The protein content of the only human milk fortifier available in South Africa was increased in 2017. The Original fortifier (OF) and the Reformulated fortifier (RF) provided similar energy. This study aimed to prospectively compare in-hospital growth during the intermediate stage of nutrition support of very low birth weight (VLBW) preterm infants receiving human milk fortified with these two formulations in a tertiary South African hospital. Intake of VLBW infants receiving exclusively human milk plus one of two fortifiers (OF 0.2gprotein/g powder; RF 0.4gprotein/g powder) was calculated. Change in Z-scores (Fenton, 2013) from start to end of fortification of weight, length and head circumference (HC) for age was calculated as primary outcomes. Additionally, weight gain velocity (g/kg/d) and gain in length and HC (cm/wk) were calculated. Fifty eight infants (52% female; gestational age: 30±2wk; birth weight: 1215±187g) received OF (2016 to 2017) and 59 infants (56% female; gestational age: 29±2wk; birth weight 1202±167g) received RF (2017 to 2018) for 15 days. Protein intake of RF (3.7±0.4g/kg/d) was significantly higher (p<0.001) than of OF (3.4±0.2g/kg/d). Protein-to-energy ratio of RF (2.6±0.2) was significantly higher (p<0.001) than of OF (2.3±0.1g/100kcal). No adverse effects were noted. In both groups Z-scores of weight and length dropped; Z-scores for HC showed slight improvements. There were no significant differences between the two groups in terms of Z-scores, weight gain velocity, length gain or HC gain. Analysed human milk from preterm infants’ mothers’ protein levels was higher than published values. In-hospital growth was not statistically different between groups, even though calculated protein intake and protein-to-energy ratio were significantly higher in RF group. / Thesis (PhD (Dietetics))--University of Pretoria, 2019. / Human Nutrition / PhD (Dietetics) / Unrestricted

Preterm infants are born after 20 weeks' gestation but before the completion of 3-7 weeks' gestation. Because of cardiopulmonary, gastrointestinal, and neuromuscular immaturity, preterm infants are at high risk for respiratory complications during bottle feedings. The purpose of this integrated review of literature was to compile evidence based nursing interventions to decrease respiratory distress during bottle feedings. Research findings were obtained through searches conducted in the CINAHL, Health Source, and MEDLINE databases. Results indicated that assessment of feeding readiness prior to the initiation of bottle-feeding was either lacking or inconsistent among neonatal units. Many hospitals lack protocols, failing to provide specific guidelines for the initiation of bottle-feeding with preterm infants. Feeding techniques such as external pacing, how the bottle was held, and oral support were statistically significant in positively influencing successful bottle-feeding. Because feeding criteria is limited and inconsistent, the risk of overlooking factors necessary for clinical decision-making to prevent respiratory distress is increased. Further research addressing the management of preterm infants during bottle feedings is needed to clarify which interventions are the most effective in preventing respiratory distress while promoting adequate nutritional intake.

Objectives: To explore why so few mothers breastfeed when their babies are admitted to neonatal intensive care unit (NICU), and to gain an understanding of the impact of this for the mothers and staff involved. DESIGN: This study adopted an ethnographic approach. The data collection involved 135 hours of participant observation over a 6-month period and 32 semi-structured interviews of 17 mothers, 10 nurses, and 5 physicians. Findings: Data from the participants’ interviews and the participant observation were analysed focusing on the two different perspectives; one relating to the mothers and the other to the staff members and their working conditions. The mothers’ experiences were revealed as a developing process as their feeling changed from fearful and terrifying toward becoming and feeling like a ‘real’ mother. Their experience of mothering and breastfeeding differed from their expectations in that breastfeeding became a complex process for some and impossible for others. Five distinct themes emerged; the first highlighted the crisis, which involved the mother's feelings of emotional instability, their strategies for coping such as not visiting the baby, and recognition of the NICU as a stressful environment. The second theme described issues relating to control and power. This involved the perception of having a lack of control and needing to seek permission, the use of language as a mechanism for control, and mothers being placed in a subordinate role. The third theme related to the separation, which included difficulties of acceptance, feeling like stranger and not being important, and the need for physical closeness. Acceptance and adaptation comprised the fourth theme in which gradual acceptance occurred and a spiritual aspect emerged. The final theme, becoming a mother, included issues such as the special moments, breastfeeding as a turning point, and practical and informational needs. Almost all the mothers in this study spoke about going through all these stages during their infants’ stay in the NICU. Analysis of these findings suggests that mothers who deliver prematurely, may have their rite of passage into motherhood interrupted, resulting in them being placed in a position of suspended liminality. v The data also suggest that while staff members agree with the benefits of breastfeeding for preterm infants, the actual implementation of a breastfeeding policy within the neonatal units is more problematic. Three key themes emerged from the analysis relating to the staff perspectives. The first described the contradiction that exists between the staff beliefs and behaviours in relation to breastfeeding and supporting mothers. Elements that comprised this theme were “breast milk is best”, perceiving breastfeeding promotion as a nicety not a necessity; lacking support for mothers, and abdication of responsibility. The second theme related to their working conditions: this included a lack of institutional support for the health care team, and barriers to support breastfeeding. The final theme of controlling relationships captured the essence of the practitioner: mother association. Together, these elements revealed a situation whereby staff appeared more preoccupied in addressing the task aspect of care for the babies than supporting mothers in feeding and subsequently mothering their preterm child. Conclusions: An understanding of the experiences of mothers of preterm infants who wish to breastfeed, and the connection that breastfeeding has to the process of becoming a mother, allows for the finding of more positive strategies to support mothers and breastfeeding within the NICU. This study reveals a new understanding of how breastfeeding is connected to the process of becoming a mother, within the context of two Jordanian NICUs. It also highlights the difficult working conditions for nurses within these units. It is anticipated that recognition of these findings may assist with service developments and lead to improvements in the NICU environment in Jordan, thus enhancing health care delivery in accordance with the individual needs of infants and their mothers.

