Preterm breastfeeding. Dr Sharon Perrella 12 August 2025

Transcript

Pam I'd like to start by acknowledging the traditional custodians of the lands upon which I live and work, the Jagera and Turrbal peoples, and I pay my respect to elders past, present, and emerging. And it's a great pleasure to welcome Dr. Sharon Perella tonight to present to us on preterm breastfeeding. Sharon's a research fellow at the Geddes Hartmann Human Lactation Research Group, which I'm sure you've heard me say before, is truly a national treasure. This group are world leaders actually in breastfeeding and lactation research, and there's scarcely a field, I think, across the spread of breastfeeding and lactation that's not been substantively contributed to by the Geddes Hartmann Human Lactation Research Group, so much so that it's not possible to teach evidence-based breastfeeding and lactation support without leaning heavily really upon the work that's been coming out over decades and continues to come out from Sharon's group. So Sharon herself is a research fellow and midwife lactation consultant in clinical practice alongside her research work and has substantive experience both clinically and then in research in the preterm NICU space. So Sharon, thank you so much for making the time to talk to us tonight.

Why Human Milk Matters for Preterm Babies [00:03:29.23]

Sharon Yeah, thanks everyone for joining us tonight. I just need to acknowledge that we do get unrestricted research funding from Medela and also from the Parent Research Institute for our funding. So it's unrestricted research funding, so they can't dictate what we do, how we research it, whether we publish it, what the findings are. So I'm going to be sharing all kinds of information from research from our group and some from experience These slides do include unpublished data that we get a bit precious about, but I know that those of you in the NDC would appreciate that. So I just ask that you don't capture any of the screens. It's recorded just for people in the NDC program, and I trust that you'll keep it within the group. So just to kick off, increasingly it's recognized how important human milk is for infant growth and development and what babies are fed impacts across the lifespan. So while for a long time now since the '50s it's been recognized that what happens in pregnancy, for example, with growth restricted infants, it puts them at risk of cardiovascular disease later in life, increasingly it's recognized that, you know, human milk plays an important part in that child's future life.

And this is particularly important for our babies that are born early. So it's well documented the immune protection they receive from human milk, but really excitingly in recent years they've done lots of MRI studies on brain development and it's showing that babies who receive predominantly human milk during their neonatal nursery stay have much better brain connectivity at term corrected age and that translates into later better developmental outcomes. Of course, respiratory disease is a big problem for preterm babies as well. And we know they do better in terms of reduced necrotizing enterocolitis, respiratory disease, and infections. And there's what's called a dose-response relationship. So the larger the proportion of human milk those babies get during their nursery stay, the better their health outcomes. It's important to know that because a lot of moms do struggle with meeting their baby's requirements and it's— we need to tread carefully around that. So we want to help these mums make as much milk as they can, and we really want to focus on any milk is good milk in these situations. So knowing how important it is, while a lot of Australian women might not understand sort of the nitty-gritty details of all of that, they— most women do realize it's a better option for feeding babies.

And so we're looking at around 95% of Australian women intending to breastfeed their babies. This is an older study now that I did as a longitudinal study of 100 mums and babies from the postnatal wards at our major tertiary women's hospital and 100 mums where their babies were discharged from the nursery. And we can see that for babies born less than 33 weeks, their breastfeeding duration rates really fell away across those first 9 months after discharge. So looking at West Australian data, we know that 96% of women initiate lactation after preterm birth, and more than 3 in 4 women have intended to breastfeed for at least 7 months. So when we look back at the breastfeeding duration rates, that's, I'm sure, a lot of disappointment.

And when we look at breastfeeding outcomes at 6 months, only around a third of babies are still receiving breast milk if they're born very preterm. Compared to about 3/4 of babies who were born at term. And overwhelmingly, this is not just in Australia, but in the United States, in Europe with large studies, the main reason that women stop before they had intended to is they feel they don't have enough milk for their babies. So it's particularly important for those of us looking after families, whether you're a supporter in the community or whether you're in a hospital or a neonatal nursery setting, it's really important that parents understand the value of mother's milk as medicine for their baby and that we talk about their breastfeeding goals. So while we know most women plan to breastfeed, we find that if women understand the benefits for their own health and their baby's health, they're much more likely to persist when things get difficult, as they often do in the nursery. If a mum's really wanting to, if she's really planning to breastfeed, we can go and get a new one for you and try it.

And we also need to think about, while thinking about the baby and the baby's needs, we need to think about risk factors that might impact that mum's supply. Now, this is probably a whole talk in itself. I'm just going to touch briefly on these. There's very clear evidence that women with an elevated BMI before they fall pregnant, for women that have had breast reduction surgery in particular or nipple surgery, gestational diabetes, and there's emerging evidence with PCOS and gestational hypertension and preeclampsia, you know, lots of pregnancy complications in the neonatal nursery space that may well impact their ability to make a full supply and those mums may need extra support. There's certainly things that we can do to encourage moms in factors that can in fact impact their milk production. So timing of that first milk removal. So after preterm birth, everyone's stressed and focused on the baby. It's super important that that mom's supported to express some milk as soon as possible after birth. So in the ideal situation, that might be within 1 or 2 hours of birth. But it seems up to around 6 hours. If someone can help a mom, if she's very unwell and not able to do that in the first 2 hours, some support to hand express some colostrum even within 6 hours of birth is super important.

