leite, another researcher involved in the study. 

According to Carmen, the reasons for low adherence at other centers range from the lack of professionals trained in quality improvement methods to high employee turnover, which undermines the sustainability of changes in practice. Now the team intends to return to the hospitals that had the greatest adherence to collect the same data and assess the impacts of the intervention more than a year later. “We want to understand what factors made the difference for the continuation of Neo-BFHI best practices in order to contribute to the inclusion of this expanded initiative as a mandatory requirements for a hospital that tends to premature babies to become Child Friendly”, says Carmen.