MOTHER-INFANT SYNCHRONY DURING INFANT FEEDING By Barbara A. Reyna, PhD A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2010. Major Director: Rita H. Pickler, PhD Endowed Nursing Alumni Professor Department of Family and Community Health Nursing, School of Nursing Synchrony between a mother and her infant is fundamental to their developing relationship. Feeding is an essential activity that provides an opportunity for interaction between a mother and her infant and may lead to synchronous interaction. The purpose this study was to develop and test a coding system, the Maternal-Infant Synchrony Scale (MISS), for assessing synchrony of feeding interaction between a mother and her preterm infant. The secondary aims were to: (1) describe mother and preterm infant synchrony during feeding; (2) examine mother-infant synchrony during feeding over time; (3) examine the mediating effects of infant severity of illness, behavior state, birth gestation, and birth weight, and maternal depression, and maternal responsiveness and sensitivity on mother-infant synchrony; and (4) test the criterion-related validity of the synchrony scale. A descriptive, longitudinal design using data collected during an earlier study was employed; a sample dataset from 10 mother-infant dyads that completed three data collection points (30 observations total) was used. Data were also collected on maternal depression and responsiveness and sensitivity and dyadic tension and reciprocity. For this analysis, scores for infant severity illness and behavior state were computed. The Noldus Observer XT 8.0 (Noldus Information Technology b.v., 2006) was used for data review and coding. The MISS was created by determining the frequency of select behaviors and the percentage of time behaviors occurred during the feeding; changes in behaviors over the three observations periods were calculated. Mothers were attentive and focused during feedings. The influence of infant maturation on feeding behaviors was evident across observations; infant attempts at interaction (gazing at mother) were greater than the mother attempts to engage her infant. MISS scores were not significantly different over the observations, the selected mediators had no significant effect on synchrony, and the criterion validity for the MISS was not established. This study revealed behaviors that are descriptive of the interaction and can be used to develop interventions that would support the developing relationship. Use of the MISS with a larger sample size and a cohort of healthy, term newborns is needed to establish the MISS as a valid and reliable measure of synchrony.

No description available.

Caffeine is used for the treatment of apnea of prematurity. The objective of this study was to determine the long term neuropathological and neurobehavioral effects of caffeine on the immature rat brain. Newborn rats were injected with either caffeine, or normal saline from postnatal days 3 to 7, equivalent to the human premature infant of 28-36 weeks. Behavioral tests revealed no abnormality in caffeine treated animals compared to controls. Fluro-Jade B stain of P4 rat brains showed that caffeine caused significant neuronal cell death in some areas of the brain, compared to controls, but this alteration was transient and not present at P8. Anti-NeuN stain at P21 showed significant neuronal cell loss in CA1 and hypothalamus regions in the caffeine group, but not at P160. Anti-Neurofilament M stain at P8, P21 and P160 showed no differences between the control and caffeine groups. We conclude that use of caffeine has no significant effect on the behavioral tests measured in our newborn rat pups. While caffeine caused neuronal cell death at P4, and neuronal cell loss in CA1 and hypothalamus regions at P21, there was no long-lasting effect on neuropathological outcome. However, given these latter findings, the use of caffeine in the premature infant must still be done with caution. / Medical Sciences