And then frequency and adequacy of milk removal. So we often talk to mums about achieving 8 or more in 24, so aiming for 8 breast expressions. It doesn't have to be strictly every 3 hours, but really trying to get that frequent removal happening to prime the breast for milk production. While colostrum can be difficult to move, and with that initial expression, it might be most appropriate to do that by hand, the evidence is very clear that use of a quality pump is really important in those early days. So it might be that some moms feel more comfortable to do some hand expressing before or after using a pump, but those who do use an electric pump have larger milk production volumes at 1 week and 2 weeks after birth than those that rely on hand expression alone. I'm talking in general terms, and of course there are going to be some mums that are really skilled at hand expression that can do just as good as a pump, but I think in our society that's probably the majority— the minority that aren't quite so skilled with that. I'm just going to quickly share the background to a study because I'm going to pull a fair bit of data from this study to tell you.

Emma Anderton is a neonatal nurse at Kingiwood Hospital and she completed her master's with me a couple of years ago. And we were looking to see whether we could track the onset of mastitis. It seemed that lots of women in the nursery were developing mastitis We know that colostrum and then in case of breast inflammation, the milk is much higher in sodium. So we wanted to regularly test the sodium concentration of milk and the sodium potassium ratio. We know it can be as high as 60 millimoles per liter in colostrum, and then it quickly drops down to below 12 once that milk is in. If a woman develops mastitis, it can quickly jump up to above 12 or 16. So these moms had babies born between 29 and 34 weeks gestation. They kept milk expression diaries, so they wrote down every time they pumped, the volume they got from each breast. And they were very kind to give us— we only needed 1 ml of milk every second day across the first 10 days, and then every third day for as long as the baby was in the nursery. So yeah, lots of committed mums providing really helpful data for us.

And the sodium meter's amazing. You can see it's about the size of a digital thermometer and it literally takes 3 or 4 drops of milk to read the sodium. You'll see that most of our mothers did express within 6 hours of birth and that came about through conversations with labor ward staff when we were concerned about a delay. In moms getting started. So in every preterm birth pack, there is a hand expression kit so that it's a visual reminder. It gets everyone on board with moms expressing before they go to the postnatal ward. And I understand that's now available in recovery for women that have cesarean section as well. Paula Meyer, who works in Chicago, she's published a lot about breastfeeding with preterm infants, she talks about the secretory activation or milk coming in as being 3 consecutive pumps of 20 mls or more. So for these pump-dependent moms, that's kind of used as the marker of secretory activation. And what we found in our moms is that most of them didn't have their milk coming till around day 7, which is really quite late when you consider for a term birth, it's usually around 60 to 70 hours after birth.

So we've known before that that's common, but that's a long time to wait. When we look at breastfeeding rates after discharge, we see quite big differences in the literature between Scandinavian countries and Australia. So a lot of Australian data would suggest about three-quarters of babies will go home receiving breast milk. The Scandinavian data looks quite astounding. It looks like almost all go home having breast milk. And while I know that we have very different healthcare systems, I was lucky to be in Denmark last year and was shown around a neonatal unit where lots of families rooming with their babies in individual rooms. And it's quite normal for babies to spend most of the time on their parent's chest rather than in an incubator or a cot with the parent sitting by their side. So definitely there's a lot more opportunity for babies to breastfeed. We also need to be aware that definitions of full breastfeeding differ between units and between countries. And in Scandinavia, babies typically get to stay in hospital much longer than our babies that are often rushed out the door with any oral feeding will do. You know, as long as they're managing to bottle feed, often they can be sent home.

So families may not have the same opportunities to establish breastfeeding. I think my slides have got jumbled up, but anyway, here we have the mother's milk production plotted over the days, and you can see that fantastic increase in milk production up to day 6. Again, in the literature they talk about women trying to achieve coming to volume. So some papers will say women should be producing 500ml by day 14 and others say 600ml. We know that for term healthy babies, by the time they're a month old, they're going to be expecting nearly 800ml in 24 hours. So, you know, saying 500 or 600 is a little bit lenient. We know that most preterm babies don't need that amount by day 14, but it's certainly what we want the mom to achieve and maintain because that is what her baby will need in the longer term. So you can see here that, you know, a lot of moms did actually achieve that, which is promising. We seem to do better than a lot of the data that's published in the States where perhaps women aren't encouraged to express as often. When it comes to actual breastfeeding, we know that the infant's health state has a big impact.

So A baby born at 24 weeks is going to have more severe lung disease and they might have other comorbidities that's going to affect their ability to breastfeed compared to, for example, a 34-weeker. I learnt from a study I'll tell you about a little while that there's a lot to do with the baby's alert state. You know, just getting a baby out for 10 minutes to sit on mum's chest often isn't enough for these babies. If we actually give them the time after 10 or 20 minutes, they'll often come to that calm alert state and start to seek out the breast. They need to be able to maintain the seal at the breast to remove the milk, and that's got a lot to do with intraoral vacuum. We'll talk about that shortly. And so nipple shields are quite often used in the nursery to help babies to maintain that seal. Sucking duration and sucking strength are important for milk removal. As is what's actually in the breast. You know, a baby can have the best sucking skills in the world, but if mom has just pumped, baby's not going to get very much. So when we're looking at a preterm baby at the breast, there's lots of things that we can observe and there's lots of things that we really— it's not possible to observe.

