{"paper_id":"f36d60b9-c07a-4d62-9aa0-09c911e885e3","body_text":"Differences between neonatal units with high and low rates of breast milk feeding for very preterm babies at discharge: a qualitative study of staff experiences | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Differences between neonatal units with high and low rates of breast milk feeding for very preterm babies at discharge: a qualitative study of staff experiences Jenny McLeish, Annie Aloysius, Chris Gale, Maria Quigley, Jennifer J Kurinczuk, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4593940/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2024 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 19 You are reading this latest preprint version Abstract Background Breast milk has significant benefits for preterm babies, but ‘very preterm’ babies born before 32 weeks are less likely to receive their mother’s milk than babies born at later gestation, as mothers have to initiate and sustain lactation through expressing their milk for tube feeding until their babies can feed orally. There are wide disparities between neonatal units in England in rates of breast milk feeding at discharge. This study explored health professionals’ experiences of barriers and facilitators to their role in supporting breast milk feeding and breastfeeding for very preterm babies. Methods 12 health professionals were interviewed, from four neonatal units in England with high or low rates of breast milk feeding at discharge. Interviews were analysed using comparative thematic analysis. Results There were notable differences between neonatal units. Five themes were developed: ( 1 )‘The role of the infant feeding specialist’ with subthemes ‘Time allocated to infant feeding support’, ‘Supportive relationships and proactive, personalised support’, and ‘Shared responsibility for feeding support’; ( 2 )‘Achieving a whole team approach to breast milk feeding’ with subthemes ‘Leadership and the feeding culture’, ‘Using external standards as levers’, and ‘Training for the multi-disciplinary team’; ( 3 )‘Supporting initiation of breastfeeding’ with subthemes ‘Attitudes to early initiation’ and ‘Joined up working with postnatal ward’; ( 4 )‘Supporting long-term expressing’ with subthemes ‘Positive feedback’, ‘Troubleshooting challenges’ and ‘Provision of breastpumps and facilities’; ( 5 )‘Supporting the transition to breastfeeding’ with subthemes ‘Attitudes to breastfeeding’, ‘Overcoming separation of mothers and babies’, ‘Breastfeeding as the only oral feeding’, ‘Maintaining confidence without measuring volume’, and ‘Reassurance about weight gain’. Conclusions Effective support can be influenced by having a supernumerary post dedicated to infant feeding; strong leadership that champions breast milk feeding and breastfeeding within Family Integrated Care; maintaining accountability by using existing quality improvement tools and accredited standards for neonatal units; and training for the whole multi-disciplinary team that encourages and enables every member of staff to take an appropriate share of responsibility for consistently informing and assisting mothers with expressing and breastfeeding. Joined-up working between staff on antenatal and postnatal wards and neonatal units is important to enable integrated feeding support for the mother-baby dyad. Neonatal unit very preterm breastfeeding expressing qualitative staff experiences barriers facilitators Figures Figure 1 Background Breast milk, which is optimal nutrition for all babies, has significant additional benefits for preterm babies, such as lower rates of infections and necrotising enterocolitis, faster development of the gastrointestinal tract, and improved neurodevelopmental outcomes ( 1 , 2 ). Providing breast milk for a baby in a neonatal unit may also have psychological benefits for the mother ( 3 ). Despite these benefits, ‘very preterm’ babies born before 32 completed weeks of gestation are less likely to receive their mother’s breast milk than babies born at or close to term ( 4 , 5 ). Very preterm babies lack the muscle tone, co-ordination and endurance to feed directly from the mother’s breast. They are initially fed expressed breast milk or infant formula by nasogastric or orogastric tube, and once they can co-ordinate sucking, swallowing and breathing they are transitioned to oral feeding from the breast or by bottle or cup ( 6 , 7 ). Establishing and sustaining lactation is more challenging for mothers who have had a very preterm birth, because their own production of breast milk may be delayed, and they have to sustain it by expressing during a prolonged period before the baby is able to feed from the breast ( 7 , 8 ). Production of breast milk is optimised by stimulating lactation as soon as possible after birth, and maintaining it by expressing multiple times every day, with frequency and duration of pumping being associated with higher volumes of milk production ( 8 – 11 ). Establishing exclusive direct breastfeeding is important for preterm babies as this is associated with longer term breastfeeding after leaving the neonatal unit ( 9 , 12 ). Transition to direct breastfeeding for preterm babies may be supported by enabling the baby to practice non-nutritive sucking before they are ready for oral feeding ( 8 ), and having single family rooms to enable parents to stay with their babies 24 hours a day ( 9 , 13 , 14 ). A Family Integrated Care model, in which parents are supported to be their babies’ primary caregivers on the neonatal unit, was associated with increased high-frequency breastfeeding at discharge for very preterm babies in a large multi-centre cluster randomised trial ( 15 ). Recent guidance, quality improvement tools and accredited standards for neonatal units in the United Kingdom recommend giving parents early and consistent information about the value of breast milk; teaching mothers to express by hand and by pump; enabling mothers to express within two hours of birth and supporting them to express 8–10 times per 24 hours in the first weeks; formally reviewing their expressing at least four times in the first two weeks and informally thereafter; promoting skin-to-skin contact; supporting mothers with positioning, attachment and recognising feeding cues; and giving mothers access to specialist support when needed ( 16 – 19 ). This guidance positions these staff actions within the context of seeing parents as equal partners in their babies’ care; providing suitable facilities and equipment for expressing and for parents to be with their babies; training for all staff; and supporting feeding as a multidisciplinary team issue but with a dedicated lead professional. The ability of neonatal units to implement these measures has been hampered by serious understaffing, with only 71.1% of neonatal nurse shifts staffed to recommended levels in 2022 ( 20 ). There are also wide disparities in breast milk feeding rates between individual neonatal units measured by the proportion of very preterm babies receiving some of their own mother’s milk at the time of discharge from neonatal care. Nationally, 60.1% of very preterm babies received their own mother’s milk at discharge in 2022, either exclusively or combined with another form of feeding, but rates in local networks of neonatal units ranged from 48.6–79.3% ( 20 , 21 ). These disparities are likely to reflect service organisation and delivery issues within individual neonatal units as well as local background population rates of breastfeeding, which are affected by socio-demographic factors ( 4 , 22 , 23 ). Staff on neonatal units have an essential role in providing mothers of preterm babies with information and support to establish and maintain breast milk feeding and breastfeeding ( 24 ). There is, however, very little evidence about health professionals’ views on why breastfeeding rates for very preterm babies differ so widely between neonatal units and how their role may contribute to these disparities. Previous studies have reported staff experiences of feeding support for mothers of babies born at any preterm gestation in Jordan ( 25 ) or in a Swedish context where all parents are able to sleep in the room with their baby ( 26 ). The 2019 report from the National Neonatal Audit Programme ( 27 ) recommended that neonatal units in England and Wales should identify barriers to breastfeeding across the patient pathway. The aim of our study was to explore and compare health professionals’ views and experiences of barriers and facilitators to their own role in supporting breast milk feeding and breastfeeding across the patient pathway in neonatal units in England. This study is part of a programme of work which also explored the perspectives of mothers at the same neonatal units (reported separately). Methods This was a qualitative comparative interview-based study, theoretically informed by phenomenological social psychology ( 28 ), aiming to explore participants’ own perceptions and thus to stay close to their accounts while acknowledging the role of both participants’ understandings and the researchers’ interpretations in the production of knowledge ( 29 ). Four neonatal units in England were purposively selected based on their rates of breast milk feeding for very preterm babies at discharge ( 30 ). Two provided tertiary level care for babies of all gestations and prolonged intensive care (Neonatal Intensive Care Units; tertiary units) and two provided initial care for babies down to 27–28 gestational weeks and short periods of intensive care (Local Neonatal Units; non-tertiary units). Two units (called Units A and B in this article) were chosen because they had high rates of breast milk feeding at discharge compared with the national average and two because they had low rates (Units C and D). Based on the research team’s previous experience, the target recruitment was three members of staff from each neonatal unit, including an infant feeding specialist (‘specialist’ is used in this article to imply specialist responsibility rather than professional qualification). A key contact at each neonatal unit invited staff from a range of professional backgrounds to participate in interviews, and passed the contact details of those who agreed to the research team. Participant information and consent forms were emailed to participants at least 24 hours in advance; written or oral informed consent was obtained at the beginning of the interview. Each participant took part in a single semi-structured telephone interview between March and November 2022. Interview topic guides were developed with the support of a Parent, Patient and Public Involvement (PPPI) group. Interviews were audio-recorded and professionally transcribed. Interview transcripts were analysed using comparative thematic analysis, in parallel with ongoing data collection. Transcripts were checked against audio-recordings and reread for familiarity. Coding was both deductive (using an initial explanatory framework derived from the literature and the PPPI group’s experience) and inductive (responding to new points raised by interviewees); codes were recorded using NVIVO software. Codes were refined and combined as data collection continued, and sub-themes and themes were developed. A comparative analytic stage was added in which the differences and similarities between the participating neonatal units were identified within each theme. JM analysed all transcripts and FA analysed a subset; codes and themes were discussed and agreed. The researchers had no prior relationship with interviewees, and reflected critically on their own varied personal experiences of infant feeding and professional experiences of working in neonatal units caring for very preterm babies and their parents. Results Participants Twelve health professionals took part in interviews – three from each neonatal unit. Infant feeding specialists at each unit have not been separately identified to protect confidentiality. Interviews lasted 35–64 minutes (mean 45 minutes). Participants’ pseudonyms and occupations are shown in Table 1 . Table 1 Participating units and interviewees Unit pseudonym Level of neonatal care Rate of very preterm babies receiving breast milk at discharge, compared to England average* Rate of breastfeeding initiation in local population, compared to England average** Interviewee pseudonym Occupation Unit A Local Neonatal Unit Higher rate Above average A01 Nurse A02 Allied health professional A03 Doctor Unit B Neonatal Intensive Care Unit Higher rate Average B01 Nurse B02 Nurse B03 Nurse Unit C Local Neonatal Unit Lower rate Below average C01 Nurse C02 Nurse C03 Midwife Unit D Neonatal Intensive Care Unit Lower rate Average D01 Nurse D02 Nurse D03 Doctor * Based on figures from the National Neonatal Audit Programme ( 30 ) **Based on the last published figures for breastfeeding initiation by NHS Trust ( 31 ) Findings Five topic-based themes were developed to describe the differences between the neonatal units in how they supported breast milk feeding and breastfeeding for very preterm babies, shown with subthemes in Fig. 1 . The first two relate to the organisation of the neonatal unit (‘The role of the infant feeding specialist’ and ‘Achieving a whole team approach to breast milk feeding’), and the remaining three relate to key points in the feeding journey (‘Supporting initiation of expressing’, ‘Supporting long-term expressing’ and ‘Supporting the transition to breastfeeding’.) Figure 1 goes here Figure 