Preterm infants are at increased risk of cardiometabolic and neurodevelopmental disorders in later life. The typical postnatal growth pattern of failure to achieve the equivalent of a normal fetal growth rate, followed up by catch-up growth, altered adiposity and altered hypothalamic-pituitary-adrenal axis (HPA) activity may be predisposing factors. Potential mechanisms that may mediate such programmed effects include altered DNA methylation and faster telomere attrition. A prospective cohort of 46 very preterm (25+2 to 31+5 weeks’ gestation, mean 28.6) and 40 full term (38+3 to 42+2 weeks’ gestation, mean 40.2) infants was established to investigate potential mechanisms. Infants were studied at birth, term equivalent age, 3 months and 1 year corrected for prematurity. At all time points, linear growth and body composition (by densitometry) were measured and buccal (epithelial) cells was collected for measurement of DNA methylation (5mC) and relative telomere length. Compared with full term infants, preterm infants were lighter (p < 0.001) and had a smaller head circumference (p < 0.05) at all time-points and were shorter at term equivalent (p < 0.001) and 3 months corrected age (p = 0.002). Preterm infants also had greater percentage body fat at term equivalent age (mean difference = 5.5%, p < 0.001), which normalised by 3 months corrected (mean difference = 0.9%, p = 0.4). Preterm infants had a blunted salivary cortisol response (mean difference 0.4 μg/dL, p = 0.02) to a stressor (physical examination) at 3 months compared to term infants at this age, suggesting altered activity of the HPA axis. 5mC is fundamental in the control of expression of imprinted genes involved in fetal growth. Notably, a number of studies in humans exposed to an adverse environment in early life have demonstrated altered 5mC at the differentially methylated regions (DMRs) controlling the expression of the key fetal growth factor insulin like growth factor 2 (IGF2) and at the linked H19 imprinting control region (H19 ICR). At birth, preterm infants had a significant decrease in 5mC at DMR2 compared with term infants at birth (β = –11.5, p < 0.001) and compared with preterm infants at term equivalent age (mean difference = -7.4, p = 0.01). By term equivalent age, preterm infants had decreased 5mC at both DMR2 (β = –2.8, p = 0.01) and the H19 ICR (β = –2.3, p = 0.048) compared with term infants at birth, although this difference disappeared at 1 year corrected. Although research has suggested that catch up growth may confer an unfavourable metabolic phenotype, poor initial weight gain can associate with worse cognitive outcome. A pathway was established for obtaining advanced magnetic resonance images of the preterm brain. 5mC at H19 ICR and DMR2 in buccal DNA showed no association with measures of white matter microstructure or whole brain volumes. Term infants demonstrated telomere lengthening over the first year of life (mean difference = -0.3, p = 0.02). There was no significant change in telomere length over the first year of life in preterm infants (mean difference = 0.2, p = 0.34). However, as preterm infants at term equivalent age had longer telomeres compared to term infants at birth (β = 0.6, p < 0.001), ultimately there were no differences between the term and the preterm groups at 1 year corrected age (β = 0.3, p = 0.07). The DNA modification 5-hydroxymethylcytosine (5hmC) is a stable modification in its own right and is also thought to be an intermediate step in DNA demethylation. 5hmC is abundant in the placenta but has not been studied in the context of fetal programming. Additionally, previous research using methods such as bisulphite conversion would not have discriminated between 5mC and 5hmC and therefore the role of 5mC may not have been accurately measured. To study the relationship between 5mC, 5hmC and fetal growth, gene expression of candidate imprinted and non-imprinted genes in full term placental samples from the Edinburgh Reproductive Tissue BioBank was analysed. 5mC and 5hmC within the IGF2/H19 and KvDMR (controlling CDKN1C) loci was estimated using chemical capture and immunoprecipitation techniques that discriminate between modifications. Relationships between the expression of IGF2 (r = 0.3, p = 0.02) and CDKN1C (r = -0.3, p = 0.01) and birth weight across the normal range were found and in keeping with the known action of these genes. 5mC at IGF2 DMR0 (β = 0.3, p = 0.02) and KvDMR (β = 0.3, p = 0.02) and 5hmC at H19 gene body (β = 0.2, p = 0.04) associated with birth weight. Thus, DNA modifications at imprinted DMRs may modulate environmental influences on fetal growth across the normal range. DNA methylation at IGF2/H19 can be influenced by early life events. It remains to be seen whether any changes are present later in childhood and whether they associate with risk factors for the metabolic syndrome.