So the strength of the baby's suck, I can tell you that what we think, you know, we think we're good at assessing the strength of a baby's suck by having them suck on our finger, and I've learned that often it's far, far different when we actually do measures of the strength of their suck. We can look at the number of sucks they do in a row and how long they're able to suck for. The baby needs to be sucking when mum's having a milk ejection, otherwise there's not going to be a lot of milk available. And with nipple shields, I mentioned they can be used quite commonly, and sizing is really important. So there are some units that routinely use a small nipple shield because they think it's going to fit the baby's mouth the best. And while that might be true, if the mom has quite a broad nipple, we might actually be causing nipple compression and stopping milk flow. So it might be good for practicing sucking, but if that nipple shield's too small for mom, they're not really going to get much milk at all. We need to keep in mind mum's milk production and how long is it since she last pumped.

If she's in a lot of pain or if she's really stressed, it might inhibit her milk ejection reflex. And if she's had breast surgery, again, it might impact her ability to actually produce a reasonable amount of milk. We know that preterm infants are not developmentally ready to fully breastfeed, and as I mentioned before, their health condition impacts that as well. We know that when babies are introduced to the breast earlier in their postnatal course, they tend to go home earlier. But we also need to keep in mind maybe it's the healthier babies that get to meet the breast earlier as well. There's huge variation in practices between units. At least I think it's fair to say in Australia where we tend to want to have those babies sucking by any means before they get home. And so if breastfeeding isn't really valued or if there's a shortage of beds. Often people are happy to discharge these babies having done maybe not fully established breastfeeding, but they can bottle feed just fine. And so we need to recognize that breastfeeding is a different skill and it may take some time until that baby is able to fully breastfeed once they go home.

I don't know if you've seen this before, but it was published about 10 years ago as a bit of a map as to how babies can progress towards exclusive breastfeeding. So there's this ideal situation where breastfeeding management is discussed with mothers before they've even had their baby. The mums get skin-to-skin throughout the nursery stay, babies get an opportunity to practice non-nutritive sucking, whether that's on an empty breast or a pacifier or a finger. They get to explore the breast from around 28 weeks. Cup feeding might be introduced from 32 weeks. Semi-demand feeding from 34 weeks and then a full breastfeeding session, some bottle feeding perhaps, and exclusive breastfeeding by 36 weeks. But I'm just not sure that this is realistic because every preterm baby is so different and there are a lot of preterm babies that just don't have those sucking skills at these prescribed time points. So Looks great on paper, does it actually work in practice? I'm not so sure that it does. And cup feeding's a whole different discussion, but I just want to point out that the act of cup feeding, you know, lapping, a baby lapping milk from a cup is a very different oral, oromotor movement to what's required at the breast.

So I'm not sure how helpful that is.

What We Know About Preterm Breastfeeding Skills and Milk Transfer [00:22:00.04]

So let's have a look at what we do know with breastfeeding. Up until recently, a lot of the evidence has been around bottle feeding, and we know that bottle feeding is a very different action to breastfeeding. Babies can use negative back— negative pressure or vacuum, or they can use positive pressure to remove milk from a teat, whereas with breastfeeding we now know they need to apply vacuum. We know they develop these skills over time and again, it varies, it varies a lot. So in this particular study, they looked at babies born at 26 to 29 weeks. It just doesn't neatly apply to breastfeeding. So what we do know from studies from our group is that vacuum is what drives milk removal from the breast. So I'm just going to talk you through this graph. Here we have a vacuum trace where on the left-hand side we've got the axis where 0 would be no vacuum at all. And this one, this graph goes down to about -120. And so a baby will apply a really low level of baseline vacuum to extend and hold that nipple in their mouth.

So that's what maintains the latch. And while they're maintaining that latch, every time they drop their tongue, they create a stronger vacuum. And it's during that stronger vacuum that the milk is removed. So here you can see this baby's got a beautiful suck trace where he has several sucks in a row, and then he has a bit of a pause, and then he starts again. The thing is we can't tell from the outside whether there's milk flow happening. We can't tell how strong that baby's suck is. So it's not as simple as just looking on the outside to decide if the baby's actually transferring milk. At the start of a feed, we might hear swallows, there might be some audible swallows, but there's lots of swallows we've seen on ultrasound that we haven't been able to guess from the outside as well. So I'll just get you to keep that graph in mind as we look in a little while at some preterm sucking traces. So this is Donna's study. It was a cross-sectional study where she went to the neonatal nursery at King Edward and she was able to do lots of submental ultrasound and vacuum measurements on babies at the breast. So this was 38 infants born between 23 weeks and 33 weeks and they were— they had breastfeed attempts measured anytime from 32 weeks up to term. So with ultrasound, Donna looked at their tongue movement, she measured their intraoral vacuum, and then using test weights, their milk transfer was measured. So I don't know if you've seen these studies done before, but essentially while the baby's suckling at the breast, a probe— a really small ultrasound probe is placed underneath the baby's chin. And so we get a cross-section through the baby's head. We can actually see the nipple extending into the baby's mouth. We can see the tongue movement, we can see the ducts dilate within the nipple when mum's having a milk ejection, and we can see milk flowing from the nipple and being swallowed by the baby. So we had Pam over a few years ago to do some of those studies with us, and I think she'll agree, I never get sick of looking at it. It's just fascinating. So what Donna commented on was that all these babies had the correct tongue movement at the breast. They knew what to do. So it's not like babies have to develop the right tongue movement to breastfeed.