1 Themes and subthemes The role of the infant feeding specialist Time allocated to infant feeding support All interviewees highlighted that neonatal staff were generally too busy to give mothers timely and consistent help with expressing and breastfeeding. “It is hard with the workload…we don’t have the time to sit there and go through expressing with mums. If the mum’s very confident with expressing she’ll do really well, but for a mum that’s not very confident, she won’t.” C01 All the units had some staff who were designated as infant feeding specialists or leads, but the ways these roles were organised varied greatly. At Unit A, the infant feeding lead had 15 hours a week for this role, and had only basic training; a lactation consultant who was formerly part of the team had not been replaced. At Unit B, there was well-developed infant feeding team including a supernumerary full-time nurse dedicated to infant feeding support. Staff felt this role had made an enormous difference to the practical and motivational support offered to mothers. “Her role is purely to support mums who are expressing, breastfeeding and bottle feeding. She sees these mums on a regular basis, there's that one person that all mums will have consistent information from. We’ve definitely seen an increase in mums who are expressing, but also who are expressing for a lot longer.” B02 At Unit C, there were breastfeeding link nurses on the unit with little dedicated time. The main support was provided by an infant feeding midwife, but she was not encouraged to spend time on the neonatal unit except to support mothers who had just given birth and were therefore under the care of the midwifery team, and her time could be reallocated to fill maternity shortages: “We do visit the neonatal unit if we’re asked to, however I'm paid by maternity services, so it's coming out of the maternity budget not the neonate budget … I can be taken off to go and do clinical and get my own patients and for that day there's no [infant feeding support].” C03 At Unit D there was also very little staff time dedicated to feeding support, with the infant feeding nurse having only 7.5 hours a week for her role. “None of us [in the infant feeding team] are supernumerary … We all have other jobs to do. And whilst I would absolutely adore to go and help mum straight after delivery and say, ‘This is your golden hour … this is when to start asking your boobs to start making milk,’ I’m actually usually ventilating the baby and putting lines in, so I can't do both.” D03 At Units C and D, staff also highlighted that there was no consistent way to ensure that mothers who needed support were seen by the specialist, or of alerting an infant feeding midwife to a new neonatal admission of a very preterm baby: “If I found a mum who was really struggling with it, at that point we can ask an infant feeding sister to see that mum, but we don’t have a specific referral process for that, that would just be me off my own back trying to find the infant feeding sister.” D02 Supportive relationships and proactive, personalised support Interviewees reflected on the ways in which an infant feeding specialist role could help mothers. Staff in Units A and B highlighted the benefits of being able to build a relationship over time with a mother, and taking responsibility for personalised continuity of care through the different stages of a mother’s feeding journey. “What we’ve changed massively is having that person who takes ownership to support these mums …I make a plan with my mums. I will know where each mum is at in her journey … I can just sit and hold their hands if baby is poorly… If that mum needs me for an hour, I can sit with that mum for an hour.” B03 Another valued aspect of specialist roles at all units was that these staff proactively talked to mothers about how their expressing or breastfeeding was going, which was not necessarily something for which mothers felt able to seek help from busy nurses who were focused on clinical tasks. “Being around to check in on them and see how they’re doing and explaining things to them. A lot of these mums tend to talk to me about how they’re feeling in general because I’m a separate person to who’s looking after their baby at that time.” A01 Infant feeding specialists were able to have these conversations sensitively and in the context of wider relational support that was not solely focused on maximising milk volumes for the baby, but was also empathetic towards the mother as an individual. “It’s just being sensitive enough to recognise where the mum is as well and what the mum needs and how best to support that mum.” A02 Shared responsibility for feeding support Staff said that the effectiveness of a specialised role was maximised if the whole staff team saw support for breast milk feeding as a shared responsibility, with all staff understanding the importance of giving time-critical information and identifying mothers in need of additional help. However, staff at Units A, C and D reported that overstretched neonatal staff tended to over-rely on an under-resourced specialist who had limited availability, instead of incorporating basic feeding support into their own work. Consequently mothers could fall through the gaps. “Everybody pushes the responsibility of that particular role onto whoever else can do it. For instance, a woman has delivered the day before … she hasn’t had the conversation [about early initiation], she’s had nothing until an infant feeding midwife has come in the next day… Now that could have been anybody giving her that bonding pack [and] doing this conversation.” C03 It was also noted that mothers’ confidence could be inadvertently undermined if they were asked about volumes of milk by lots of members of staff, insensitively and without co-ordination. “People have gone, ‘How much milk are you getting every time you express? Oh, that’s not enough you need to be getting this amount.’ … Some mums do then start to question whether they're doing enough. We've had that feedback before, that actually asking too much pushes them away.” D01 To help make feeding support a whole-team responsibility while lactation was being established, Unit A had introduced a structured assessment tool to ensure that mothers were consistently asked about expressing by whichever nurses were on shift, every day for the first week. Interviewees at Unit D believed that a similar approach would help their team, but this had been opposed by colleagues because of a perception that this would add to their workload. “I tried to implement [an assessment checklist from Baby Friendly Initiative] but got told, ‘No, we don’t need more paperwork.’” D01 Shared responsibility for feeding support without adequate training also created problems when staff gave mothers non-evidence based or inconsistent information. Although interviewees at all four units reported that some staff gave mothers conflicting information, it was a particular problem at Units C and D. “The information that parents get is quite different from person to person ... [Staff] give information based off their own experience or what they’ve seen, not necessarily with a mum who’s got a baby that’s 25 weeks.” D02 Achieving a whole team approach to breast milk feeding Leadership and the feeding culture Interviewees highlighted the importance of leadership in supporting cultural change around breast milk feeding on neonatal units. In particular, leadership was needed to change staff perspectives, for example moving beyond seeing breast milk only as food to seeing feeding as part of a relationship between mother and baby. At Units A and B there were active efforts to persuade staff to see support for parents as integral to the neonatal nursing role, and to promote full partnership between parents and staff (Family Integrated Care). “The family needs to be seen as the baby with parents [but] a lot of staff still like that little bit of control….As [an infant feeding] group we’ve got a very supportive matron. So it’s very much a team effort … to make things as positive as we can for families, and listening to their feedback as well.” B02 In units where this leadership was not yet in place, staff who championed breast milk feeding described efforts to bring together a multi-disciplinary group and in particular to encourage buy-in from doctors and other senior staff: “Getting the right people on board, I think the higher you go, the better…That’s usually how it goes, if you can get doctors or paediatricians on board then you can get changes.” C03 Using external standards as levers Unit B was actively working towards full Baby Friendly Initiative (BFI) accreditation ( 16 ), and Unit D had registered to begin the process. Interviewees at all units believed that BFI could be an important lever to drive change within their units. “BFI gives us a lot of access to educational tools and things that will help us, and I think it focuses the unit’s culture in terms of ‘watch our mouths’ when it comes to the language we use around breastfeeding and breast milk.” D03 At Unit C which was not engaged with BFI, an interviewee was trying to convince her colleagues to prioritise breast milk using other external standards, such as the PERIPrem bundle which includes promotion of maternal early breast milk ( 32 ) and the Saving Babies’ Lives care bundle for reducing perinatal mortality ( 33 ). “PERIPrem as a strategy, you have that as a leverage to say, ‘Well, you're not doing this and that and the other’... To say [to colleagues], ‘This isn't about food, this is gut treatment, this is like giving the probiotics and the antibiotics.’” C03 At Unit A, interviewees noted that external criteria such as those used by the National Neonatal Audit Programme were influential but could have unintended consequences when staff prioritised supporting breast milk feeding (which was recorded and reported) but not direct breastfeeding (which was not). “We scored really high on all babies having breast milk, but in terms of babies actually being breastfed, we didn’t do that well. I think because it’s not something that’s particularly measured, there’s no funding attached to that, people are not maybe as vigilant or as committed to making it work.” A03 Training for the multi-disciplinary team At Unit B, neonatal infant feeding training for all staff was a priority, reflecting their engagement with Baby Friendly Initiative. At the other units, lack of training on expressing and breastfeeding specifically for very preterm babies was repeatedly mentioned as an obstacle to supporting mothers effectively. “The long term expressing is so much more challenging because it takes a lot to keep going … The training that’s provided by the midwives is not really helping in that sense for us nursing staff … They do a small portion on preterm babies but most of it’s about full-term babies.” A01 Specific training on supporting mothers of very preterm babies was felt to be important for doctors as well as nurses, as some parents turned for advice to professionals who they perceived as more senior, to double check information given by nurses with more training: “[Mums] say to a doctor, ‘The nurse told me I should be expressing 20ml from each breast, is that correct?’ and the doctor goes, ‘Yeah, whatever the nurse says,’ but that nurse might have given them the wrong information… I think if [doctors] had the same training as [nurses], that would be a real positive in terms of helping certain families who like that reassurance from somebody more senior.” D02 Interviewees suggested that infant feeding training should also include communication skills because parents, who were trying to make sense of a confusing and stressful situation, were liable to read unintended meanings into what staff said. “Parents pick up on so much, staff sometimes think that parents aren't listening or aren't aware, but they are, they're full of adrenaline, they're very acute …[It’s] a very frightening situation as well, very vulnerable … so I think body language is a massive thing. Use of words, definitely.” B02 Interviewees also acknowledged that training was not the whole solution: even where there was good investment in training, this was not necessarily enough to change the practices of some colleagues who were set in their ways. “On our unit a lot of the staff have been there for a really long time and you can’t change attitudes that are ingrained in people …We’ve tried to address this because they’ve been on training, they’ve had the infant feeding coordinators come in to do specific training with them … so there’s no excuse really.” A03 Supporting initiation of expressing Attitudes to early initiation of expressing Interviewees at all four units were keen to motivate mothers to express their colostrum and then breast milk, by explaining its unique benefits for their very preterm babies. They encouraged mothers to start expressing milk irrespective of how they planned to feed their babies later. “At the beginning my question to a mum isn't, ‘How do you want to feed your baby?’ It's, ‘Would you be willing to express your breast milk, because actually your milk is golden medicine for your baby?’ A 22-weeker, it doesn’t matter how a mum wants to feed down the line … it's actually the importance of expressing that milk and getting that milk into the baby.” D01 They noted that this approach was often successful for mothers who had no intention of breastfeeding. “Once you explain to parents the importance of the breast milk, a lot of parents will change their mind … even if they don’t go on to breastfeed but just give the milk by bottle…‘We didn’t want to do this, but because my baby is poorly I’ll do it for a little while.’” C02 Interviewees at all the units believed that it was beneficial, where possible, to talk to mothers before the baby was born about breast milk feeding and how to start expressing, as they might be too distressed to absorb this information after birth. At Unit B, the infant feeding nurse spent time with all pregnant women admitted to the hospital with the risk of premature birth. She explained feeding choices and the support available, underlined the importance of starting to express shortly after birth, and began to build a relationship with the mother that would continue throughout their baby’s time on the neonatal unit. “I sit with them and very gently ask them how I can support them with their choices of feeding. I go through the [feeding] pack, and I’ll say to them, ‘I will see you on the unit’... The hardest thing for me is getting mums to hand express within that hour of babies being born, and so I go through the importance of it, I tell them that what we do at this stage will help their milk supply later down the road, and I ask them to ask the midwives to help them with the hand expressing very quickly after birth. I’m almost giving them the confidence to say to someone, ‘Please will you help me with hand expressing?’” B03 At Units A, C and D, interviewees said there was no capacity for neonatal staff to do this and no system to alert neonatal staff when pregnant women were admitted at risk of very preterm birth. They noted that obstetricians, midwives and neonatal staff who saw the mother antenatally or in the immediate postnatal period did not necessarily prioritise information about feeding: “I find it's a battle… [Doctors] appreciate what breast milk is for a premature baby, but then they feel like it's not a priority to be telling mum straightaway ... I've had an incident yesterday, a 22-weeker born [at another hospital], transferred to us. The consultant has told the mum that she doesn’t need to express overnight, ‘Go and get some rest and we’ll start tomorrow.’ That’s then two days down the line, and actually that’s not the right information to be sharing with a mum.” D01 Even if breast milk feeding was generally promoted, staff might tell mothers who had a multiple birth that it would not be possible for them to feed all their babies. “The attitude of that person probably would come into it, saying to the mum, ‘You’re not going to be able to feed two or three.’” A01 Joined-up working with the postnatal ward At all four units there were challenges in the working relationships between the midwives caring for mothers on the postnatal ward, and staff caring for the babies on the neonatal unit. Interviewees believed that when midwives did not promote early expressing this could be due to lack of time, lack of understanding, or feeling protective of the wellbeing of the mother in the short term. “There is quite a lot of resistance from the midwives, quite often the parents aren't shown how to express or encouraged to express on the wards … The midwives are very much, ‘The women’s their job, once the baby’s born it's not their problem.’ … So, where we will say, ‘Have a go at expressing, it's really important to get it started,’ then they go back up to the ward [and] they get the opposite, so it's not that consistent message.” C02 “The midwives have obviously got a lot of other things going on and being able to sit with [mothers] in a dedicated supportive fashion and teach them a brand new skill, it's time-consuming and sadly that time is not always freely available, gets interrupted, gets put off, or mum’s tired because she’s delivered and they go, ‘We don’t want to push her,’ and it gets delayed and delayed.” D03 At Unit C, there were also inconsistent policies between the neonatal unit and the postnatal ward on how best to initiate expressing after very preterm birth, leaving mothers confused in the middle. “We know that getting babies’ mums on the pump is beneficial right from the very beginning, and they're still being told by our midwifery team that you can't pump for 48 hours, you should just hand express for 48 hours... I had a mum where I said to her, ‘Yes, go and pump now.’ ‘But the midwife told me not to.’ I had to then talk her round that my point of view was correct.” C02 At Units A and B, the infant feeding specialist from the neonatal unit would visit mothers on the postnatal ward to proactively offer support with early initiation of expressing. They had to overcome initial opposition from postnatal staff and build trust to be ‘allowed’ to support mothers: “It was very much ‘them and us’ … To begin with when I went over to [the postnatal ward] they were a little bit, ‘Who is this? Why is she interfering?’ But now they know I’m a great help to them, because they’re really busy on that unit, so if I can go in and sit with that mum and talk to her about hand expressing or set her up on a pump, I’m taking a job away from them which is another job that they’re sometimes struggling to get round to doing.” B03 Supporting long term expressing Positive feedback Interviewees at all four units said that giving mothers praise and positive feedback was important at all stages to reinforce their motivation, but they particularly emphasised the challenges mothers faced in expressing for weeks or months before a very preterm baby was able to feed orally. “I think a constant reinforcement of the importance of her breast milk, and also the fact that we recognise mums, how hard it is and how laborious it must be, and how committed they are in order to provide breast milk for their baby for such a long period of time.” B02 However this promotion of breast milk had to be handled sensitively, as some mothers were unable to produce enough milk or found it too difficult to keep up the demanding schedule of expressing, particularly if they were looking after other children. Interviewees recognised that worrying about maintain and increasing the milk supply could in itself reduce the milk supply, and some continued to emphasise the process rather than the amount of milk produced. “We try to take the pressure off, because it is a lot of pressure… The more they stress, the less they produce because they’re thinking about, ‘Oh, we need 300 ml.’ … So we say, ‘Just do what you can and the baby will get fed anyway.’” C01 Troubleshooting challenges At all the units, specialist staff responded to mothers’ milk supply difficulties by personalised troubleshooting with them to consider ways they could increase lactation, such as lifestyle changes (eating well and resting), spending time skin-to-skin with the baby, power pumping, pumping regularly including at night, and taking medication. When a mother was highly motivated but her milk supply remained insufficient to meet her baby’s needs, or she stopped expressing while her baby was still on the neonatal unit, specialist staff tried to support the mother to avoid feeling she had failed her baby, by helping her to understand possible reasons and to focus on what she had achieved. “It may help them come to terms with the fact that what they're doing is absolutely fantastic, but we've perhaps got to the limit of what they're going to be able to do. …Going through their history, going through what they’ve done since they started to express, they can then visualise, ‘Actually, I've done everything you’ve asked me to do and obviously my body is not going to be able to do anything more.’” B02 Provision of breast pumps and facilities There were differences between units in the equipment provided to support expressing milk. Unit D had fewer pumps than cots so mothers had to queue to express milk if the pumps were in use: “We don’t have enough pumps on the unit, ideally it’s a pump per space, isn't it? That would be great. But actually, let's go for a pump in each bay and then have the expressing room kitted out with pumps .” D01 Units B, C and D had hospital grade breast pumps to lend to mothers for expressing at home while their baby was on the unit, but Units C and D did not have robust systems for monitoring the return of these free loans, and at both sites most of the loaned pumps were currently missing. “All our breast pumps that we had to loan to parents have disappeared. Our housekeeper is currently trying to phone round parents to find out where they’ve gone .” C02 All of the units had a separate room where mothers could express milk, but interviewees noted that these were not particularly comfortable places where mothers would feel relaxed, which would encourage milk flow. They also said that while they encouraged mothers to express beside their babies, this could be difficult if the unit had not been designed with this in mind, and the cots were in a noisy, crowded environment with little privacy. “We don’t have a lot of space on our unit, so I don't think parents feel that they can sit and express cot-side very often … It's a very noisy, stressful environment...We don’t have curtains, we only have screens on wheels, which aren't the greatest and they're not always available.” B02 Supporting the transition to breastfeeding Attitudes to direct breastfeeding The units had different levels of success in supporting mothers to begin directly breastfeeding when their babies were developmentally ready, and these reflected different staff attitudes. Breastfeeding was strongly supported at Unit B, where there was intensive support from specialist staff to help mothers and babies transition to breastfeeding. Mothers were supported to introduce babies to the breast at a much earlier stage than in the other units, which was believed to be motivating as well as enabling mothers and babies to learn the practical skills of breastfeeding over a much longer period. “If I’ve got a 28-weeker who is stable, I look at all the observations, I’ll also talk to the medical team …I always ask mums to pump first, so the baby is going to go onto an empty breast, they’re just sucking and might get just a small amount … I think it’s so important that these babies start tasting, and the closeness as well for mum. All that hard work these mums have done to get to this point, so they feel that they’re getting somewhere.” B03 At Unit A, breast milk feeding was a high priority for the wider staff team but encouraging direct breastfeeding was not: “Generally people are not so positive with breastfeeding, it’s sort of seen as, ‘Yes, if they want to breastfeed, that’s fine.’” A01 Likewise at Units C and D, establishing breastfeeding was not seen as particularly important or even feasible, compared to bottlefeeding with expressed milk. “I don’t think we’ve recently had many mums go home exclusively breastfeeding and I don’t blame them to be honest, it’s just really hard when you’ve got a baby on the neonatal unit … I think most mums are happy if it’s their milk to bottle feed anyway.” C01 Overcoming separation of mothers and babies All of the units had transitional care rooms where parents could stay immediately before their baby was discharged, but none had space for all parents to routinely room-in. Staff at all four units said that having only limited facilities for parents to stay on site was particularly problematic at the point where the mother was trying to establish direct breastfeeding, and therefore needed to be with her baby as much as possible. “If we had more facilities where the mums could room-in and establish breastfeeding 24/7 they might be more successful with exclusive breastfeeding, but we’ve only got two parent bedrooms and the mum is only there at the time of discharge.” C01 At Unit A, night staff were reported to obstruct mothers’ attempts to spend time with their babies on the ward to breastfeed at night. “ They don’t want mums on the unit at night, because one of them even said to the mum, ‘This is not a hotel, you can’t come and go as you please.’” A03 At Unit B, mothers were encouraged to room-in while they were establishing breastfeeding, but there could be competing needs for the limited rooms such as accommodating the parents of a critically ill baby. To avoid the problem of separation the unit had changed their discharge criteria so that mothers could establish breastfeeding at home with the support of an an outreach team: “As soon as baby starts to show feeding cues for breastfeeding … we will get that mum to come in and stay until their baby goes home… It used to be the fact that [to be discharged] babies had to be having half and half, so half their requirements would be either by the bottle or by the breast, and then the other half could be down the tube … Things have now changed where [with] our outreach team, as soon as the baby is having at least one breastfeed a day and we can see effective feeding and mum recognises effective feeding, then we get that baby home for her then to establish her breastfeeding at home.” B02 Breastfeeding as the only oral feeding At all four units there was pressure from some staff for mothers to agree to give expressed milk or formula by bottle to babies who were developmentally ready to begin oral feeding, rather than continuing partial tube feeds while the mother and baby established breastfeeding. Staff typically proposed this as a solution when breastfeeding was slow to be established, or because of their desire to respond to the baby’s feeding cues when the mother was not on the unit (and none of the units used cup feeding as an alternative). “If a baby’s awake and rooting for a feed, we ask the mum would she consent to a bottle feed, because it’s not nice tube feeding a baby that’s awake and wanting a feed.” C01 Pressure to introduce bottles could also be driven by a lack of time or skills to support the transition to breastfeeding, which could be a long process for a very preterm baby. “Because of our short staffing the priority of most people is to do those things like basically keeping the babies alive, and although breastfeeding is an addition to helping them thrive, it's not in that moment going to keep them alive.” D02 This pressure could undermine mothers’ resolve to breastfeed, and some staff were also reported to make unhelpful critical comments to mothers who were trying to establish breastfeeding. “It’s a difficult culture to change because the staff are quite fixated on ‘The baby needs to bottle feed and if the baby’s looking to suck, why are we not offering bottles’?’ … [They] make the mum feel really bad about wanting to breastfeed or that she’s not there in the evenings, so it makes it very difficult and very uncomfortable, then all the work that you have done before gets undone, and this has happened on numerous occasions.” A02 Maintaining confidence without measuring volume Some parents and staff preferred to introduce bottles of expressed milk or formula rather than establish breastfeeding, because there was an objective measure of the volume of milk a baby had taken. Interviewees said they tried to reassure parents about other ways of assessing the efficacy of a breastfeed, but this was time-consuming. “Parents get very institutionalised with focusing on numbers, so if they can see that the baby’s had a certain number [of ml] then they feel less anxious, whereas a breastfeed you're not seeing any numbers …You’ve got to find other things to make them feel confident in what they're doing. It's time again, just spending time with them.” B01 Less experienced staff might undermine mothers’ confidence by communicating their own desire for certainty: “On the NICU [neonatal intensive care unit] it’s all about numbers, isn't it? … Some staff members, they’re more interested in the figures, how many mls a baby has had. With more experience you know whether a baby has [breast]fed properly or not.” C01 Once a mother had begun direct breastfeeding, nurses typically used a time-based rating scale to assess the efficacy of a feed and thus the amount of top-up that would be given by tube. However, some interviewees said that that these mechanistic ways of assessing breast milk transfer were flawed, and again the key support was to build a mother’s own confidence to assess a feed by observing the baby and her own bodily sensations. “There's a general expectation that there's some kind of linear relationship between the length of a feed and how much milk has been taken in, and as many times as I tell them that’s complete nonsense, [the nurses] still ask me. Because they want a plan … I talk to the parents about how their breasts are feeling before, during and after a feed, what the babies look like when they're feeding, are they actively feeding or are they having a few sucks and then drifting off to sleep?” D03 Reassurance about weight gain All the interviewees were aware that it was normal for babies’ weight gain to falter briefly when they began to fully breastfeed, for several reasons: the baby would be using more energy on feeding and would be tired; the baby was now in control of feeding rather than being fed a predetermined amount of milk on a predetermined schedule; and whereas breast milk fortifier was usually added to expressed breast milk as a nutritional supplement, the baby did not receive these extra nutrients when feeding directly from the mother’s breast. Interviewees tried to reassure parents that temporary slowing of growth was normal, but they described interactions where colleagues had undermined mothers’ confidence by telling them that that this was a sign that breastfeeding was not succeeding, so top-ups should be given. “Sometimes the difficulty has been where mum has mostly established breastfeeding, and the baby has maybe dropped 50g, and then [staff say], ‘Oh well, you need to top up with a bottle or you need top up with a tube.’ And then it’s all panic stations.” A03 Interviewees had conflicting opinions about whether or not it was true that babies would go home a few days more quickly if they were bottlefed than if they were breastfed. These were linked to perceptions of babies’ ability to master these different feeding skills, how much time an individual mother was able to spend on the unit, and unit policies that required weight gain with oral feeding before a baby could be discharged. “They're absolutely desperate to get home, and it doesn’t help that the chitchat in the unit and in the parents’ room is all about how they're quickest to feed when they're bottlefed … It's only a matter of days, but if you’ve been in hospital for three months probably every day counts.” D03 On Unit B, fully breastfed babies could be given a ‘shot’ of breast milk fortifier just before a breastfeed to help maintain their growth. As described above, this unit had an early discharge policy that did not require weight gain before discharge but enabled mothers to initiate breastfeeding on the unit, and their babies to be discharged primarily tube feeding, so that breastfeeding could be established at home with the support of an outreach team. Discussion Comparing the experiences and views of staff at four neonatal units in England has revealed substantial variation in support for breast milk feeding for very preterm babies across different time points in the neonatal feeding journey from pre-admission to discharge, despite the same guidance, quality improvement tools and accredited standards being available to all units ( 16 – 19 ). Unit B, which had a higher rate of breast milk feeding at discharge compared with other neonatal units in England despite an average breastfeeding initiation rate in the local population, had committed leadership, a dedicated full time infant feeding specialist who saw mothers on the antenatal and postnatal wards as well as the neonatal unit, regular infant feeding training for all staff, and a culture of Family Integrated Care. Unit A, which had a higher rate of breast milk feeding at discharge that may have been influenced by an above average rate of breastfeeding initiation in its local population, had an infant feeding specialist with 15 hours a week of protected time. Staff at Unit A said that their high rate of breast milk feeding at discharge masked a low rate of direct breastfeeding, which was not an indicator measured by the National Neonatal Audit Programme, although it is recorded in neonatal electronic healthcare records. Units C and D had a lower rate of breast milk feeding at discharge and an average (Unit D) or below average (Unit C) breastfeeding initiation rate in the local population. There was minimal protected time allocated to the infant feeding specialist role (Unit D) or reliance on an infant feeding midwife from the postnatal ward (Unit C). Despite the commitment of individual members of staff, there was no strategic leadership or systematic support for breast milk feeding and breastfeeding across these units, and some staff were fatalistic in their perception that exclusive direct breastfeeding at discharge was an almost unattainable goal for a very preterm baby. These issues resulted in missed opportunities to support mothers effectively at each point on the feeding timeline, echoing the findings of Shattnawi ( 25 ) that overworked neonatal staff saw breastfeeding promotion as ‘a nicety instead of a necessity’ and abdicated the responsibility to support mothers to others. To achieve cultural change, Bliss recommends that each neonatal unit should have a dedicated lead professional to champion the issue and support mothers, and also that feeding should be seen as an issue for the multidisciplinary team, who should be trained on the benefits of breast milk, lactation physiology, and how to support parents ( 19 ). The experience of these four neonatal units illustrates the importance of these two recommendations being implemented together. Where the lead professional role existed but was under-resourced, inadequately trained staff would nonetheless treat support for breast milk feeding and breastfeeding as the responsibility of the lead, whether or not the lead was present on the ward. The support and information that staff gave parents was uncoordinated and inconsistent, and the time-critical optimal window for initiating lactation could be missed. By contrast, an adequately-resourced infant feeding lead could build an empathetic relationship with mothers that enabled her to give proactive, personalised, and consistent feeding support throughout the very preterm babies’ time on the neonatal unit. Where this role was part of a core infant feeding team and embedded in a multi-disciplinary staff team who regularly took part in infant feeding training that was specifically relevant to preterm babies, mothers could be effectively supported to initiate and sustain prolonged expressing and then to transfer to direct breastfeeding, which is associated with longer term breast milk feeding after leaving the neonatal unit ( 9 , 12 ). The importance of protected time for the infant feeding lead role has been recognised in guidance ( 18 ), but current guidance does not specify specialist staffing levels ( 16 ), leading to extreme variation in the allocated hours, banding and job descriptions between neonatal units in England (Personal communication from Karen Read, Neonatal Professional Lead for UNICEF Baby Friendly Initiative, shared with permission). Although there has been a policy focus in England on improving information sharing and partnership working between midwives and health visitors in the community ( 34 , 35 ), there has not been a similar focus on partnership between midwifery and neonatal care. This study has highlighted the gaps for mothers antenatally if the neonatal team were not aware of admissions of mothers at risk of very preterm birth, and postnatally if there was no joined-up working between midwives caring for the mother on the postnatal ward and the neonatal team caring for the baby, contrary to guidance from the Baby Friendly Initiative (BFI) standards ( 16 ). In some cases mothers were given directly contradictory advice by nurses and midwives about when or how to start expressing, or midwives were actively opposed to neonatal infant feeding staff supporting ‘their’ mothers on the postnatal ward. Some neonatal units in Sweden offer ‘couplet care’, where mothers (including those with complex medical needs) stay on the neonatal ward from birth and receive postnatal care for their own recovery there ( 36 ). In this model it is the postnatal team who which moves around the hospital, rather than the mother. While most English neonatal units lack the space and resources to reorganise care this way, neonatal and maternity staff could commit to joint working to provide integrated care for the mother-baby dyad, recognising both the mother’s own need to rest and recover and importance of the mother starting to express milk within two hours after very preterm birth in order to optimise her chance of reaching and maintaining a full supply ( 16 , 17 ). Previous research on training neonatal nurses in breastfeeding support for preterm babies found that this significantly increased the rate of preterm babies who were exclusively breastfed at discharge ( 24 ). This study indicates the importance of extending training to neonatal doctors and the whole multi-disciplinary team, and indeed to any health professionals involved in intrapartum care, fetal medicine and perinatal care, as recommended by the National Neonatal Audit Programme ( 21 ). This can ensure that mothers who experience very preterm birth are given information about early initiation of expressing at the first appropriate opportunity by whichever health professional is caring for them; that they receive consistent information and support about sustaining expressing from any staff members they encounter; and that they are enabled to transfer to direct breastfeeding without being undermined by a focus on weight gain or inflexible discharge criteria. Training could also address the challenge for nurses of how to feed an older baby who is showing sucking behaviour but whose breastfeeding mother is not able to be on the unit for all of the baby’s feeds. It is well established that physical separation of parents and their baby in neonatal care is one of the causes of breastfeeding difficulties as well as delays in establishing the parenting relationship ( 3 , 37 ). Parents’ experiences are very different in units where they are able to stay with their babies all the time, either in a private single family room or with a cotside bed or reclining chair that they are encouraged to see as their own space ( 38 ). Accommodating parents on the neonatal unit can facilitate Family Integrated Care where the family is seen as a team led by the very preterm baby, and the role of staff is conceptualised as supporting and guiding the family team in their feeding process ( 26 ). It has, however, also been noted that sleeping next to their baby may