Table 1.

Late Preterm Breastfeeding Promotion Interventions That Affect Breastfeeding Exclusivity and Duration By Level of Evidence

Author	Study Design	Level of Evidence	Study Purpose	Sample	Setting	Results	Limitations	Recommendations
Morelius, 2015	Randomized controlled trial Continuous skin-to-skin care (SSC) versus general practice of SSC	1a	To evaluate the effect of almost continuous skin-to-skin contact for late preterm infants, to study the concordance between the mothers’ and the preterm infants’ salivary cortisol levels at four moth corrected age, a third outcome was to study parental stress, depression, and breastfeeding	N = 42 Gestational age 32 to 35 6/7 weeks	NICU and post discharge	Exclusive and duration of breastfeeding: All infants n=18 in the SSC group were breastfeeding partly or exclusively at discharge compared to 16 out of 19 in the SC group but reported as not significant. More infants were breastfeeding partly or exclusively in the SSC group, compared to the SSC group at one and four months, but the differences did not reach significance.	Unable to provide a control group of no skin-to-skin	Rapid development of regularity Facilitates spouse relationship No statistical significance in improving the rate of breastfeeding
Hayes Brook/2008	Randomized controlled trial Kangaroo care versus standard care procedure (wrapped when being held)	1b	To determine the effects of kangaroo care (KC) on breastfeeding status in mother-preterm infant dyads from postpartum through 18 months Hypothesis: Breastfeeding exclusivity would be greater and duration would be longer for dyads experiencing KC, than for control dyads experiencing standard care	A subsample of 66 mothers and their preterm infants (32–36 completed weeks gestation, 1,300–3,000 g, 5 minute Apgar > or = 6)who intended to breastfeed (n=36 in the KC group and n = 30 in the control group)	NICU/post partum unit and post discharge	Duration of Breastfeeding : KC dyads, compared to control dyads, breastfed significantly longer (5.08 months vs 2.05 months), p = .003. Exclusive Breastfeeding: KC dyads also breastfed more exclusively from hospital discharge through 18 months (p = .047). At six months statistically the difference was statistically significant (p=.041)	Duration and exclusivity during follow-up were based entirely on self-report by the mothers. Control group did not receive the same attention from researchers as the intervention group (control group received care from staff versus the intervention group receiving care from researchers	Kangaroo care is an effective way to facilitate breastfeeding exclusivity and duration Need to look at amount and timing of kangaroo care Need to look at infants of other gestational ages
Rao et al/2008	Prospective randomized controlled Trial (Kangaroo Care versus Conventional Method Care)	1b	To assess the effect of Kangaroo Mother Care (KMC) on growth of infants weight <2000 g at birth	206 singleton KMC 45(43.7%) 35 to 36 weeks Control 47(45.6%) 35 to 36 weeks	NICU/post partum/post discharge	KMC babies achieved significantly better growth at the end of the study Head circumference p = 0.02	Poor follow-up in the control	Examining the effect of implementation in the community
Ravn et al/2011	Randomized controlled trial (Intervention group versus without intervention group)	1b	Assess the effects of the Mother-Infant Transaction program on maternal depression and stress, breastfeeding and mothers’ perception of infant temperament and impact on preterm infant communication skills at 12 months	Gestational age of 30 to 36 weeks Intervention Group 19(33.9%) Control 17 (34%)	Not identified	Breastfeeding duration: At 9 months 34.1% mothers in the intervention group were not breastfeeding their infants compared with 60% in the control group (p = .02). At 12 months (61.9%) versus (80%) (p=.07)	Results not broken down per gestational age Limited to Norwegian background Small sample size	Further follow-up of this cohort
Yilmaz et al/2014	Randomized Controlled trial Cup (treatment) Versus Bottle (control)	1b	Determine the effect of bottle and cup feeding on breastfeeding rates in 32 to 35 week late preterm infants during hospital stay, as well as upon discharge at 3 and 6 months Hypothesis: Cup feeding of late preterm infants could improve breastfeeding rates.	Infants born between 32 to 35 week gestation late preterm infants Cup feeding started at 35 week gestation Total = 522 Bottle = 268 Cup = 254	NICU and post discharge	Exclusive Breastfeeding: Infants randomized to the cup-feeding versus bottle feeding method more like to be exclusively breastfed on Discharge home (RR 1.58, 95% CI, 1.36–1.83) Duration of Breastfeeding 3 months (RR, 1.64, 95% CI, 1.42–1.89) 6 months (RR, 1.36, 95% CI, 1.14–1.63) No significance in weight gain at seven days between bottle and cup feedings (p=.64)	Breastmilk and formula spillage were not measured. No data on infant weight beyond day seven Analysis were not by intention to treat 85 infants were excluded because of noncompliance with the randomly assigned oral feeding protocol and development of a disease preventing oral feeding Inability to generalize results to all preterm infants as study participants were only late preterm infants	Further studies recommended for those infants born more premature