Choledochal cysts (CCs) are rare, congenital cystic dilations of the hepatobiliary tree that require surgical resection to avoid complications such as increased risk of malignancy. A 25‑week gestational age male infant developed acholic stools, elevated alkaline phosphatase, and ultrasound findings consistent with CC Todani Type IVA. Surgery was deferred due to the patient’s low weight. The patient’s symptoms and radiographic findings subsequently resolved spontaneously. CCs have not been previously reported in extremely preterm infants. There are rare reported cases of spontaneously resolving hepatic cysts, all containing key differences from our patient. In patients in whom immediate surgery is not feasible, conservative management with close follow‑up and serial ultrasound examinations would appear to be a reasonable course of action.

Clinicians use growth curves to assess infant health. Most children are measured on growth curves that contain percentiles for height, weight, and head circumference by sex. Preterm infants have their own growth curves. Infants who present with measurements below the 10th percentile are considered small-for-gestational age (SGA), and infants who present with measurements above the 90th percentile are considered large-for-gestational age (LGA). Growth curves and centiles can be generated using 3 and 4 parameter distribution models. To date, no studies have been published to investigate whether growth curves generated using a 3- or 4-parameter model differ significantly. Additionally, researchers have found mixed results when exploring the association between race and pregnancy/delivery. Black mothers may have greater risks and babies with lower weights than babies born to White mothers (Borrell, Rodriguez-Alvarez, Savitz, & Baquero, 2016), and growth curves that do not consider race may misclassify non-White babies (Buck-Louis et al., 2015). In this study, I had two specific aims: (1) to compare the preterm infant growth curves and centiles generated using 3 and 4 parameter methods (Lamba Mu Sigma [LMS] and Box-Cox Power Exponential [BCPE], respectively) and assess each model for adequate fit, and (2) to use percentile cut points from race-specific and non-race-specific LMS curves to classify babies in a validation dataset as SGA or LGA. Regarding the differences in curves generated from the LMS and BCPE distributions, the curves produced using the BCPE distribution had a lower GAIC in some cases but model fit criteria for the LMS curves were adequate. The simpler models generated by the LMS method were retained for birth length, head circumference, and weight by sex with an explanatory variable of gestational age. For aim 2, results indicated that race-specific curves classified babies within expected ranges. Non-race-specific curves overidentified Black babies as SGA and underidentified them as LGA. More research is required to test if this relationship persists for babies delivered at full term.

The overall aim of this thesis was to describe the prevalence of breastfeeding in preterm infants and to evaluate the effectiveness and mother’s experiences of proactive person-centred telephone support after discharge. Furthermore, to describe the duration of breastfeeding and risks of ceasing breastfeeding up to 12 months. The first study, a register study with data from the Swedish Neonatal Quality register (SNQ), included breastfeeding data at discharge from 29 445 preterm infants born from 2004-2013. The results demonstrated that the prevalence of exclusive breastfeeding among preterm infants in Sweden decreased during the study period, especially among extremely preterm infants (&lt;28 weeks). We also performed a multicentre randomised controlled trial (RCT) of 493 breastfeeding mothers of preterm infants discharged from six neonatal units in Sweden. The intervention consisted of a proactive breastfeeding telephone support system in which a breastfeeding support team called the mothers once everyday up to 14 days after discharge. The control group received reactive support; the mothers were invited to call the breastfeeding support team if they wanted to talk or ask any questions (i.e., usual care). The RCT demonstrated that the intervention did not affect exclusive breastfeeding at eight weeks after discharge (primary outcome) or up to 12 months. The proactive support did not affect maternal breastfeeding satisfaction, attachment, quality of life or method of feeding (secondary outcomes). However, parental stress was significantly reduced in mothers in the intervention group. Mothers in the intervention group were significantly more satisfied and involved in the support and felt empowered compared with mothers in the control group, who experienced reactive support as dual. Further findings showed that a lower maternal educational level, partial breastfeeding at discharge and longer stay in the neonatal unit increased the risk of ceasing breastfeeding during the first 12 months of postnatal age. In conclusion, the trend for exclusive breastfeeding at discharge in preterm infants is declining, which necessitates concern. The evaluated intervention of telephone support did not affect breastfeeding, in the short-or long-term. However, maternal stress was reduced and mothers were significantly more satisfied with the proactive support and felt empowered by the support.