compromise the quality of parents’ sleep because of staff activity and noise; therefore parents’ mental health may be better protected by being offered a sleep space that is near but not with their baby ( 39 ). None of the units in this study had the space or facilities to routinely offer parents the ability to room-in with their babies until just before discharge. Staff said this both hampered the establishment of direct breastfeeding, and discouraged some mothers from even trying, because they believed their baby was likely to meet the discharge criteria about oral feeding and weight gain sooner if bottlefed, as also reported by Bonet et al ( 40 ) for French and English neonatal units. Unit B had addressed this issue in two ways: firstly by encouraging mothers to start putting their babies to the breast much earlier so that the transition to breastfeeding was a gentle process of familiarisation and closeness long before there was any meaningful feeding; and secondly by changing their discharge criteria so that a baby could be discharged before oral feeding was fully established. This meant that mother and baby could establish breastfeeding at home without separation, with the support of an outreach team from the neonatal unit. This system contrasts with the policies in Italy reported by Bonet et al ( 40 ), where very preterm babies were bottlefed on the neonatal unit before being discharged to begin breastfeeding at home. There is as yet no evidence on the impact of Unit B’s approach on mothers’ ability to sustain longer term direct breastfeeding for very preterm babies, and this could be a topic for future research. Irrespective of facilities for rooming in, the BFI standards require that parents should have 24-hour access to their babies, consistent with valuing them as partners in care, with policies in other paediatric settings, and with the Convention on the Rights of the Child article 9.1: “a child shall not be separated from his or her parents against their will” ( 41 ). Although all four units adhered to this principle in theory, some night staff at Unit A were reported to create an unwelcoming environment for parents, whose presence they found annoying, similar to some staff observed by Shattnawi ( 25 ). This underlines the importance of building a culture of support for feeding as part of Family Integrated Care throughout the whole neonatal team. Strengths and limitations It was a strength of this study that it involved health professionals from a range of professional backgrounds, working in four different neonatal units of different types in England and with different local population breastfeeding rates, so giving insight into the successful and less successful implementation of national policy and practice recommendations. The interviewees included both staff with a lead responsibility for supporting feeding for very preterm babies and staff with general clinical responsibilities. It was a limitation that all the staff who volunteered to be interviewed had a positive personal attitude to breast milk feeding and breastfeeding, so information about staff with less positive attitudes relied on interviewees’ descriptions of colleagues. Conclusion There are different challenges for health professionals in supporting mothers of very preterm babies at different stages of their feeding journey, but the variation in practice in this study shows that there is much to learn from neonatal units that have high rates of breast milk feeding at discharge. Effective support can be influenced by having a supernumerary post dedicated to infant feeding; strong leadership that champions breast milk feeding and breastfeeding within family integrated care; maintaining accountability by using existing quality improvement tools and accredited standards for neonatal units; and training for the whole multi-disciplinary team that encourages and enables every member of staff to take an appropriate share of responsibility for consistently informing and assisting mothers when the specialist is not available. National guidance could define recommended staffing levels for infant feeding support. Even when neonatal units do not have rooms for parents to live with their preterm babies throughout their stay, unit policies can support the transition to direct breastfeeding by encouraging mothers to start the process at the earliest opportunity, and minimise separation by supporting mothers to establish breastfeeding at home rather than requiring full oral feeding as a criterion of discharge. Joined-up working between staff on antenatal and postnatal wards and neonatal units can enable integrated feeding support for the mother-baby dyad, overcoming the risk of staff seeing the mother’s and baby’s needs as unconnected or opposed. The National Neonatal Audit Programme could consider reporting the rate of exclusive direct breastfeeding at discharge in addition to breast milk feeding, so that this transition is treated with equal importance. Declarations Ethical approval and consent The Health Research Authority East of England – Essex Research Ethics Committee (reference 21/EE/0144) approved the study. Informed consent was obtained from all subjects and all methods were carried out in accordance with relevant guidelines and regulations. Consent to publish Not applicable Availability of data and materials The datasets generated during the current study are not publicly available due to the consent process but are available from the corresponding author on reasonable request. Conflict of interest The authors declare they have no competing interests. Funding This research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21202. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Authors’ contributions JM, FA, CG and JK designed the study. JM conducted the interviews and analysed the data, and FA and AA analysed a subset of the data. JM wrote the first draft, and all authors reviewed and agreed the final version of the manuscript. Acknowledgements Thank you to the staff who took part in this study, and to our PPPI contributors: Josie Anderson (BLISS), Jane Denton (Multiple Births Foundation), and Janet Rimmer (Twins Trust). References Menon G, Williams TC. Human milk for preterm infants: why, what, when and how? Archives of Disease in Childhood -. Fetal Neonatal Ed. 2013;98(6):F559. Tudehope DI. Human Milk and the Nutritional Needs of Preterm Infants. J Pediatr. 2013;162(3):S17–25. Ikonen R, Paavilainen E, Kaunonen M. Preterm Infants' Mothers' Experiences With Milk Expression and Breastfeeding: An Integrative Review. Adv Neonatal Care. 2015;15(6):394–406. Bonet M, Blondel B, Agostino R, Combier E, Maier RF, Cuttini M, et al. 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Oxford\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jennifer\",\"middleName\":\"J\",\"lastName\":\"Kurinczuk\",\"suffix\":\"\"},{\"id\":320391855,\"identity\":\"52a2ac74-514a-42fb-aca3-65e1388977da\",\"order_by\":5,\"name\":\"Fiona Alderdice\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Oxford\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Fiona\",\"middleName\":\"\",\"lastName\":\"Alderdice\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-06-17 11:44:22\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4593940/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4593940/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12884-024-07039-0\",\"type\":\"published\",\"date\":\"2024-12-26T15:57:16+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":60448379,\"identity\":\"2d7906ee-096a-4192-9487-7f640934c734\",\"added_by\":\"auto\",\"created_at\":\"2024-07-16 22:15:13\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":82436,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eThemes and subthemes\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Picture1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4593940/v1/a57c909bb68d3a3d13970ee6.jpg\"},{\"id\":72640578,\"identity\":\"2ff9c6ad-a57a-4290-8f1b-620f516a7449\",\"added_by\":\"auto\",\"created_at\":\"2024-12-30 16:07:05\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":917651,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4593940/v1/2efa8941-3e3c-4c4b-9811-f66e1d8a913a.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Differences between neonatal units with high and low rates of breast milk feeding for very preterm babies at discharge: a qualitative study of staff experiences\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eBreast milk, which is optimal nutrition for all babies, has significant additional benefits for preterm babies, such as lower rates of infections and necrotising enterocolitis, faster development of the gastrointestinal tract, and improved neurodevelopmental outcomes (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Providing breast milk for a baby in a neonatal unit may also have psychological benefits for the mother (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). Despite these benefits, \\u0026lsquo;very preterm\\u0026rsquo; babies born before 32 completed weeks of gestation are less likely to receive their mother\\u0026rsquo;s breast milk than babies born at or close to term (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Very preterm babies lack the muscle tone, co-ordination and endurance to feed directly from the mother\\u0026rsquo;s breast. They are initially fed expressed breast milk or infant formula by nasogastric or orogastric tube, and once they can co-ordinate sucking, swallowing and breathing they are transitioned to oral feeding from the breast or by bottle or cup (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eEstablishing and sustaining lactation is more challenging for mothers who have had a very preterm birth, because their own production of breast milk may be delayed, and they have to sustain it by expressing during a prolonged period before the baby is able to feed from the breast (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). Production of breast milk is optimised by stimulating lactation as soon as possible after birth, and maintaining it by expressing multiple times every day, with frequency and duration of pumping being associated with higher volumes of milk production (\\u003cspan additionalcitationids=\\\"CR9 CR10\\\" citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eEstablishing exclusive direct breastfeeding is important for preterm babies as this is associated with longer term breastfeeding after leaving the neonatal unit (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). Transition to direct breastfeeding for preterm babies may be supported by enabling the baby to practice non-nutritive sucking before they are ready for oral feeding (\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e), and having single family rooms to enable parents to stay with their babies 24 hours a day (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). A Family Integrated Care model, in which parents are supported to be their babies\\u0026rsquo; primary caregivers on the neonatal unit, was associated with increased high-frequency breastfeeding at discharge for very preterm babies in a large multi-centre cluster randomised trial (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eRecent guidance, quality improvement tools and accredited standards for neonatal units in the United Kingdom recommend giving parents early and consistent information about the value of breast milk; teaching mothers to express by hand and by pump; enabling mothers to express within two hours of birth and supporting them to express 8\\u0026ndash;10 times per 24 hours in the first weeks; formally reviewing their expressing at least four times in the first two weeks and informally thereafter; promoting skin-to-skin contact; supporting mothers with positioning, attachment and recognising feeding cues; and giving mothers access to specialist support when needed (\\u003cspan additionalcitationids=\\\"CR17 CR18\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). This guidance positions these staff actions within the context of seeing parents as equal partners in their babies\\u0026rsquo; care; providing suitable facilities and equipment for expressing and for parents to be with their babies; training for all staff; and supporting feeding as a multidisciplinary team issue but with a dedicated lead professional.