The Effects of Education Program Applied to the Families of Moderate and Late Premature Infants on Breastfeeding, Parental-infant Attachment and Parents' Anxiety Levels in the First Year: A Randomised Controlled Trial
Introduction: To evaluate the effect of education given by home visiting on the families of moderate/late premature infants (MLPI) in respect of exclusively breastfeeding (EBF), complementary feeding and parent-infant interaction up to 1-year. Method: MLPI were randomly separated into three groups (n=22) as Standard Care (SCG), Mothers Education (MEG) and Family Education Group (FEG). Four home visits were made to MEG/FEG. They were evaluated at 1-week after discharge and 1/2/3/4/6/9/12 months. Infant-Character-Perception-Scale, Maternal-Attachment-Inventory, Paternal-Postnatal-Attachment-Questionnaire, State-Anxiety-Inventory were used. Results: EBF was higher in MEG/FEG than SCG at 3th (respectively 72.7%, 59.1%, 27.3%, p=0.01, OR:7.11; 95% CI; 1.89-26.80 and OR:3.85; 1.01-13.66), 4th (72.7%, 54.5%, 13.6%, p<0.001, OR:16.89; 3.63-78.56 and OR:7.6; 1.73-33.34) and 6th month (68.2%, 54.5%, 27.3%, p=0.02, OR:13.57; 2.99-61.59 and OR:6.3; 1.45-27.73). At 12 months, breastfeeding cessation was higher in SCG (50%) than MEG (18.2%) and FEG (22.7%) (p=0.04). Mothers' baby perception, mother/father-infant attachment were better in MEG/FEG. Conclusion: Education program can improve EBF and parent-infant interaction in MLPI.
Keyword : Breastfeeding; Parents; Premature infants
Moderate and late premature infants (MLPI-gestational week 320/7-366/7) constitute 84% of the premature. MLPI has worse breastfeeding results compared to term babies due to low rates of exclusively breastfeeding (EBF) and breastfeeding rates, early cessation, breastfeeding difficulties, feeding problems, and frequent hospitalisations.1,2 On the other hand, increased stress and anxiety levels in MLPI parents decreased social interaction with their babies, which cause the development of an unsafe attachment model and increased risk of insensitive parenting. It is recommended that MLPI families receive extra support at the hospital and after discharge, both for successful and long-term breastfeeding of these babies, as well as for parents to interact appropriately with a healthy mood.3 The most effective intervention for this is the education given to the families.4-6
The majority of studies on breastfeeding have focused on the mother-infant couple. Whereas fathers are often overlooked, they are in the ideal position to help their breastfeeding partners. In many studies, it has been reported that the father's attitudes and approaches towards breast milk have a positive effect on the mother's desire to breastfeed, the beginning and duration of breastfeeding, and the EBF rate.7-9 However, these studies were conducted on term babies and their families, the effect of attitudes and approaches towards breast milk, especially of fathers with MLPI, on breastfeeding results is not clear. At the same time, there are a limited number of studies investigating the effects of both parents' training on baby care on the MLPI and their family.
Aim and Objectives
The education program aimed to provide emotional and social support to the families based on two main components; 1) to improve the EBF and breastfeeding of MLPI, 2) to ensure that parents with MLPI gain more knowledge and become more sensitive parents.
H1: the duration of breastfeeding and EBF rates would be significantly higher difference in the intervention groups compared control group at first 1 year CA.
H2: the rate of positive perception of the infant by the mother, mother-infant attachment, father-infant attachment and the state-anxiety levels of the parents would be significantly difference between the interventions and control groups at first 1 year CA.
Design and Setting
Randomisation and Sample
The education program was applied in a 2-hour home visit by the same paediatrician and paediatric nurse at one week after discharge than at 1, 2, and 3 months CA of the infant. In the home visit, information was given about the general health of the infant, breastfeeding, feeding, and the parent-infant relationship. Breastfeeding mothers were observed while feeding, as well as parent-infant communication. Solutions to the problems experienced or observed during breastfeeding were investigated. During the home visits, questions of the mothers in MEG and mothers and fathers in FEG were answered. In the period up to 3 months CA, in the weeks where no home visit was made, the mothers in the MEG and FEG were contacted via phone calls, and information was obtained. The subject headings and details of the education program are shown in Table 1. The same paediatrician made the follow-up of the SCG participants at the same time intervals in the Paediatric Polyclinic.
Data Collection Instruments and Procedures
Anthropometric measurements of all the infants in the study were performed during systemic examinations at one week after discharge than at 1, 2, 3, 4, 6, 9 and 12 months CA. The physical and neurological development of the infant was interpreted according to CA. All the follow-up examinations of the infants in the SCG, and the follow-up examinations after the home visits for those in MEG and FEG, were performed in the Paediatric Polyclinic.
