**5. Risk factors**

significant increase in the prevalence of breastfeeding after 2 or 3 months [8–11]. One study only found an effect after one week [12], and in two studies no significant effects were found [13, 14]. Sosa et al. studied 40 Guatemalan mothers, randomly distributed in a group with early contact and a control group, followed by home visits [8]. Early contact began after delivery of the placenta and suture of the episiotomy, and lasted 45 minutes. According to the study of Sosa, the control group had their first contact 24 hours after delivery. Three months later, 72% of mothers with early contact performed breastfeeding to their son/daughter, and only 42% did not, in the control group. The mean duration of lactation was 196 days (six and a half months) in the group with early contact and 104 days (three and a half months) in the control group (p < 0.05). According to the study by De Château and Wiberg they studied 40 primiparous women in Sweden [9]. The mothers were randomly assigned to a control group to another intervention group with "extra contact" (15 to 20 minutes of suction and skin-to-skin contact during the first hour after delivery). At 3 months, 58% of the mothers in the additional contact group continued to breastfeed, compared to 26% in the control group (p < 0.05). Mothers with more contact spent more time kissing and looking at their children's eyes, while they smiled more and cried less. The study by Thomson, Hartsock and Larson compared the effect of early contact, initiated 15 to 30 minutes after delivery and continued for 15 to 20 minutes, with routine contact less than 5 minutes immediately after delivery, followed by a separation of 12 to 24 hours, in 30 primiparas who were destined to breastfeed [10]. Two months after delivery, breastfeeding without milk supplements was more common in the early contact group than in the control group (9/15 versus 3/15, p < 0.05). According to the study by Ali and Lowry they compared routine contact (starting around 9 a.m.) with early contact (45 minutes immediately after delivery, and then separation until 9 a.m.) in 74 Jamaican mothers, randomized [12]. The prevalence of complete breastfeeding was higher in the group with early contact, both at 6 weeks (76 versus 49%, p < 0.02) and at 12 weeks (57 versus 27%, p < 0.05). Observed at 12 weeks, mothers with early contact talked more with their children, and got up and followed them in greater proportion when someone took the baby. Strachan-Lindenberg, Cabrera and Jiménez studied the effect of early contact, the promotion of breastfeeding and joint accommodation on the initiation and continuation of breastfeeding

Immediately after delivery, the mothers were assigned to a control group, with complete separation until discharged (12 to 24 hours after delivery), or to an early contact group, in which mother and child were in contact for 45 days. Minutes immediately after delivery and then completely separated until discharged. Full breastfeeding, 1 week later, was significantly more prevalent in the group with early contact than in the control group, but no differences were observed at 4 months. It was not adjusted for age, although about half of the mothers were teenagers. A meta-analysis of these seven studies concluded that early contact had a positive effect on the duration of breastfeeding at 2 or 3 months (p < 0.05). However, it warns that "the effect of the size between the studies was heterogeneous", and some studies included other interventions (guidance on breastfeeding, presence of the father during the early contact), which could have contributed independently to increase breastfeeding [15]. A cross-sectional study of 726 primiparae in the USA. A study found that the prevalence of exclusive breastfeeding in the hospital was lower if the first blowjob took place between 7 and 12 hours after delivery (adjusted odds ratio = 0.5, 95% confidence interval). More than

12 hours after delivery (adjusted OR = 0.2; 95% CI, 0.1–0.4) [16].

in the Nicaraguan primipara [12].

46 Selected Topics in Breastfeeding

The risk factors that lead to the failure of access to breast milk related to the mother and the newborn, the clear majority are presented together. Although, the problems raised do not contemplate the suspension of breast milk if one way to solve them is to continue breastfeeding.

According to some problems that appear in the prematurity stage, the Breastfeeding Section of the American Academy of Pediatrics issued a policy statement that represents a significant change from the previous statements in its recommendation that all premature babies should receive human milk, pasteurized breast milk instead of premature infant formula the preferred alternative cannot provide adequate volume. The current recommendation, according to the studies, is based on an extraordinary variety of benefits that breast milk provides to highly vulnerable newborns such as premature infants, including the reduction of late onset infection rates, necrotizing enterocolitis (NEC) and retinopathy of prematurity, fewer readmissions in the first year of life and better results of neurodevelopment.

Preterm infants receiving breast milk have lower rates of metabolic syndrome, lower blood pressure and low density lipoprotein levels and less resistance to insulin and leptin when they reach adolescence, compared to premature infants who receive formula.

What has been shown in different studies is that the most determining benefit is that feeding with human milk decreases the appearance of NEC, given its high prevalence (5–10% of all newborns with birth weight < 1500 grams), high mortality and morbidity, long-term complications such as stenosis, cholestasis, short bowel syndrome and poor growth and alterations in neurodevelopment. According to these results, it is understood that there is a dose–response effect of feeding with breast milk. For example, breast milk >50 ml/kg/day reduces the risk of late-onset infection and NEC compared to <50 ml/kg/day, and for every 10 ml/kg/day increase in milk, there is a 5% reduction in the recurrent hospitalization rate. According to studies, the mechanisms by which breast milk protects the premature newborn against NEC are probably multifactorial. Human milk IgA, lactoferrin, lysozyme, bile salt stimulating lipase, growth factors and HMOs provide protective benefits that could contribute to the reduction of NEC. Clinicaltrials.gov (NCT00854633) published a multicenter randomized clinical trial, concerning bovine lactoferrin treatment, which decreased late-onset sepsis but not NEC in preterm infants. Recombinant human lactoferrin assays are currently being carried out in preterm infants. In animal models, epidermal growth factor (EGF) and pooled HMOs prevent NEC, but have not yet been tested in premature infants. These studies are carried out in order to evaluate the safety, toxicity and efficacy of talactoferrin in reducing the incidence of nosocomial infections in preterm infants. Even the support and authenticity are being evaluated in the United States.