\\u003c/p\\u003e \\u003cp\\u003eThe ability of neonatal units to implement these measures has been hampered by serious understaffing, with only 71.1% of neonatal nurse shifts staffed to recommended levels in 2022 (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). There are also wide disparities in breast milk feeding rates between individual neonatal units measured by the proportion of very preterm babies receiving some of their own mother\\u0026rsquo;s milk at the time of discharge from neonatal care. Nationally, 60.1% of very preterm babies received their own mother\\u0026rsquo;s milk at discharge in 2022, either exclusively or combined with another form of feeding, but rates in local networks of neonatal units ranged from 48.6\\u0026ndash;79.3% (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). These disparities are likely to reflect service organisation and delivery issues within individual neonatal units as well as local background population rates of breastfeeding, which are affected by socio-demographic factors (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eStaff on neonatal units have an essential role in providing mothers of preterm babies with information and support to establish and maintain breast milk feeding and breastfeeding (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). There is, however, very little evidence about health professionals\\u0026rsquo; views on why breastfeeding rates for very preterm babies differ so widely between neonatal units and how their role may contribute to these disparities. Previous studies have reported staff experiences of feeding support for mothers of babies born at any preterm gestation in Jordan (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e) or in a Swedish context where all parents are able to sleep in the room with their baby (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e). The 2019 report from the National Neonatal Audit Programme (\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e) recommended that neonatal units in England and Wales should identify barriers to breastfeeding across the patient pathway. The aim of our study was to explore and compare health professionals\\u0026rsquo; views and experiences of barriers and facilitators to their own role in supporting breast milk feeding and breastfeeding across the patient pathway in neonatal units in England. This study is part of a programme of work which also explored the perspectives of mothers at the same neonatal units (reported separately).\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eThis was a qualitative comparative interview-based study, theoretically informed by phenomenological social psychology (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e), aiming to explore participants\\u0026rsquo; own perceptions and thus to stay close to their accounts while acknowledging the role of both participants\\u0026rsquo; understandings and the researchers\\u0026rsquo; interpretations in the production of knowledge (\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e). Four neonatal units in England were purposively selected based on their rates of breast milk feeding for very preterm babies at discharge (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). Two provided tertiary level care for babies of all gestations and prolonged intensive care (Neonatal Intensive Care Units; tertiary units) and two provided initial care for babies down to 27\\u0026ndash;28 gestational weeks and short periods of intensive care (Local Neonatal Units; non-tertiary units). Two units (called Units A and B in this article) were chosen because they had high rates of breast milk feeding at discharge compared with the national average and two because they had low rates (Units C and D). Based on the research team\\u0026rsquo;s previous experience, the target recruitment was three members of staff from each neonatal unit, including an infant feeding specialist (\\u0026lsquo;specialist\\u0026rsquo; is used in this article to imply specialist responsibility rather than professional qualification). A key contact at each neonatal unit invited staff from a range of professional backgrounds to participate in interviews, and passed the contact details of those who agreed to the research team. Participant information and consent forms were emailed to participants at least 24 hours in advance; written or oral informed consent was obtained at the beginning of the interview. Each participant took part in a single semi-structured telephone interview between March and November 2022. Interview topic guides were developed with the support of a Parent, Patient and Public Involvement (PPPI) group.\\u003c/p\\u003e \\u003cp\\u003eInterviews were audio-recorded and professionally transcribed. Interview transcripts were analysed using comparative thematic analysis, in parallel with ongoing data collection. Transcripts were checked against audio-recordings and reread for familiarity. Coding was both deductive (using an initial explanatory framework derived from the literature and the PPPI group\\u0026rsquo;s experience) and inductive (responding to new points raised by interviewees); codes were recorded using NVIVO software. Codes were refined and combined as data collection continued, and sub-themes and themes were developed. A comparative analytic stage was added in which the differences and similarities between the participating neonatal units were identified within each theme. JM analysed all transcripts and FA analysed a subset; codes and themes were discussed and agreed. The researchers had no prior relationship with interviewees, and reflected critically on their own varied personal experiences of infant feeding and professional experiences of working in neonatal units caring for very preterm babies and their parents.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipants\\u003c/h2\\u003e \\u003cp\\u003eTwelve health professionals took part in interviews \\u0026ndash; three from each neonatal unit. Infant feeding specialists at each unit have not been separately identified to protect confidentiality. Interviews lasted 35\\u0026ndash;64 minutes (mean 45 minutes). Participants\\u0026rsquo; pseudonyms and occupations are shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eParticipating units and interviewees\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnit pseudonym\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLevel of neonatal care\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRate of very preterm babies receiving breast milk at discharge, compared to England average*\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRate of breastfeeding initiation in local population, compared to England average**\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eInterviewee pseudonym\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eOccupation\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnit A\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLocal Neonatal Unit\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigher rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAbove average\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eA01\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eA02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eAllied health professional\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eA03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eDoctor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnit B\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNeonatal Intensive Care Unit\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHigher rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAverage\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eB01\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eB02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eB03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnit C\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLocal Neonatal Unit\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eLower rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eBelow average\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eC01\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eC02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eC03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMidwife\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnit D\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eNeonatal Intensive Care Unit\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eLower rate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAverage\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eD01\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eD02\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eNurse\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eD03\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eDoctor\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003e* Based on figures from the National Neonatal Audit Programme (\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e)\\u003c/td\\u003e\\u003c/tr\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003e**Based on the last published figures for breastfeeding initiation by NHS Trust (\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e)\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFindings\\u003c/h2\\u003e \\u003cp\\u003eFive topic-based themes were developed to describe the differences between the neonatal units in how they supported breast milk feeding and breastfeeding for very preterm babies, shown with subthemes in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. The first two relate to the organisation of the neonatal unit (\\u0026lsquo;The role of the infant feeding specialist\\u0026rsquo; and \\u0026lsquo;Achieving a whole team approach to breast milk feeding\\u0026rsquo;), and the remaining three relate to key points in the feeding journey (\\u0026lsquo;Supporting initiation of expressing\\u0026rsquo;, \\u0026lsquo;Supporting long-term expressing\\u0026rsquo; and \\u0026lsquo;Supporting the transition to breastfeeding\\u0026rsquo;.)\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e \\u003cb\\u003egoes here\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e \\u003cb\\u003eThemes and subthemes\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eThe role of the infant feeding specialist\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eTime allocated to infant feeding support\\u003c/h2\\u003e \\u003cp\\u003eAll interviewees highlighted that neonatal staff were generally too busy to give mothers timely and consistent help with expressing and breastfeeding.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;It is hard with the workload\\u0026hellip;we don\\u0026rsquo;t have the time to sit there and go through expressing with mums. If the mum\\u0026rsquo;s very confident with expressing she\\u0026rsquo;ll do really well, but for a mum that\\u0026rsquo;s not very confident, she won\\u0026rsquo;t.\\u0026rdquo;\\u003c/em\\u003e C01\\u003c/p\\u003e \\u003cp\\u003eAll the units had some staff who were designated as infant feeding specialists or leads, but the ways these roles were organised varied greatly. At Unit A, the infant feeding lead had 15 hours a week for this role, and had only basic training; a lactation consultant who was formerly part of the team had not been replaced. At Unit B, there was well-developed infant feeding team including a supernumerary full-time nurse dedicated to infant feeding support. Staff felt this role had made an enormous difference to the practical and motivational support offered to mothers.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Her role is purely to support mums who are expressing, breastfeeding and bottle feeding. She sees these mums on a regular basis, there's that one person that all mums will have consistent information from. We\\u0026rsquo;ve definitely seen an increase in mums who are expressing, but also who are expressing for a lot longer.\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003cp\\u003eAt Unit C, there were breastfeeding link nurses on the unit with little dedicated time. The main support was provided by an infant feeding midwife, but she was not encouraged to spend time on the neonatal unit except to support mothers who had just given birth and were therefore under the care of the midwifery team, and her time could be reallocated to fill maternity shortages:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We do visit the neonatal unit if we\\u0026rsquo;re asked to, however I'm paid by maternity services, so it's coming out of the maternity budget not the neonate budget \\u0026hellip; I can be taken off to go and do clinical and get my own patients and for that day there's no [infant feeding support].\\u0026rdquo;\\u003c/em\\u003e C03\\u003c/p\\u003e \\u003cp\\u003eAt Unit D there was also very little staff time dedicated to feeding support, with the infant feeding nurse having only 7.5 hours a week for her role.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;None of us [in the infant feeding team] are supernumerary \\u0026hellip; We all have other jobs to do. And whilst I would absolutely adore to go and help mum straight after delivery and say, \\u0026lsquo;This is your golden hour \\u0026hellip; this is when to start asking your boobs to start making milk,\\u0026rsquo; I\\u0026rsquo;m actually usually ventilating the baby and putting lines in, so I can't do both.\\u0026rdquo;\\u003c/em\\u003e D03\\u003c/p\\u003e \\u003cp\\u003eAt Units C and D, staff also highlighted that there was no consistent way to ensure that mothers who needed support were seen by the specialist, or of alerting an infant feeding midwife to a new neonatal admission of a very preterm baby:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;If I found a mum who was really struggling with it, at that point we can ask an infant feeding sister to see that mum, but we don\\u0026rsquo;t have a specific referral process for that, that would just be me off my own back trying to find the infant feeding sister.\\u0026rdquo;\\u003c/em\\u003e D02\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSupportive relationships and proactive, personalised support\\u003c/h2\\u003e \\u003cp\\u003eInterviewees reflected on the ways in which an infant feeding specialist role could help mothers. Staff in Units A and B highlighted the benefits of being able to build a relationship over time with a mother, and taking responsibility for personalised continuity of care through the different stages of a mother\\u0026rsquo;s feeding journey.