What we found was more about the strength of their suck. So, you know, when people talk about suck training, it does make me wonder because even babies at 32 and 34 weeks had the right idea with what to do with their tongue. What we did find was that their vacuum measurements were much lower than that of a term baby. So here we see on average a term baby will apply a peak vacuum of about -145, with a preterm baby— now keeping in mind this was cross-sectional and we saw a huge range— the average was about two-thirds less than what we see with the term baby, and the baseline was much weaker as well. And when we measured milk transfer at the breast, on average they were taking about 14 mL, but again a huge range from nothing at all to 60 mLs, and on average about a quarter of what their prescribed volume was. So a lot of these babies were having tube feeds and some bottle feeds as well, and on average only a quarter of what they were assigned to take. Donna found no relationship between milk intake and their birth weight, their current weight, their birth gestational, their current gestational age, whether they used a nipple shield or not and their intraoral vacuum. So lots of confounding things there. It was a lot to do with the active sucking time. So, you know, a baby could have 2 or 3 quite strong sucks in a row, but that's not going to be enough. They need to have that continual sucking, like, you know, maybe 15, 20, 30 sucks in a row to really generate and maintain that vacuum. To remove the milk. So back to a study I did of about 60 preterm babies and their breastfeeding moms where it was really nice to go from being the bedside nurse where you kind of get the feed started and you have to race off and look after everyone else in your care. My job was simply to sit with the mom and baby during a breastfeed to measure the intraoral vacuum and do ultrasound where I could, but just to have that time and space to actually watch a mom and baby and to watch that baby slowly wake up and start rooting for the breast and then eventually latch and start suckling. So here you can see, this is a 34-weeker. For the first 7 minutes, this baby really didn't do very much at all. He applied a really weak vacuum, about -20, just to hold that nipple in his mouth. And very occasionally he'd drop his tongue and create tiny, tiny vacuum. And it was beautiful just to watch them having a cuddle. He wasn't actively feeding, but I think this is all part of the learning process. After about 7 minutes, he started to wake up a little bit more, and you can see he could do 2 or 3 sucks in a row, have a bit of a pause, another 2 sucks and a longer pause. Here he did 4 sucks and so he was kind of warming up to his breastfeed. So about, for about 3 minutes he did this, and then after a further 3 minutes, you can see how his baseline got stronger and stronger. Now he's applying a baseline of about -40, and some of his peak vacs are great, almost hitting -120, so much more promising for milk removal. So, you know, a snapshot in time or these really short little exposures to the breast, I think don't really give babies a good chance to practice and develop their skills. So in this study, you can see I got to sit with them.

So from 33 weeks, I would make a time with the mom to go and sit with them once a week. So at 33, 34, 35 weeks, by 36 weeks they were either going home or they're being back-transferred to another hospital. And so I have much less data for them. But you can see that there's a bit of a jump in the peak baseline from 33 to 34 weeks. The baseline slowly but surely got stronger. The number of sucks per burst didn't increase a lot. The sucking rate was about the same, but slowly but surely they were taking more and more milk at the breast. Keeping in mind a lot of babies are being sent home at 36 and 37 weeks corrected age, their intraoral vacuum's nothing like what we'd see in a term baby. And here I've just graphed milk transfer over time. So I remember one little boy who I figured he didn't read the book, didn't realize he was born preterm. And he had amazing vacuums. He sucked beautifully at the breast and took some really great volumes. And then at the other end, we've got some babies that just really didn't know what they were doing. Often, now typically, they had a complicated postnatal course and they were taking a long time to learn what they're meant to do at the breast. So highly, highly individual. We can't say that all 34- weekers should be able to you know, transfer a certain amount of milk and all 36-weekers can fully breastfeed. Clearly you can see there's a huge range in ability here. And, you know, while we breastfeed for lots of reasons including bonding, essentially they need to be able to transfer milk for nutrition as well. Our breasts don't have a dial on them. It's not that easy to see how much a baby's taking from the breast. But certainly digital scales that are sensitive to 2 grams are accurate. I don't know what it's like on the eastern side of the country, but in the west people have been quite cautious about measuring breast milk intake. They're concerned that it's going to stress moms out. In Scandinavia they're used quite widely and they've got publications reporting that it boosts moms' confidence to know how their baby's progressing in units where it's used a lot. They say they get to earlier attainment of exclusive breastfeeding and more exclusive breastfeeding on discharge.