The parents were evaluated regarding the levels of anxiety, how the mother perceives the infant, mother-infant, and father-infant attachment. The questionnaires for the mother and father were filled at the appropriate time in the polyclinic or during home visits. The flowchart of the study is shown in Figure 1.
The Maternal Attachment Inventory (MAI)
The Paternal Postnatal Attachment Questionnaire (PPAQ)
Infant Character Perception Scale (ICPS)
The Edinburgh Postnatal Depression Scale (EPDS)
State Anxiety Inventory (SAI)
Data obtained in the study were analysed statistically by using SPSS version 17.0 software. Baseline data were summarised with descriptive statistics. Chi-square tests were used to compare between-group differences, and the ANOVA test was applied for parametric analysis. A value of p<0.05 was accepted as statistically significant.
The study initially enrolled 79 MLPI and their families and was completed with 66 MLPI and the parents (Figure 1). The gestational age, birth weights, APGAR scores, and follow-up characteristics in the NICU of infants were similar in all three groups. There was no significant difference between the sociodemographic characteristics of the parents in the groups (Table 2).
The mothers' time to decide breastfeeding and previous breastfeeding experiences were similar in all three groups (p=0.094). However, the rate of mothers who intend to breastfeed their babies for at least two years was significantly higher in MEG and FEG than SCG (p=0.014) (Table 3).
There was no significant difference between the groups in terms of EBF rates at the time of discharge, at one week after discharge, and at 1-month CA (p=0.242, p=0.242 and p=0.126, respectively). EBF rates were significantly higher in MEG and FEG than SCG at 3 months (respectively 72.7%, 59.1% and 27.3%, p=0.008), at 4 months (respectively 72.7%, 54.5%, 13.6%, p<0.001) and at 6 months (respectively 68.2%, 54.5% and 27.3%, p=0.022). According to the results of this study; compared to the SCG the probability of infants in the FEG to be fed EBF was higher 3.85 times (OR:3.85, 95 Cl 1.01-13.66), 7.6 times (OR:7.60, 95 Cl 1.73-33.34) and 6.33 times (OR:6.33, 95 Cl 1.45-27.73) respectively at 3, 4 and 6 months CA. Similarly, it has been found that the probability of EBF in the MEG was higher 7.11 times (OR:7.11, 95 Cl 1.89-26.80), 16.89 times (OR:16.89, 95 Cl 3.63-78.56) and 13.57 times (OR:13.57, 95 Cl 2.99-61.59) compared to the SCG, respectively at 3, 4 and 6 months CA.
At 9 months CA, 36.4% of the infants and at 12 months CA 50% of the infants were not receiving breast milk in SCG, and this rate at the 12 months CA was significantly higher than the other two education groups (p=0.046) (Table 3).
In our study, one baby at 3 months CA (4.5%), nine babies at 4 months CA (40.9%), and 17 babies (77.3%) at 5 months CA had complementary feeding in the SCG. No infant had complementary feeding at 3 months CA in the MEG and FEG. The rate of infants who started complementary feeding at 4 and 5 months CA in SCG was significantly higher than the other two groups (p=0.001 and p<0.001, respectively). While all babies were introduced with supplementary food in MEG and FEG at 6 months CA, this rate was found to be 86.4% in SCG (p=0.043) (Table 3).
When the mother's perception of her baby was evaluated, the mothers in both MEG and FEG were determined to have a more positive perception of their infants at all times. However, only the result at 6 months CA was not statistically significant (p=0.072) (Table 4).
In the evaluation of mother-infant attachment, the mothers in SCG were found to have the lowest values at 1, 2, 3 and 4 months CA. The MAI scores of the mothers in MEG and FEG were similar and significantly higher than the SCG mothers (p<0.001) (Table 4).
The father-infant attachment points in all three sub-dimensions were highest in FEG fathers and lowest in SCG fathers at 6 months CA, and the difference was statistically significant (p=0.016 for patience and tolerance, p=0.010 for pleasure in interaction and p=0.009 for love and pride). In the "love and pride" sub-dimension, the points of MEG fathers were significantly higher than those of SCG at 6 months CA. The results of all three groups at 12 months CA were similar, with the only difference was that the significantly higher scores of FEG than SCG in the sub-dimension of "love and pride" (p=0.004) (Table 4).
The state-anxiety levels of the fathers were similar in all groups (p>0.05), but the highest anxiety level was seen in the SCG mothers. At 3 months CA, the anxiety level of SCG mothers was significantly higher than the mothers of the other two groups, and at 6 and 12 months CA, significantly higher than the level of FEG mothers (p<0.001 and p<0.001, respectively) (Table 5).