Flacking/2010	Prospective longitudinal	2a	Rapid development of regularity Facilitates spouse relationship No statistical significance in improving the rate of breastfeeding	103 very preterm infants (<32 gestational weeks) NICU 197 preterm (32–36 weeks)	NICU and post discharge	Duration of Breastfeeding: Very preterm infant dyads that breastfeed experienced more time in kangaroo mother care than Very preterm infants that did not breastfeed at 1 (p=.04), 2 (p=.04), 5 (p=.01), and 6 months (p=.04); no significant differences could be detected at 3 (p=.08) or 4 months (p=.06). In the preterm group, no differences were observed between those dyads that breastfed and those that did not. Exclusive breastfeeding: The association between duration of kangaroo mother care per day and exclusive versus partial breastfeeding at 1 and 6 months and were not significant at all gestational ages.	Lack of study group identified as late preterm infant (34 to 36 6/7 week gestation)	All efforts should be made to keep mothers and infants together
Maastrup et al, 2014	Prospective Observational (Questionnaires and structured telephone interviews)	2a	To investigate the association between early breastmilk expression, early initiation of skin-to-skin contact, rooming-in, nipple shield use, test-weighting, and pacifier use, and the establishment of exclusive breastfeeding at discharge, as well as, at a predefined interval after discharge, in order to gain more evidence on which to base guidelines for mothers to preterm infants in the NICU	Total n = 1488 Extremely preterm (24 to 27 weeks) = 60 Very preterm (28–31 weeks) = 257 Moderate preterm (32–34 weeks) = 688 Late preterm (35–36) =483	NICU/post partum/post discharge	Exclusive breastfeeding 66% of those mothers using a nipple shield were not exclusively breastfeeding at discharge (p<0.0001) 61% of infants receiving skin-to-skin were exclusively breastfeeding at discharge (p<0.0001) Mother and infant admitted to NICU was significant with 31% exclusively breastfeeding at discharge compared to 22% not exclusively breastfeed (p<0.01) Duration of breastfeeding Use of nipple shields was associated with a higher OR for inadequate breastfeeding duration (OR 1.4 (95% CI 1.1–1.9).	Results not broken down per gestational age Findings based on mother’s self-report Results could not be generalized to all late preterm infants, as late preterm infants admitted to NICUs have more health problems than late preterm infants care for in maternity units.	Restriction of nipple shields to preterm infants. First time mothers, smokers, mothers with lower level of education, mothers of infants less than 32 weeks and mothers of multiples should be given special breastfeeding support and guidance
Mattsson et al/2015	Prospective Comparative Study	2a	To compare the influence of supplementary artificial milk feeds on breast feeding and certain clinical parameters among healthy late preterm infants given regular supplementary artificial milk feeds with late preterm infants exclusively breastfed from birth. Clinical parameters: *Patterns of breastfeeding, milk expression and use of nipple shield *Infants’ age at first breastfeed *Weight loss and age of first weight gain *Incidence of hypoglycemia and jaundice *Duration of hospital stay *Readmission to hospital after discharge *Exclusive breast feeding at discharge	Postpartum/post discharge	Infants given artificial milk on a regular basis had their first initial breast feeding later than infants who were exclusively breastfed (p<0.01). Exclusive breastfeeding: Exclusively breastfed infants had a shorter duration of hospital stay (P<0.01). Duration of breastfeeding: 87% of infants exclusively breastfed from birth continued after discharge (p<0.001).	Findings based on mother’s self-report Alteration of WHO’s definition of exclusive breastfeeding	Findings based on mother’s self-report Alteration of WHO’s definition of exclusive breastfeeding	Observation and self-reports would strengthen results Longitudinal breastfeeding data would help to strengthen findings
Niela-Vilen et al./2013	Structured Survey	2a	To describe and compare, between two university hospitals in Finland, the early physical contact of mothers and their preterm or sick infants in the delivery room and medical factors related to it. The perceptions of staff regarding factors facilitating2)The perceptions of staff regarding factors facilitating and promoting or impeding this contact were evaluated and compared between the hospitals To determine whether or not there was an association between early physical contact and the initiation of breastfeeding	Finland Hospital A N=76 Hospital B N – 94 Divided: < 32 weeks very preterm ≥32 to<37 weeks late preterm ≥ 37 sick full term	NICU	Exclusive Breastfeeding: Hospital A – 47% of the late preterm infant who had had early physical contact with their mothers were fully or partially breast fed, while the same was true for 34% of the late preterm infants who had not had early physical contact with their mothers (p=0.49).. Hospital B were 82% and 36%. The strongest association between early contact and breast feeding was with the late preterm infants in Hospital B (p = 0.014).	Inadequate sample size (unable to reach recommended sample size of 10 subjects for each item of the instrument) Findings not generalizable due to the different populations of infants admitted between institutions	Early physical contact essential for breastfeeding