So I'm really happy to chat about this at the end, but I think it's got a lot to do with how we communicate the information to mothers, that it's not a judgment, it's a measurement, like taking a baby's temperature. On the other hand, you know, as clinicians, often we think we're really good at being able to tell what a baby's doing at the breast. Sometimes we're right, sometimes we're wrong. And then for mums, you know, first-time mums often will tell us they've got no idea, you know, if they're asked, was that a good breastfeed? Well, they're not quite sure what to compare that to. With experienced mums, they may be in a better place, you know, comparing with previous children to comment on how that baby's going. So just as an example from our unit, this little boy, appeared to breastfeed beautifully for 10 minutes with some nice long suck bursts, and then he put himself off to sleep, and he appeared to be milk drunk. So in our unit, we do use a breastfeeding assessment tool. This has not— this tool has not been published. It was modified by a New Zealand midwife from a tool that's designed for term babies. And this feed was rated as, you know, fantastic latch maintained with multiple bursts with rhythmical sucking, multiple audible swallows, and the baby coped well with the feed. It may be a long feed or a short feed, effective milk transfer noted. So that feed was rated as a 6 by the nurse, which would mean he didn't need a top-up. When we actually did the test weigh, he'd taken 14 mL, which certainly wasn't his assigned full quota for a feed. So sometimes we think we know what's going on, but it's not actually reflecting what the baby's transferred. There are lots and lots and lots of breastfeeding assessment tools out there. The thing I find curious is most places aren't using them right clinically. I don't think we see that a lot of these are used. Certainly with the preterm tools, they are not— they don't correlate well with milk transfer. And to be honest, I'm not sure that anything actually could because nothing's going to account for— nothing knows how much milk's in that mother's breast, how strong that baby's suck is. So probably not. I don't think tools are ever going to be useful. Just by observation, knowing whether a baby's taken a full feed. So I don't expect you to read all of the criteria for this, but if you just get the idea that if a baby is scored between 1 and 3 in our unit, it means the baby's going to get a full top-up. If the baby scores a 4 or 5, then the nurse is going to give half of a top-up because we don't know what a partial feed is. We don't know what that estimate is of what they've taken. And if they scored a 6, and they won't be given a top-up at all. Interestingly, some nurses scored 0 when I looked at the documents as well. So I actually have data for 1,186 breastfeeds where the nurse scored the baby's performance using that tool first, and then the test weigh was completed. All of these babies were born less than 33 weeks and their assessments were performed at somewhere between 33 and 39 weeks corrected age. So what you can see here is if a baby was scored between— I told you there were some zeros which are probably like ones— if they scored between 0 and 3, nurses were correct 90% of the time that a full top-up was required.

So Neonatal nurses are good at telling when the baby's not taking anything at all, so that, that was a good starting point. But when it comes to did the baby need a partial top-up, they were correct 1 in 4 times. And did that— when they needed no top-up at all, they were right half the time. There was huge overestimation as well as underestimation. So even though this tool's been used for over 10 years in the unit, we're finding it's really not a useful indicator of how much the baby's taken at the breast. And while it's nice to measure baby's vacuum and to look at their tongue function, research tools aren't available and they're not practical in the clinical setting. However, a set of digital scales is, is accessible, it is fine. But there seems to be a lot of reluctance to use something as simple as digital scales that are sensitive to 2 grams. So I'm just going to show you some more data now from a large study I did a couple of years ago. The primary— I don't know if any of you ever heard of the Karmita teat. So it's a vacuum-triggered teat, it only releases milk if the baby makes vacuum with their mouth as they would with breastfeeding. We wanted to know in the preterm setting if they used a vacuum-triggered teat instead of a standard teat, was that helpful to breastfeeding? What I'm going to talk to you about today more though is looking at the development of baby's skills. So as well as having the PBAT, which was routinely used in the nursery at the time, we also used the Preterm Infant Breastfeeding Behavior Scale, which rates different aspects of a baby's breastfeeding. We'll go through that shortly. We looked to see how that related to their breastfeeding performance. So 60 mother-infant dyads born between 28 and 33 weeks, the babies needed to be medically stable at 33 weeks, mothers had to be planning to breastfeed, and they needed to have a production of more than 300 mL in 24 hours. We excluded moms that had breast surgery, babies receiving assisted ventilation at 34 weeks, and if the baby was acutely unwell or had a congenital disease or malformation, they were excluded from the study. So this is where I sat with the moms and babies every week until they went home and performed submental ultrasound and vacuum measurements. The mother completed the Preterm Infant Breastfeeding Behavior Scale, and I'll show you that shortly.

And test weights were completed after the mother had completed the rating of the baby's breastfeeding. So this is a Scandinavian tool. It looks quite long and complicated, but the mums were quite happy to fill this out. So they got a score for whether they showed any signs of rooting at the breast, the degree of areola grasp, whether they latched and fixed onto the breast, if they did, how long they managed that for, characteristics of their sucking, their longest sucking burst, and then whether swallowing was actually noticed or not. So the mums did this every week with the monitored breastfeed. This tool's been shown to have high inter-rater reliability, so if we get two neonatal nurses to do this on the same breastfeed, they'll typically get very similar scores. And it's thought that higher scores show further progress or further maturation with breastfeeding skills. So in this group, we had a highly motivated group of mothers. So most intended to breastfeed for around 12 months. 90% of the moms rated breastfeeding as very important. And lots of them did have a full milk supply, which was great. The babies typically were born around 30 weeks and were relatively healthy. So when we look at the— when we add up all of the scores, the total PIBS score, we can see there was quite a jump from 34 to 35 weeks. It seems to be a time of lots of great development in feeding skills. I'm not going to talk too much about findings at 36 weeks because the numbers had really dropped off with babies being back transferred or sent home at that time. The median rooting score really didn't change much from 33 to 36 weeks, and with areola grasp again from 34 to 36 weeks, to 35— no, actually the median, yeah, 34 to 35 weeks we see the areola grasp was about the same. Latching to the breast didn't change all that much and sucking, sucking scores increased from 34 to 35 weeks. But where we see a really big jump is the sucking the longest sucking bursts. So babies being able to suck for 20 sucks in a row became much more common at 35 and 36 weeks. And that's what John had found was associated with milk intake. And swallowing's always a funny one. So the median score was the same across time. And I've mentioned, you know, with term babies, sometimes we can hear them swallowing with big boluses of milk. But with little babies and little mouths, we don't always hear swallowing. So it might not be a very reliable measure. And we found a weak relationship between that total PIBBS score and the amount of milk transferred. So while statistically it was a significant finding, it's really not precise enough for clinical use. It was a lot better than the PBAT that's routinely used, but still we wouldn't look at this as a, as a proxy for milk transfer. Because we had such a wide range of birth gestations in the study, we split the group— the babies into— actually, I think we'd started recruiting older babies, but we ended up going down to babies born as early as 25 weeks gestation. So we compared outcomes between babies born between 25 and 29 weeks and those born at 30 and 33 weeks. And what we can see is that babies born at an earlier gestation take a little bit longer to develop their breastfeeding skills. So advances in skill development such as active sucking time really seem to progress, you know, from 34 weeks onwards. And we know that development of breastfeeding skills is slower in preterm babies born at less than 30 weeks gestation.