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;What we\\u0026rsquo;ve changed massively is having that person who takes ownership to support these mums \\u0026hellip;I make a plan with my mums. I will know where each mum is at in her journey \\u0026hellip; I can just sit and hold their hands if baby is poorly\\u0026hellip; If that mum needs me for an hour, I can sit with that mum for an hour.\\u0026rdquo;\\u003c/em\\u003e B03\\u003c/p\\u003e \\u003cp\\u003eAnother valued aspect of specialist roles at all units was that these staff proactively talked to mothers about how their expressing or breastfeeding was going, which was not necessarily something for which mothers felt able to seek help from busy nurses who were focused on clinical tasks.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Being around to check in on them and see how they\\u0026rsquo;re doing and explaining things to them. A lot of these mums tend to talk to me about how they\\u0026rsquo;re feeling in general because I\\u0026rsquo;m a separate person to who\\u0026rsquo;s looking after their baby at that time.\\u0026rdquo;\\u003c/em\\u003e A01\\u003c/p\\u003e \\u003cp\\u003eInfant feeding specialists were able to have these conversations sensitively and in the context of wider relational support that was not solely focused on maximising milk volumes for the baby, but was also empathetic towards the mother as an individual.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;It\\u0026rsquo;s just being sensitive enough to recognise where the mum is as well and what the mum needs and how best to support that mum.\\u0026rdquo;\\u003c/em\\u003e A02\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eShared responsibility for feeding support\\u003c/h2\\u003e \\u003cp\\u003eStaff said that the effectiveness of a specialised role was maximised if the whole staff team saw support for breast milk feeding as a shared responsibility, with all staff understanding the importance of giving time-critical information and identifying mothers in need of additional help. However, staff at Units A, C and D reported that overstretched neonatal staff tended to over-rely on an under-resourced specialist who had limited availability, instead of incorporating basic feeding support into their own work. Consequently mothers could fall through the gaps.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Everybody pushes the responsibility of that particular role onto whoever else can do it. For instance, a woman has delivered the day before \\u0026hellip; she hasn\\u0026rsquo;t had the conversation [about early initiation], she\\u0026rsquo;s had nothing until an infant feeding midwife has come in the next day\\u0026hellip; Now that could have been anybody giving her that bonding pack [and] doing this conversation.\\u0026rdquo;\\u003c/em\\u003e C03\\u003c/p\\u003e \\u003cp\\u003eIt was also noted that mothers\\u0026rsquo; confidence could be inadvertently undermined if they were asked about volumes of milk by lots of members of staff, insensitively and without co-ordination.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;People have gone, \\u0026lsquo;How much milk are you getting every time you express? Oh, that\\u0026rsquo;s not enough you need to be getting this amount.\\u0026rsquo; \\u0026hellip; Some mums do then start to question whether they're doing enough. We've had that feedback before, that actually asking too much pushes them away.\\u0026rdquo;\\u003c/em\\u003e D01\\u003c/p\\u003e \\u003cp\\u003eTo help make feeding support a whole-team responsibility while lactation was being established, Unit A had introduced a structured assessment tool to ensure that mothers were consistently asked about expressing by whichever nurses were on shift, every day for the first week. Interviewees at Unit D believed that a similar approach would help their team, but this had been opposed by colleagues because of a perception that this would add to their workload.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;I tried to implement [an assessment checklist from Baby Friendly Initiative] but got told, \\u0026lsquo;No, we don\\u0026rsquo;t need more paperwork.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e D01\\u003c/p\\u003e \\u003cp\\u003eShared responsibility for feeding support without adequate training also created problems when staff gave mothers non-evidence based or inconsistent information. Although interviewees at all four units reported that some staff gave mothers conflicting information, it was a particular problem at Units C and D.\\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003e\\u0026ldquo;The information that parents get is quite different from person to person ... [Staff] give information based off their own experience or what they\\u0026rsquo;ve seen, not necessarily with a mum who\\u0026rsquo;s got a baby that\\u0026rsquo;s 25 weeks.\\u0026rdquo;\\u003c/em\\u003e D02\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAchieving a whole team approach to breast milk feeding\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eLeadership and the feeding culture\\u003c/h2\\u003e \\u003cp\\u003eInterviewees highlighted the importance of leadership in supporting cultural change around breast milk feeding on neonatal units. In particular, leadership was needed to change staff perspectives, for example moving beyond seeing breast milk only as food to seeing feeding as part of a relationship between mother and baby. At Units A and B there were active efforts to persuade staff to see support for parents as integral to the neonatal nursing role, and to promote full partnership between parents and staff (Family Integrated Care).\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;The family needs to be seen as the baby with parents [but] a lot of staff still like that little bit of control\\u0026hellip;.As [an infant feeding] group we\\u0026rsquo;ve got a very supportive matron. So it\\u0026rsquo;s very much a team effort\\u003c/em\\u003e \\u0026hellip; \\u003cem\\u003eto make things as positive as we can for families, and listening to their feedback as well.\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003cp\\u003eIn units where this leadership was not yet in place, staff who championed breast milk feeding described efforts to bring together a multi-disciplinary group and in particular to encourage buy-in from doctors and other senior staff:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Getting the right people on board, I think the higher you go, the better\\u0026hellip;That\\u0026rsquo;s usually how it goes, if you can get doctors or paediatricians on board then you can get changes.\\u0026rdquo;\\u003c/em\\u003e C03\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eUsing external standards as levers\\u003c/h2\\u003e \\u003cp\\u003eUnit B was actively working towards full Baby Friendly Initiative (BFI) accreditation (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e), and Unit D had registered to begin the process. Interviewees at all units believed that BFI could be an important lever to drive change within their units.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;BFI gives us a lot of access to educational tools and things that will help us, and I think it focuses the unit\\u0026rsquo;s culture in terms of \\u0026lsquo;watch our mouths\\u0026rsquo; when it comes to the language we use around breastfeeding and breast milk.\\u0026rdquo;\\u003c/em\\u003e D03\\u003c/p\\u003e \\u003cp\\u003eAt Unit C which was not engaged with BFI, an interviewee was trying to convince her colleagues to prioritise breast milk using other external standards, such as the PERIPrem bundle which includes promotion of maternal early breast milk (\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e) and the Saving Babies\\u0026rsquo; Lives care bundle for reducing perinatal mortality (\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;PERIPrem as a strategy, you have that as a leverage to say, \\u0026lsquo;Well, you're not doing this and that and the other\\u0026rsquo;... To say [to colleagues], \\u0026lsquo;This isn't about food, this is gut treatment, this is like giving the probiotics and the antibiotics.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e C03\\u003c/p\\u003e \\u003cp\\u003eAt Unit A, interviewees noted that external criteria such as those used by the National Neonatal Audit Programme were influential but could have unintended consequences when staff prioritised supporting breast milk feeding (which was recorded and reported) but not direct breastfeeding (which was not).\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We scored really high on all babies having breast milk, but in terms of babies actually being breastfed, we didn\\u0026rsquo;t do that well. I think because it\\u0026rsquo;s not something that\\u0026rsquo;s particularly measured, there\\u0026rsquo;s no funding attached to that, people are not maybe as vigilant or as committed to making it work.\\u0026rdquo;\\u003c/em\\u003e A03\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTraining for the multi-disciplinary team\\u003c/h2\\u003e \\u003cp\\u003eAt Unit B, neonatal infant feeding training for all staff was a priority, reflecting their engagement with Baby Friendly Initiative. At the other units, lack of training on expressing and breastfeeding specifically for very preterm babies was repeatedly mentioned as an obstacle to supporting mothers effectively.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;The long term expressing is so much more challenging because it takes a lot to keep going \\u0026hellip; The training that\\u0026rsquo;s provided by the midwives is not really helping in that sense for us nursing staff \\u0026hellip; They do a small portion on preterm babies but most of it\\u0026rsquo;s about full-term babies.\\u0026rdquo;\\u003c/em\\u003e A01\\u003c/p\\u003e \\u003cp\\u003eSpecific training on supporting mothers of very preterm babies was felt to be important for doctors as well as nurses, as some parents turned for advice to professionals who they perceived as more senior, to double check information given by nurses with more training:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;[Mums] say to a doctor, \\u0026lsquo;The nurse told me I should be expressing 20ml from each breast, is that correct?\\u0026rsquo; and the doctor goes, \\u0026lsquo;Yeah, whatever the nurse says,\\u0026rsquo; but that nurse might have given them the wrong information\\u0026hellip; I think if [doctors] had the same training as [nurses], that would be a real positive in terms of helping certain families who like that reassurance from somebody more senior.\\u0026rdquo;\\u003c/em\\u003e D02\\u003c/p\\u003e \\u003cp\\u003eInterviewees suggested that infant feeding training should also include communication skills because parents, who were trying to make sense of a confusing and stressful situation, were liable to read unintended meanings into what staff said.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Parents pick up on so much, staff sometimes think that parents aren't listening or aren't aware, but they are, they're full of adrenaline, they're very acute \\u0026hellip;[It\\u0026rsquo;s] a very frightening situation as well, very vulnerable \\u0026hellip; so I think body language is a massive thing. Use of words, definitely.\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003cp\\u003eInterviewees also acknowledged that training was not the whole solution: even where there was good investment in training, this was not necessarily enough to change the practices of some colleagues who were set in their ways.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;On our unit a lot of the staff have been there for a really long time and you can\\u0026rsquo;t change attitudes that are ingrained in people \\u0026hellip;We\\u0026rsquo;ve tried to address this because they\\u0026rsquo;ve been on training, they\\u0026rsquo;ve had the infant feeding coordinators come in to do specific training with them \\u0026hellip; so there\\u0026rsquo;s no excuse really.\\u0026rdquo;\\u003c/em\\u003e A03\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSupporting initiation of expressing\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eAttitudes to early initiation of expressing\\u003c/h2\\u003e \\u003cp\\u003eInterviewees at all four units were keen to motivate mothers to express their colostrum and then breast milk, by explaining its unique benefits for their very preterm babies. They encouraged mothers to start expressing milk irrespective of how they planned to feed their babies later.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;At the beginning my question to a mum isn't, \\u0026lsquo;How do you want to feed your baby?\\u0026rsquo; It's, \\u0026lsquo;Would you be willing to express your breast milk, because actually your milk is golden medicine for your baby?\\u0026rsquo; A 22-weeker, it doesn\\u0026rsquo;t matter how a mum wants to feed down the line \\u0026hellip; it's actually the importance of expressing that milk and getting that milk into the baby.\\u0026rdquo;\\u003c/em\\u003e D01\\u003c/p\\u003e \\u003cp\\u003eThey noted that this approach was often successful for mothers who had no intention of breastfeeding.