Is it Possible to Prolong the Duration of Exclusive Breastfeeding in Premature Infants? a Prospectivt Study

The purpose of this project, which consists of three studies, is to investigate whether insufficient protein in breastmilk and / or inadequate intra oral vacuum of the infant can explain early breastfeeding cessation in the premature infant. Furthermore to test whether the breastfeeding period may be extended by oral stimulation.

The rate of breastfeeding in mothers of infants born prematurely is lower than in mothers who give birth on time. A Danish survey shows that about 70% of premature are on exclusive breastfeeding at discharge and that this rate is decreasing to about 30% six weeks after discharge. Breastmilk is the healthiest nutrition for the newborn and based on WHO's strategy for the feeding of infants Board of Health recommends that newborn infants, including premature, as far as possible are exclusively breastfed for six months. Exclusively breastfeeding means that the infant only gets the breastmilk of the mother. Exclusively breastfeeding has health implications for both mother and infant. Breastfeeding reduces lactation incidence of infectious diseases, improves cognitive development and visual function in the infant and reduces the risk of developing later obesity. In addition, the level of immune protective factors and anti-inflammatory elements is high in the mother's milk to the preterm infant and therefore reduce the infant's increased risk of early and severe infections, and death late effects. Furthermore, breastfeeding may reduce the risk of premature infant's abnormal vessel growth in the eye, and appears to have a protective effect on the disease being of significant excess mortality primarily attack the intestines of the preterm infant (necrotizing enterocolitis).

Problem Area / factors in milk composition with the importance of breastfeeding Breastmilk contains the necessary nutritional components and energy that the infant needs. Therefore, the milk of the mother delivering early have a higher content of fat and protein, and thereby a higher level of energy comparing with the milk from the mother who have given birth to term. The content of protein in the milk of the mother who gives birth prematurely is about 12 grams per liter and thus approximately one-third higher than that from the mother who gives birth on time. The nutritional composition of breastmilk vary considerably over time and the content of protein is decreasing why the premature infant are at risk of protein deficiency and thereby insufficient growth. During the hospital stay, and while the infant are feed by tube this decreasing protein content are made up by adding, while it is more difficult when the infant breastfeed exclusively. Protein is important for the infant's growth and strength and a local statement from Hvidovre Hospital found that 18% of all hospitalized preterm infants in 2014 were added additional protein to breastmilk, because growth was not sufficient. The question is whether reduced protein content in breastmilk has a correlation with the number of days where preterm infants are exclusively breastfed?

Problem Area / intra oral vacuum strength of the infant with significance for breastfeeding The period from birth to the premature infant feed exclusively at the breast without supplementary tube feeding varies from weeks to months, depending on how early the infant is born. The premature infant is characterized as being immature and with low muscle tone and therefore, a decreased ability to breastfeed the first time. The transfer of milk from mother to infant is an interaction between the mother and her milk ejection reflex creates a positive pressure on the milk and the infant creates a vacuum. If the infant not create a vacuum at the back of the mouth, the nipple of the mother is just pushed together and the infant is not transferred milk from the breast to the oral cavity. The amount of milk is regulated in relation to demand and a weak or shortage of vacuum will cause a shortage of milk transfer, which in turn physiologically will lead to less milk production and thereby decreasing amount. Studies that investigates this process and measured intra oral vacuum, shows all the importance of the infant's contribution by milk transfer, but does not answer to the extent the premature infants ability to create vacuum importance of breastfeeding establishment and maintaining. The question is whether the premature infants sucking strength is too weak to establish sufficient intraoral vacuum to ensure milk transfer from the breast to the infant and it can be related to a fewer number of days where the infant is exclusively breastfed.

In addition to the premature infants muscle tone has its immaturity also affect the organization and quality of body movements. Organization and quality in the movements may be referred to neuro motor processes and form among others the oral motor base supporting the movements involving the infant's ability to create vacuum. The processes preceding the creation of vacuum and studies have shown that by early intervention with oral stimulation in the form of stimulation of the nerves and muscles in and around the mouth, it can be oral motor basis strengthened. Studies where the infant carefully is stimulated with a finger, showing that the premature infant's muscles and sucking reflex can be influenced so that it is able to suck a larger volume in a shorter time in the bottle compared to the infant that is not stimulated orally. This presents an opportunity to influence the premature infant´s strength and maybe increase the ability to create intra oral vacuum affected by oral stimulation as a skill the infant preserves. The question is whether oral stimulation can increase the premature infant's ability to create vacuum and thus increase the power to transfer milk from the breast and thereby extending the number of days when with exclusively breastfed? The 3 studies are based on the same cohort. The cohort is identified and recruited at the Neonatal Intensive Care Unit at Hvidovre Hospital and relevant families where the mother delivers prematurely are included consecutively in accordance to the inclusion and exclusion criteria. The cohort will be demographically representative of everyday life in clinical practice with various family formation, education levels and socio-economic background conditions.