We really need individualized assessment. So we're talking about preterm breastfeeding, but we can't sort of make blanket rules or blanket recommendations here. I think that while the PIBS isn't useful for gaging milk transfer, it was really valuable for the moms to actually have something written on paper that describes different aspects of breastfeeding. I think it gave them a sense of what was to come. So if the baby was doing 2 or 3 sucks in a row, just by filling out the assessment each week, they could see, oh, these next categories show longer suck bursts and they can see what the top rating was for. Otherwise, you know, often at the bedside there isn't a lot of time for really detailed education. It actually gave them something to refer to and think about what the next steps might be. So low milk transfer is common, not just during the hospital stay, but around the time of discharge. And so mums often need to continue pumping until that baby develops a strong enough vacuum and long enough suck bursts to actually remove the milk. Now I know that's really not popular, you know, for a mom who's had her baby in hospital for weeks and weeks to learn that actually you're not done with pumping yet, you're going to have to continue that. I'm sure that's quite difficult. So I think it's important if we're caring for women that have had a preterm birth to paint the picture earlier on that it takes these babies some time to develop their skills and it's very common for moms to have to do some supplemental pumping once they get home. Nipple shields, a lot of babies in this study went home using a nipple shield and most of them hadn't had weaned from it within 6 weeks. I imagine because their baseline vacuum had got strong enough that they were able to grasp and hold that nipple in place for the whole of a feed. There's so much going on once they get home, you know, the babies that have had infections and they've got immature lungs and they might have low energy, they can all complicate the breastfeeding picture. They're trying to bond with their baby and establish themselves as a mother outside of that nursery environment. And typically, you know, preterm babies are reported to be quite unsettled with this change of environment. They tend to, I think, be more stressed and maybe spill a bit more milk, which might be, you know, new for the mom dealing with that all by herself for the first time.

The Gap at Home: What Happens After Discharge [00:45:54.14]

And often mental health issues crop up. Often mums and dads have held it all together while their baby's in the nursery, and then they get home and sort of the reality of what they've been through hits. And so there's lots and lots going on for them. On top of wanting to be able to breastfeed this baby. And so these babies really need— these families need lots of additional support. You know, we're all working lactation and we get that, that mental health is a really important part of the work we do. But I just want to stress that for these families, there's often a lot of major things going on. And so, you know, I've shared some fairly recent data about what happens with preterm babies in the hospital, but the fact is there's huge, huge gaps when they go home. And this is where lots of you will be, you know, looking to care for these families. We know that the main reason women stop after they go home is they don't have enough milk, but we don't know how they manage the challenges of achieving and maintaining that milk supply once they go home. Achieving adequate milk transfer. No one's really tracked what happens, measured what happens when they go home. Apart from my study, I've found one other that comments on nipple shield use, and the analysis I did showed that those who went home using nipple shield, they were no more likely to wean than those that went home not using a nipple shield. We know women don't like using them in particular, but we have very limited data. It seems to be supportive, but we don't know enough in this context. And certainly our home visiting midwives tell us that often there's concerns about latching issues and baby getting— babies getting tired and not being able to maintain a latch for a long time. So the lovely lady in the blue is Judy Adams, who I think is one of the people that inspired me to become a lactation consultant. She was our home visiting nurse for a long time and I think for over 20 years she's been asking for a preterm lactation follow-up clinic, and it finally happened in May this year. So they can see 4 families a week on top of all the work they do. So there's a wealth of knowledge in a few individuals, I'm sure, scattered all across Australia, but we really need to study this area more so we're in a better place to support these families. So we can see there's a really wide range in breastfeeding skills and how they progress in these families, and it's influenced not by just how early they're born, but the illnesses that they encounter along the way, as well as what's going on for mom. It's really important that we protect that mum's built milk supply, that we help her establish a healthy milk supply and maintain that. While that baby's still learning their breastfeeding skills, and that may progress for many, many weeks after discharge. Mental health and breastfeeding support is so important. So I've shared a whole lot of information there, and I'd like to stop here and open up for questions and discussion.

Questions [00:49:27.15]

Participant I'd just like to say thank you very much, Sharon. It was absolutely fascinating. I'm a nurse midwife lactation consultant based now in New Zealand, and I think one of the biggest things that has really helped us in New Zealand is having BFHI nationally. Every single unit has to be BFHI accredited. I'm a little bit biased because I was a BFHI coordinator for about, well, 15 years, I think, until I semi-retired last year. It means that step 10 Everybody who has been an inmate in NICU's Skaboo automatically usually gets a referral to the lactation support services. And for the really little babies, the fragile ones at home, mums with babies that are oxygen dependent, certainly for twins and triplets bad weather, I would really try to go and do a home visit. But I've equally had mums with triplets decide to come in because they just really need to get out of the house. Yeah, having that really good follow-up care, I'd love to have more time to do that. I used to work in NICU as a midwife in the UK for half of my hours and half in birthing before I got so interested in lactation. But I do think that, that BFHI should really be pushed a lot, lot more because it does put some of those services in place where it's part of a package and the hospital doesn't have any choice. If they want to be BFHI, they've got to be able to provide that service. And that's only beneficial for the mothers and babies that we look after.