It has been determined that MLPI have serious problems in early initiation and maintenance of breastfeeding due to inpatient monitoring in NICU, long-term hospital follow-up requirements, and high re-hospitalisation rates.1,5,6 In addition, it has been reported that breastfeeding is challenging in these babies since they are more hypoactive and hypotonic compared to term babies, they get tired quickly, and their sucking-swallowing coordination is insufficient.22 Goyal et al,5 reported that low rates of EBF in late premature infants compared even with early premature infants. The EBF rate of MLPI at the time of discharge was reported between 20% and 60% in several studies.2,6,23,24 All infants in our study were on breastfeeding at the time of discharge. The EBF rates at the time of discharge were similar, with over 70% in all three groups. Our breastfeeding rates on discharge were higher than in previous studies. We think that this result is related to the fact that our hospital is a "baby-friendly hospital," as well as the sensitivity of our healthcare staff.
In the current study, although the breastfeeding rates of the groups were similar at one week after discharge and at 1-month CA, it was noteworthy that there was a remarkable decrease in rates of breastfeeding and EBF in the SCG as the infants grew. In our study, one-third of the infants (31.8%) were not on breastfeeding in the SCG at 6 months, CA. In a study performed in late premature infants, the rate of EBF and not receiving any breast milk were reported as 20% and 52% in the 3rd month. In the same study, the rate of breastfeeding and EBF was 24% and 12% in the 6th month, respectively.2 In a previous study, EBF rate of premature infants at 2, 4, and 6 months were reported to be 51%, 37%, and 9%, respectively.25 In another study, the rates were reported as 66%, 38%, and 13% in premature infants at 1, 4, and 6 months, respectively.26 In the literature, educating families and home visits have been shown to contribute positively to EBF and breastfeeding for both term infants and MLPI, similar to our study. Morrow et al,27 reported that the EBF rate in term infants at three months was 67% in the group that was visited six times in the home, while the group that had three visits this rate was 50% and expectedly the group that did not receive any visits the ratio decreased to 12%. Ravn et al,28 also stated that the rate of breastfeeding was 77.3% in the education given group and 63.6% in the uneducated group in MLPI.
In a review including 73 studies and the information of 74.656 mothers and term babies, it was stated that high background initiation rates of breastfeeding, spousal support, and special education interventions made face-to-face 4-8 times were effective in the improvement of EBF.29 The results of our study, which includes similar features in terms of intervention methods, coincide with the results of term babies. In our study, it was noticed that the EBF rates were significantly higher in the education groups compared to the control group as the baby grows. Especially in the 4th month, this rise is most prominent, and compared to SCG, probability of EBF was found to be 16.89 times higher in MEG and 7.6 times higher in FEG. However, more studies are needed on this subject for MLPI. We believe that solving the breastfeeding problems promptly with the education program and home visits explain the high rates of EBF and breastfeeding determined in our study. On the other hand, in current study although not statistically significant, the rates related to breastfeeding in MEG were better than FEG. This result suggests that the main target of the education provided was mothers and that the effect of fathers on breastfeeding was limited. It has been reported in previous studies that educational interventions on families were the most effective methods in supporting breastfeeding and reducing the risk of cessation of breastfeeding by 10-33%.30
WHO recommends that term infants should be fed with EBF in the first 6 months, and complementary foods with high nutritional value in addition to breastfeeding should be initiated from the 6th month.11 It was reported that early initiation of complementary feeding did not provide additional improvement in the growth of the infant, and even increased the frequency of atopic diseases, gastrointestinal infections, and obesity.31,32 On the other hand, delay of initiation of complementary foods has been associated with increased celiac disease, wheat allergy, type 1 diabetes disease, iron deficiency anemia, eating disorders, and anorexia.33 These data were achieved from studies subjecting term infants; therefore, it was also discussed whether chronological age or CA would be used for transition to complementary food in premature infants. Norris et al,12 determined that the initiation of complementary feeding in MLPI was earlier than recommended and that they started supplementary food in an average of 16.3 weeks according to chronological age, and 11.8 weeks according to CA while babies who received EBF were introduced with complementary food later. Fewtrell et al,34 reported that early initiation of complementary foods in premature infants reduces breast milk intake. In our study, the babies in MEG and FEG have introduced with complementary food mostly at 6 months CA, while the initiation of complementary feeding in SCG tends to be earlier or later. Similar to previous studies, lower breast milk rates in SCG may be a reason for the initiation of complementary feeding in the early periods, and early complementary feeding may have reduced breast milk rates.12,34
