A Review of the Literature Examining the Benefits and Challenges, Incidence and Duration, and Barriers to Breastfeeding in Preterm Infants

Jennifer Callen, RNC, MSC; Janet Pinelli, RNC, MSCN, DNS


Adv Neonatal Care. 2005;5(2):72-88. 

In This Article

Barriers to Establishing and Maintaining Breastfeeding in Preterm Infants

To locate literature on the barriers to the establishment and maintenance of breastfeeding in preterm infants, the following key words were applied to the PubMed, Medline, CINAHL, Health Star, and the Cochrane Library databases: breastfeeding, breastfeed, VLBW, LBW, premature, preterm, barriers, difficulty, lactation, weaning. Studies were limited to those addressing VLBW (BW < 1500 g), LBW (BW < 2500 g), or preterm infants (GA < 37 weeks). Limits included studies performed in developed countries, written in the English language, and published since 1990. Additional studies were located from reference lists of meta-analysis, systematic reviews, and previous articles.

Six studies fit the inclusion criteria listed above, and are described and critiqued in Table 2 .[2,3,6,7,18,19] The results from 3 of the 6 studies indicated that the primary concern for mothers in feeding their preterm infants was inadequate milk supply.[6,7,18] Bottle feeding before breastfeeding was also a barrier.[2] Other problems included high stress and noise in the neonatal intensive care unit, the small size and fragility of the infant, the infant's medical complications, maternal exhaustion due to return to work, and the mother's dislike of nursing.[2] Multiple reasons for weaning included infant fighting at the breast, weak suck, infant refusing the breast, inadequate milk supply, fussy and hungry infant, difficulty latching, and mother concerned about the infant not getting enough milk.[3] In both studies, the frequency of each problem cannot be determined.[2,3] Others report that the primary maternal concern was whether infants consumed an adequate volume of milk by breastfeeding alone.[19]

It is important to recognize the difference between inadequate milk supply and inadequate consumption, as these problems require different solutions in the clinical setting. For example, one study suggested that mothers of LBW infants have an adequate milk supply because they express it for complements and supplements.[3] The concern for mothers of LBW infants is whether the infant is getting enough; this concern reflects a potential problem in milk transfer from the breast to the infant rather than an inadequate milk supply.

Although half of the studies determined that the primary concern for mothers of preterm infants was milk supply, different definitions of breastfeeding once again make studies difficult to compare.[6,7,18] For example, 3 studies[3,6,7] used the breastfeeding definitions proposed by Labbok and Krasovec[113] (Fig 1). One study defined breastfeeding as the mother stating that over half of the infant's daily feedings were taken exclusively at the breast for > 1 month.[2] Another defined breastfeeding as both breastfeeding and expressing milk.[18] Future research must use consistent breastfeeding definitions to increase comparability of data collected from several countries or regions and to increase the usefulness of research.[118]

Unfortunately, the breastfeeding definitions by Labbok and Krasovec do not capture feeding circumstances related specifically to mothers of VLBW infants.[113] Breastfeeding definitions should be developed to recognize mothers who choose to pump and provide human milk but never intend to put the infant to the breast.[3,114]

The poor methodological rigor of some studies further decreases their utility. One study attempted to incorporate both quantitative and qualitative methods.18 Advocates of mixed-method studies argue that the complexity of human phenomena mandates more complex research designs; mixed-method studies may expand the scope of research and provide deeper insights.[115] It was unclear from this report which method (quantitative or qualitative) was used to examine each research question,[18] creating confusion surrounding the validity and interpretation of the results. From a quantitative perspective, the sample size was too small to explore its multiple outcomes,[112] whereas a small sample size is acceptable when using a qualitative design.[116]

Four studies used descriptive designs to answer their research questions.[2,3,6,7] Although the descriptive studies were methodologically sound, causation cannot be established and, consequently, evidence from these studies is weaker. To establish causation, a randomized controlled trial must be performed. No study used a longitudinal design to follow VLBW infants until the elective weaning from the breast. The studies that followed infants for the longest period after discharge examined infants until 8 weeks postdischarge.[6,7]


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