Sharon Yeah, we're in a bit of an odd— well, first of all, I'll say that my state has the lowest rate of BFHI hospitals, I think, too. Where my studies were done is a BFHI hospital, but now we're in a funny situation where neonatology belongs to the children's hospital. But we all came under the one banner before, and so Until we had the follow-up clinic, families did have the option of going to the breastfeeding center at King Edward, but the problem is they are so busy there's often a 3 or 4 week wait to get an appointment. And as you know, these families just can't wait that long. But well done, New Zealand, for having more hours.

Participant I would love to have more hours to do more work with prematures. I love looking after prems, and it's always been a passion of mine. So, um, It's really valuable. And I was lovely to see some of Carol Bartle's work there. And obviously we all know her very well, a fantastic experience, and such a brilliant policy advisor as well, my mind. And her work is really amazing. Yeah, but lovely to see you using that, even though, as we know, it's so different for each baby.

Participant 2 Given what we know and practice now with Pam's work, is it— is there a comparison with that group to the Gestalt method, do you think?

Sharon It's difficult to say. I can't say that the ultrasound definitely doesn't impact. I think that, you know, it's done very gently and carefully, but I can't say 100% that it's, you know, be exactly the same as a breastfeed without that. For all of the study breastfeeds, we had a lactation consultant accompany Donna and assist with the positioning.

Participant 2 So in terms of the Gestalt method though, with the things that we align and the face burry instead of the, you know, the Special K lips and we get all the vectors right between the hips and the head and the head and the breast and all of that, do you have any sense whether breastfeeding was of a gestalt nature or more the traditional whichever way it goes it comes type?

Sharon It's really challenging to say. I mean, some, you know, some women will have like an H-cup breast and they will have a 1.4 kilo baby, and the space between the mother's body and that little baby, you know, often we do need to use pillows and things to get some stability because you can't You can't have them tummy to tummy, otherwise they'd be hyperextending. So there's lots of challenges with those really little ones depending on the mother's body and how they fit together.

Participant 2 Yeah, I'm just really interested in the question of their energy expenditure if they were positionally stable at the breast as a prem. I've had a little bit of practice with it in my unit, particularly bubs on flow, say around that 34, 35 weeks, or even the ones that come in and they've had hypoxic ischemic encephalopathy, meconspiration, stuff like that, term babies, and they're on flow still at term learning to breastfeed. And they do have that fatigue where they just can't sort of suck consistently for long enough. But I really was noticing when you get them held positionally stable using the Gestalt method, they settled into it and had to make to what I was gleaning more consistent sucking without fussing. And Ijust wonder, it'd be interesting to, to see if Donna got all of that confounding outcome, whether it was because there were just lots of various— lots of degrees of positional stability, I guess.

Sharon Yeah, I wasn't directly involved in that study, but I'd say with the ones where I was sitting with the mums and babies for those feeds, I think I'd be very comfortable with lots of them, but with not all of them, like I said, depending on the size of the baby and you raise the thing about baby's energy at the breast, and, you know, so often people make these throwaway comments that babies, they'll get too tired if they if they breastfeed for too long. And, you know, for all of these feeds, we had the baby's heart rate and oxygen saturation and respiratory rate measured. And those of you that have worked with surgical and cardiac kids, you know, babies, you know that if they're working too hard, they work up a sweat, their heart rate goes up. But if you just let a preterm baby nuzzle at the breast and do their thing, we didn't see their vital signs showing any sign of stress. So I think that fits in with, you know, are they feeling— are they supported? Are they positioned properly? They're not having to work to stay at the breast.

Participant 2 I'll have a read of her publication. That was very interesting, that the findings that you showed us

Pam Sharon, I wondered if you could comment on the WHO recommendations around kangaroo care for our preterm babies?

Sharon I just think having visited the neonatal units in Scandinavia, we've got a long way to go. But I also know across Australia, I think there's some really exciting things happening in some neonatal units on the East Coast that we haven't seen happening here yet. So lots of work to do.

Pam Are you able to let those who may not know what the recommendations are with the WHO kangaroo care guidelines now for preterm bubs?

Sharon I guess I'm more familiar with what they've said, what they do in Scandinavia, but wherever possible, it's like the normal place for a preterm baby to be, and I think here it's more of a seen as a bonus than what would be what the baby expects.

Pam Is it, I think, is there advice, am I right, that 8 hours a day, unless you've got a very sort of severely ill preemie, that 8 hours a day regardless of the setting, whether it's in an advanced economy or indeed low or middle income countries, 8 hours a day in the kangaroo position at least is the evidence-based recommendations that have come out from the WHO. Does that— that's how I understand it.

Sharon Yeah, I haven't seen it, but I'll definitely go looking for it because that sounds amazing. I think what the recommendation is— Yep.

Participant 3 We've had from the WHO has diluted it down somewhat. We've been told that for premature babies, extended periods, multiple extended periods daily for a minimum of 6 months to achieve the greatest brain growth. But for term babies, extended daily periods for a minimum of 3 months. So they're very good at watering things down. But I mean, that's a huge difference compared with occasional skin-to-skin or just putting the baby into skin-to-skin for 5 minutes before trying to feed, which is what seems to happen mainly in, in special care baby unit. Certainly they're lucky if they get 15 minutes in skin-to-skin prior to a feed. So over a whole day, they may only be getting a couple of hours. But we do have a lot of recommendations for using a sling as much as possible.