It has been reported that parents of premature infants had higher levels of anxiety at birth and in the following months compared to parents of term infants.35 In our study, while state anxiety levels of fathers were similar at all times, it was observed that mothers had similar anxiety levels in the first months. However, from 3 months, CA onwards, the lowest anxiety levels were seen in the FEG mothers and the highest in the SCG. In previous studies, it was stated that anxiety in premature baby parents was significantly lower in intervention groups receiving social support, but the difference disappeared as the baby grew.36-38 Also, the anxiety levels of parents of MLPI decreased as the baby grew in our study. Our results show that the education and support given to the parents was effective in making a significant difference in the anxiety levels of the mothers, and the participation of fathers in the FEG to the education seemed to play a role in reducing the anxiety of the mothers. The anxiety levels of parents with a premature infant gradually reduce over time, but with social support, this period is shortened.39,40
Preterm delivery is a risk factor for early mother-baby interaction. However, a safe mother-baby interaction and attachment are necessary for both the mother's and child's healthy mood. It has been reported that mothers of premature infants develop severe fears about the safety of their babies and have difficulties in accepting their babies and establishing harmonious communication compared to mothers of term babies.41 In order to prevent this situation, education programs starting at the hospital and continuing at home after discharge is the most effective intervention.4 In a study, it was shown that the educational training conducted in NICU aiming to increase mother-baby interaction reduces anxiety levels of mothers and provides a more positive mother-baby communication when the babies are two months old.42 In another study, the education given after discharge was found to be associated with low anxiety symptoms in parents of premature infants at postnatal 6 and 12 months.36 Newnham et al,37 also showed that early intervention increased the quality of mother-infant interaction and better communication skills in infants with less regulatory problems in premature babies. Recently, it has been shown that educational intervention has positive effects on the mental health of the mother rather than premature babies.28,43 In our study, MAI scores were higher in both education groups, and it can be said that mothers performed a healthier attachment with their babies as a result of the intervention. These results may be in association with the mothers' reduced anxiety levels and high rates of breastfeeding.
Positive thoughts of the mother about her baby may also affect the healthy mother-infant attachment. It has been reported that mothers have a negative perception of their premature infants starting from birth and sometimes continuing for years.44,45 In a previous study, the premature infants in the intervention group were easier and more approachable by their mothers compared to a control group, and at six months, they were described as more compliant and happy.37 Similarly, the results of the current showed that mothers in the education group had a more positive perception of their infants. The positive baby perceptions in MEG and FEG started at one week after discharge and continued up to 12 months, CA. When mothers are supported to perceive their baby's tips correctly and respond appropriately, a more sensitive mothering model and a stronger mother-infant attachment can be provided.4,37,46-48
On the other hand, the effects of premature birth on father-infant attachment are controversial, and there are few studies on this subject. A previous study has shown that there was no significant difference between the fathers of MLPI and term infants regarding the bonding model, but the fathers of premature infants were seen to be more hesitant and have a more negative attitude in communication with the infant. Therefore, to avoid the risk of an unhealthy bonding model, giving information to the parents on the subject of communication with the infant is the most fundamental approach.45,49 As a matter of fact, in our study, in the FEG, where fathers also participated in the training program, the PPAQ scores were the highest in all sub-dimensions at six months CA. The father-infant attachment results of the groups were similar as the infant grew over time. These results suggest that the fathers took a more active role in interaction with the infant as time went on. The education given to the fathers seems to be effective in the development of a more potent bonding model with an earlier start. The similarity of the results of the MEG and FEG at six months particularly suggests that mothers indirectly influence the fathers even if they are not included in the education program. Consistent with the findings of previous studies, the results of the current study showed the positive effect of the education on father-infant attachment.45,50
The strong aspects of this study are that it was designed as a randomised, controlled study with a specific group evaluation (MLPI), and the extensive data presented were obtained throughout a long follow-up period. However, for many reasons, the findings should be interpreted with caution. The most important limitation of the study is that the data of the assessment scales are based on the statements of the mothers and fathers.
In conclusion; the educational training program and home visits that were given to families of MLPI had positive contributions to the EBF and breastfeeding of these babies and on the transition to the right time-appropriate complementary nutrition. While the education program provided a significant decrease in anxiety levels of mothers, it also had positive effects on mother-infant and father-infant attachment. In order to reduce the experienced problems by the families of MLPI, a standard education and support program should be applied to this group. For the development of the infant and public health, there is a need for further studies in this area, which include the fathers.
The authors thank all the families who participated in the study, Dr. Fatih Bolat and the NICU nurses; Rabia Altun, Nilgün Durmaz and Ayşe Beyaztoprak who undertook the home visits.
Declaration of Interest
The authors declare no conflicts of interests.
This study was given the first prize in oral presentation at the 1st Internatioal Eurasian Congress of Social Pediatrics (November 28th - December 1st 2018, İstanbul) by the jury, including Stuart Logan and Nicholas Spencer.
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