Abouelfettoh/2009/Cairo Egypt	Quasi-experimental cohort Bottle (control) versus cup (intervention)	2b	Are premature infants 34.9 to 35.3weeks gestation supplemented by cup during hospitalization more likely to be fully breastfed six weeks after discharge when compared to premature infants supplemented by bottle during hospitalization? Do preterm infants supplemented by cup during hospitalization demonstrate more mature breastfeeding behavior at 1,2,3,4,5 and 6 weeks after discharge when compared to preterm infants supplemented by bottle?	Convenience sample of 60 late preterm infants (30 in control and 30 in the intervention group) – at conclusion of the study there were 25 mothers in the control group and 13 mothers in the intervention group Mean gestational age of bottle group (35.3 weeks) Mean gestational age of cup group (34.9 weeks)	NICU and post discharge	Medium effect size and a power of 80% PIBBS score higher in the cup feeding group (p=<0.01) Duration of Breastfeeding: At one week after discharge there was a higher proportion of breastfeeding in the cup feeding group than in the bottle feeding group (p=0.03). Exclusive Breastfeeding: No statistical differences between the two groups in relation to the type of breastfeeding (either exclusive or partial)p=0.29.	A randomized experimental design not used The principal investigator collected all of the data – not blinded Determination of breastfeeding practices should have continued longer after discharge (Low maternal education levels made long term documentation not feasible). Small sample size Gestational age reported in means	Cup feeding preterm infants as a form of supplementation may support increased duration of breastfeeding.
Olson et al/2010	Quasi-experimental (Peer counselor versus no peer counselor)	2b	To estimate the effectiveness of a peer counselor breastfeeding program for low income women in Michigan	336 women who requested services prenatally and were contacted by a peer counselor (treatment)/6 54 women who requested services prenatally but were not contacted by a peer counselor (control) Treatment 36.4 weeks gestation Control 36.9 weeks gestation	NICU or otherwise not identified/post discharge	Breastfeeding duration: The treatment group breastfed 2.6 weeks longer than the control group (p<.001). Treatment group was 22.3% more likely to initiate breastfeeding (p<.001), 9% more like to breastfeed at 3 months (p=.002) and 6.2% more likely to breastfeed at 6 months (p=.008).	A randomized controlled study would help to collaborate findings from this study due to how women were contacted	Cost benefit analysis for feasibility of implementation
Wataker, 2012	Quasi-experimental design (Family Care program versus Traditional Care)	2b	To investigate the effects of a Family Care Program in a NICU on maternal confidence and breastfeeding compared with mothers in a comparable NICU offering traditional care without such room facilities	Family Care Group (n=36) (31.4–34.0) 32.7 weeks gestation Control Group (n= 30)(33.7–35.7) 34.7 weeks gestation.	NICU/post discharge	Duration of breastfeeding: At 3 months: No breastfeeding FC group 6(26%), Control group 12(57%)(p = .04) Partly breastfeeding FC Group 1(4%) Control 0(0%)(p = >.99) Full breastfeeding FC group 16(70%) Control 9(43%)(p = .07)	Study had a small sample size No Randomization Fathers’ participation was not assessed.	Further studies regarding maternal assessment of lactation support in both a FC environment and a traditional care environment.
Lucas et al/2014	Case Presentation	4	Case presentation of a late preterm’s transition to full breastfeeding	35 weeks	Not identified	Exclusive and Duration of breastfeeding Full breastfeeding achieved by 4 months		Need for further community based resources including lactation consultants, peer support groups and hospital grade pumps and scales

Note. Levels of evidence: 1a: Systematic reviews of randomized controlled trials. 1b: Individual randomized controlled trials. 1c: All or none randomized controlled trials. 2a: Systematic reviews of cohort studies. 2b: Individual cohort study or low quality randomized controlled trials. 2c: “Outcomes” research; ecological studies. 3a: Systematic review of case-control studies. 3b: Individual case-control study. 4: Case-series. 5: Expert opinion with explicit critical appraisal, or based on physiology, bench research or first principles.