milk group, 20% of the children switched to formula due to poor growth. A more recent comparison of own breast milk with pasteurized human donor milk showed better growth

Support for Breastfeeding

49

http://dx.doi.org/10.5772/intechopen.80383

All these risk factors lead to high rates of hospitalization and sequelae that are installed for the

The following evidence-based recommendations should be applied at the appropriate scale in

**1.** Provide capacities in hospitals and health centers to support exclusive breastfeeding, including revitalizing, expanding and institutionalizing the initiative of child-friendly

• Maintaining the effectiveness of the initiative of hospitals friendly to the child requires institutionalization in the health system to allow certification and recertification of hospitals, as well as continued investments in training, monitoring and supervision of

• Sustainability also requires monitoring progress and measuring the number and proportion of non-domiciliary deliveries that take place in hospitals and other health centers

• The promotion of breastfeeding and the corresponding support measures should be integrated throughout the spectrum of maternal and child health care, especially in the

**2.** Implement community strategies to support exclusive breastfeeding, which includes the

• It is necessary to ensure that there is a strong link between the strategies in the centers and in the community. The influence on exclusive breastfeeding of health-based programs, such as the child-friendly hospital initiative, may decrease when women return

• It is necessary to provide ongoing family and community support through community

• In countries with low rates of hospital delivery, community support can be provided

• Communication channels and messages must be adapted to the context based on the literacy levels of the recipients, their use of the different means of communication, as well as their access to them, and contact with health professionals. Behavioral change messages

implementation of communication campaigns adapted to the local context.

rest of their lives in the term newborn and especially prematurity.

**6.1. Measures to promote progress in the increase of exclusive breastfeeding**

order to achieve progress on the 2025 global target for exclusive breastfeeding.

and less ECN with the former.

**6. Promotion of breastfeeding**

hospitals in health systems.

health personnel.

that are child-friendly.

prenatal and puerperal periods.

home and need community support.

through home visits or support groups.

leaders and various other communication channels.

On the other hand, it is believed that microbial colonization plays an important role in the risk of NEC. Breastfeeding is one of the many factors that influence the composition of the intestinal microbiota in full-term infants; Limited studies suggest that diet may have a lesser effect on the composition of the gut microbiota in the premature baby than other factors (such as the administration of antibiotics). The new bioinformatics tools to correlate the wide range of fecal metabolites and fecal microbiota offer great promise to understand the factors that influence the premature baby's microbiota. Studies to date suggest that metabolites that differ between infants fed human milk and those fed formula that are most closely associated with the conformation of the microbiota include sugars and fatty acids. It is unknown whether these metabolites differ functionally in the extremely premature newborn and in what way.

Other potential benefits of human milk to premature infants have been studied with mixed results. There do not appear to be consistent benefits of human milk in premature infants in relation to feeding tolerance, time to full enteral feeding, or allergic/atopic outcomes. Providing human milk has been postulated to decrease parental anxiety, increase skinto-skin contact and parent-infant bonding, but data to support these hypotheses are limited. The provision of human colostrum in the form of oral care for intubated premature infants has been proposed as a method of stimulating the oropharyngeal-associated lymphatic tissue and altering the oral microbiota, but data to support this intervention are Lacking [17].

Studies of the benefits of human milk in premature infants to date have predominantly compared mother's own milk to premature infant formula. Whether pasteurized donor human milk (which generally is provided by women who delivered at term) provides similar or superior protection is unclear. In premature infants receiving only mother's own milk or pasteurized donor human milk (no formula), increasing amounts of mother's own milk correlate with better weight gain and less NEC. A meta-analysis in 2007 concluded that formula feeding was associated with both increased short term growth and increased incidence of NEC compared to donor human milk feeding number needed to harm 33 with no differences in long term growth or Neurodevelopment [18]. However, of the 8 studies included in the meta-analysis, 7 were published before 1990, during which time nutritional comparisons were limited. For example, several of the reviewed studies did not include formulas designed for premature infants and none included nutrient-enriched donor milk. One study, initiated in 1982 followed a cohort of premature infants that received either premature infant formula or unfortified donor human milk with the latter group showing decreased blood pressure and improved lipoprotein profiles as adolescents. In the single included study published since 1990, infants whose mothers were unable to provide sufficient milk for their extremely premature infants (< 30 weeks gestation) were randomly assigned to receive supplementation with either premature infant formula or nutrient-enriched donor human milk; donor human milk led to slower weight gain but did not decrease episodes of sepsis, or ROP, length of hospital stay or mortality compared to supplementation with premature infant formula.

The incidence of NEC decreased in the group of human milk donors to almost half compared to the formula group, but this did not reach statistical significance due to the small sample size. It is noteworthy in this study that, despite the increase in supplementation in the donor milk group, 20% of the children switched to formula due to poor growth. A more recent comparison of own breast milk with pasteurized human donor milk showed better growth and less ECN with the former.

All these risk factors lead to high rates of hospitalization and sequelae that are installed for the rest of their lives in the term newborn and especially prematurity.