Participant 4 Thank you. I'm so glad to be here. Pamela, maybe you can refer to the huge clinical trials that were done in 6 different centers around the world, in third world countries, second world countries, and even in Scandinavia. What they found was that they took babies born at 1,000 to 1,700 grams. One group was placed immediately on their mothers while receiving all necessary medical treatment. The other group received regular treatment in the standard way. They stopped the trial midway because there were 25% more deaths in the regular treatment group. So the WHO recommendation in 2022 changed to say that babies born at 1,000 grams should be left on their mothers while all necessary rescue treatment is carried out. Mothers were then advised to keep their babies skin-to-skin as much as possible. All over the world and in Israel too, people read the trials, read the journals, and yet this evidence is being ignored. Especially the work of Dr. Nils Bergman on skin-to-skin contact. Sean, you've probably met him. If you're connected to Scandinavians, I envy you. It's truly frustrating that we have all this research and such important findings are simply being set aside.

Pam Thanks very much. But back to you, Sharon. I'm not sure that was the best link I just put in, by the way. I'm still looking for but I've got it somewhere. Anyway, over to you, Sharon.

Sharon I'm about to get back into the neonatal nursery and kick off a study. It's going to be consumer-involved, where we design resources for expressing mums, then follow up with mums after discharge to find out what was useful, what they needed during the nursery stay, and then ask detailed questions about those early weeks at home and the support they actually need. It's easy for us as health professionals to think we know what they need, but it's really important that they're part of the process. And Beth, I'll be coming to you soon. We have a PhD student arriving from Munich in the next few weeks and we have some ideas for where you work, so watch out.

Pam I must admit, Sharon, when you were talking about how Donna found so little actually is directly associated with milk transfer other than those longer bouts of sucks. I too was thinking, wouldn't it be great to have a study that was really optimizing, you know, what can we do to actually optimize that little one's positioning at a woman's breast to support that milk transfer? Given what we know about the impact really of positional stability. I was thinking that too as you spoke. I think my second link that I've put in there is better, it's the actual WHO direct link to their recommendations around kangaroo and mother care for the reduction of morbidity and mortality in low birth weight infants. So really interesting to hear.

Participant 5 Hi, thanks so much. It was lovely to listen to that talk. You had such great information. Just a quick question. When you mentioned you've got the preterm packs that are given in maternity and now recovery for cesarean sections, how did you engage to have that kind of really up and coming and what is in those packs. I guess that is one area we find the most difficult is to really have that expression kind of within that first 6 hours and kind of really give the breast milk prior to offering pasteurized donor milk in the NICU.

Sharon Sharon Yeah, the nursery has a lactation advisory group, and back when I was working clinically, it was only people in the nursery that were on that committee. But it's expanded out so that the manager of delivery suite is on that committee. There's a representative from the breastfeeding center, you know, other people from other departments. And the midwifery manager really took it on board. She took it back to the staff and said, 'This is something we need to help with.' And they came up with the solution, and it's essentially just like a hand expressing kit. It's a, you know, it's a little plastic pot a pot and syringes and I think some written instructions and they took on board and said, right, we're gonna include this, you know, there's a preterm birth pack, we're gonna put it in all of those. And then that's rolled out to having them in recovery as well. So now, now mums that have a preterm or sick baby have the same midwife stay with them in recovery and transfer them back to the postnatal ward where it used to be midwife in theater and then a registered nurse looking after them in recovery and then someone else would come and get— it was really quite disjointed and I think the whole mom and the getting breastfeeding started thing kind of got lost in the wash. So that's been a big improvement too.

Pam Sharon, are these resources related to the resources you mentioned that you were working on with the charity, the preterm?

Sharon I've noticed lots of term mums are recording every feed on some kind of app, breastfeeding, pumping, bottle feeding, all of it. Women at one of our large neonatal units are given an expressing booklet with photos and instructions, but there's so much we know from the evidence that optimizes pumping around sizing, vacuum, temperature, and troubleshooting. If you've got low supply, blocked ducts, or mastitis, what should you do? All of that is missing. It covers how to wash your kit and store the milk, but the things that are actually going to help a mum build her supply are missing. WA has an organization called Tiny Sparks, similar to Miracle Babies but only for preterm families, and they've been really enthusiastic about the idea. I went to them saying I thought this would be useful and asked what they thought, so now I'm co-designing with them. It will be a physical diary, though my daughter has a friend who's an app designer, so there are bigger dreams on the horizon. In the meantime, we're going to start with a physical diary with evidence-based recommendations around establishing milk supply after a preterm birth, and perhaps some quotes and things mums have told us they would have found helpful to know. They're not always told their baby might only need a few mls initially, and then someone comes at them with a 250ml bottle saying pump your milk. We want to break it down day by day across the first two weeks so they know what to expect. Everyone's excited about it, and Tiny Sparks is going to continue consulting with me and put some money towards a graphic designer to produce the diary.

Pam Thanks. Well, I wonder, no one else has questions for Sharon. I imagine we're pretty much coming to a close. So again, just a very big thank you to you, Sharon, for giving up your time, sharing so generously of your expertise. It's just been a fabulous hour that we've spent together, so thank you very much.

Sharon Thanks for having me.