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Once you explain to parents the importance of the breast milk, a lot of parents will change their mind \\u0026hellip; even if they don\\u0026rsquo;t go on to breastfeed but just give the milk by bottle\\u0026hellip;\\u0026lsquo;We didn\\u0026rsquo;t want to do this, but because my baby is poorly I\\u0026rsquo;ll do it for a little while.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e C02\\u003c/p\\u003e \\u003cp\\u003eInterviewees at all the units believed that it was beneficial, where possible, to talk to mothers before the baby was born about breast milk feeding and how to start expressing, as they might be too distressed to absorb this information after birth. At Unit B, the infant feeding nurse spent time with all pregnant women admitted to the hospital with the risk of premature birth. She explained feeding choices and the support available, underlined the importance of starting to express shortly after birth, and began to build a relationship with the mother that would continue throughout their baby\\u0026rsquo;s time on the neonatal unit.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;I sit with them and very gently ask them how I can support them with their choices of feeding. I go through the [feeding] pack, and I\\u0026rsquo;ll say to them, \\u0026lsquo;I will see you on the unit\\u0026rsquo;... The hardest thing for me is getting mums to hand express within that hour of babies being born, and so I go through the importance of it, I tell them that what we do at this stage will help their milk supply later down the road, and I ask them to ask the midwives to help them with the hand expressing very quickly after birth. I\\u0026rsquo;m almost giving them the confidence to say to someone, \\u0026lsquo;Please will you help me with hand expressing?\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e B03\\u003c/p\\u003e \\u003cp\\u003eAt Units A, C and D, interviewees said there was no capacity for neonatal staff to do this and no system to alert neonatal staff when pregnant women were admitted at risk of very preterm birth. They noted that obstetricians, midwives and neonatal staff who saw the mother antenatally or in the immediate postnatal period did not necessarily prioritise information about feeding:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;I find it's a battle\\u0026hellip; [Doctors] appreciate what breast milk is for a premature baby, but then they feel like it's not a priority to be telling mum straightaway ... I've had an incident yesterday, a 22-weeker born [at another hospital], transferred to us. The consultant has told the mum that she doesn\\u0026rsquo;t need to express overnight, \\u0026lsquo;Go and get some rest and we\\u0026rsquo;ll start tomorrow.\\u0026rsquo; That\\u0026rsquo;s then two days down the line, and actually that\\u0026rsquo;s not the right information to be sharing with a mum.\\u0026rdquo;\\u003c/em\\u003e D01\\u003c/p\\u003e \\u003cp\\u003eEven if breast milk feeding was generally promoted, staff might tell mothers who had a multiple birth that it would not be possible for them to feed all their babies.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;The attitude of that person probably would come into it, saying to the mum, \\u0026lsquo;You\\u0026rsquo;re not going to be able to feed two or three.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e A01\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eJoined-up working with the postnatal ward\\u003c/h2\\u003e \\u003cp\\u003eAt all four units there were challenges in the working relationships between the midwives caring for mothers on the postnatal ward, and staff caring for the babies on the neonatal unit. Interviewees believed that when midwives did not promote early expressing this could be due to lack of time, lack of understanding, or feeling protective of the wellbeing of the mother in the short term.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;There is quite a lot of resistance from the midwives, quite often the parents aren't shown how to express or encouraged to express on the wards \\u0026hellip; The midwives are very much, \\u0026lsquo;The women\\u0026rsquo;s their job, once the baby\\u0026rsquo;s born it's not their problem.\\u0026rsquo; \\u0026hellip; So, where we will say, \\u0026lsquo;Have a go at expressing, it's really important to get it started,\\u0026rsquo; then they go back up to the ward [and] they get the opposite, so it's not that consistent message.\\u0026rdquo;\\u003c/em\\u003e C02\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;The midwives have obviously got a lot of other things going on and being able to sit with [mothers] in a dedicated supportive fashion and teach them a brand new skill, it's time-consuming and sadly that time is not always freely available, gets interrupted, gets put off, or mum\\u0026rsquo;s tired because she\\u0026rsquo;s delivered and they go, \\u0026lsquo;We don\\u0026rsquo;t want to push her,\\u0026rsquo; and it gets delayed and delayed.\\u0026rdquo;\\u003c/em\\u003e D03\\u003c/p\\u003e \\u003cp\\u003eAt Unit C, there were also inconsistent policies between the neonatal unit and the postnatal ward on \\u003cspan type=\\\"Underline\\\" class=\\\"Underline\\\" name=\\\"Emphasis\\\"\\u003ehow\\u003c/span\\u003e best to initiate expressing after very preterm birth, leaving mothers confused in the middle.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We know that getting babies\\u0026rsquo; mums on the pump is beneficial right from the very beginning, and they're still being told by our midwifery team that you can't pump for 48 hours, you should just hand express for 48 hours... I had a mum where I said to her, \\u0026lsquo;Yes, go and pump now.\\u0026rsquo; \\u0026lsquo;But the midwife told me not to.\\u0026rsquo; I had to then talk her round that my point of view was correct.\\u0026rdquo;\\u003c/em\\u003e C02\\u003c/p\\u003e \\u003cp\\u003eAt Units A and B, the infant feeding specialist from the neonatal unit would visit mothers on the postnatal ward to proactively offer support with early initiation of expressing. They had to overcome initial opposition from postnatal staff and build trust to be \\u0026lsquo;allowed\\u0026rsquo; to support mothers:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;It was very much \\u0026lsquo;them and us\\u0026rsquo; \\u0026hellip; To begin with when I went over to [the postnatal ward] they were a little bit, \\u0026lsquo;Who is this? Why is she interfering?\\u0026rsquo; But now they know I\\u0026rsquo;m a great help to them, because they\\u0026rsquo;re really busy on that unit, so if I can go in and sit with that mum and talk to her about hand expressing or set her up on a pump, I\\u0026rsquo;m taking a job away from them which is another job that they\\u0026rsquo;re sometimes struggling to get round to doing.\\u0026rdquo;\\u003c/em\\u003e B03\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSupporting long term expressing\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec18\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003ePositive feedback\\u003c/h2\\u003e \\u003cp\\u003e Interviewees at all four units said that giving mothers praise and positive feedback was important at all stages to reinforce their motivation, but they particularly emphasised the challenges mothers faced in expressing for weeks or months before a very preterm baby was able to feed orally.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;I think a constant reinforcement of the importance of her breast milk, and also the fact that we recognise mums, how hard it is and how laborious it must be, and how committed they are in order to provide breast milk for their baby for such a long period of time.\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003cp\\u003eHowever this promotion of breast milk had to be handled sensitively, as some mothers were unable to produce enough milk or found it too difficult to keep up the demanding schedule of expressing, particularly if they were looking after other children. Interviewees recognised that worrying about maintain and increasing the milk supply could in itself reduce the milk supply, and some continued to emphasise the process rather than the amount of milk produced.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We try to take the pressure off, because it is a lot of pressure\\u0026hellip; The more they stress, the less they produce because they\\u0026rsquo;re thinking about, \\u0026lsquo;Oh, we need 300 ml.\\u0026rsquo; \\u0026hellip; So we say, \\u0026lsquo;Just do what you can and the baby will get fed anyway.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e C01\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eTroubleshooting challenges\\u003c/h2\\u003e \\u003cp\\u003eAt all the units, specialist staff responded to mothers\\u0026rsquo; milk supply difficulties by personalised troubleshooting with them to consider ways they could increase lactation, such as lifestyle changes (eating well and resting), spending time skin-to-skin with the baby, power pumping, pumping regularly including at night, and taking medication.\\u003c/p\\u003e \\u003cp\\u003eWhen a mother was highly motivated but her milk supply remained insufficient to meet her baby\\u0026rsquo;s needs, or she stopped expressing while her baby was still on the neonatal unit, specialist staff tried to support the mother to avoid feeling she had failed her baby, by helping her to understand possible reasons and to focus on what she had achieved.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;It may help them come to terms with the fact that what they're doing is absolutely fantastic, but we've perhaps got to the limit of what they're going to be able to do. \\u0026hellip;Going through their history, going through what they\\u0026rsquo;ve done since they started to express, they can then visualise, \\u0026lsquo;Actually, I've done everything you\\u0026rsquo;ve asked me to do and obviously my body is not going to be able to do anything more.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eProvision of breast pumps and facilities\\u003c/h2\\u003e \\u003cp\\u003eThere were differences between units in the equipment provided to support expressing milk. Unit D had fewer pumps than cots so mothers had to queue to express milk if the pumps were in use:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We don\\u0026rsquo;t have enough pumps on the unit, ideally it\\u0026rsquo;s a pump per space, isn't it? That would be great. But actually, let's go for a pump in each bay and then have the expressing room kitted out with pumps\\u003c/em\\u003e.\\u0026rdquo; D01\\u003c/p\\u003e \\u003cp\\u003eUnits B, C and D had hospital grade breast pumps to lend to mothers for expressing at home while their baby was on the unit, but Units C and D did not have robust systems for monitoring the return of these free loans, and at both sites most of the loaned pumps were currently missing.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;All our breast pumps that we had to loan to parents have disappeared. Our housekeeper is currently trying to phone round parents to find out where they\\u0026rsquo;ve gone\\u003c/em\\u003e.\\u0026rdquo; C02\\u003c/p\\u003e \\u003cp\\u003eAll of the units had a separate room where mothers could express milk, but interviewees noted that these were not particularly comfortable places where mothers would feel relaxed, which would encourage milk flow. They also said that while they encouraged mothers to express beside their babies, this could be difficult if the unit had not been designed with this in mind, and the cots were in a noisy, crowded environment with little privacy.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We don\\u0026rsquo;t have a lot of space on our unit, so I don't think parents feel that they can sit and express cot-side very often \\u0026hellip; It's a very noisy, stressful environment...We don\\u0026rsquo;t have curtains, we only have screens on wheels, which aren't the greatest and they're not always available.\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSupporting the transition to breastfeeding\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec22\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eAttitudes to direct breastfeeding\\u003c/h2\\u003e \\u003cp\\u003eThe units had different levels of success in supporting mothers to begin directly breastfeeding when their babies were developmentally ready, and these reflected different staff attitudes. Breastfeeding was strongly supported at Unit B, where there was intensive support from specialist staff to help mothers and babies transition to breastfeeding. Mothers were supported to introduce babies to the breast at a much earlier stage than in the other units, which was believed to be motivating as well as enabling mothers and babies to learn the practical skills of breastfeeding over a much longer period.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;If I\\u0026rsquo;ve got a 28-weeker who is stable, I look at all the observations, I\\u0026rsquo;ll also talk to the medical team \\u0026hellip;I always ask mums to pump first, so the baby is going to go onto an empty breast, they\\u0026rsquo;re just sucking and might get just a small amount \\u0026hellip; I think it\\u0026rsquo;s so important that these babies start tasting, and the closeness as well for mum. All that hard work these mums have done to get to this point, so they feel that they\\u0026rsquo;re getting somewhere.\\u0026rdquo;\\u003c/em\\u003e B03\\u003c/p\\u003e \\u003cp\\u003eAt Unit A, breast milk feeding was a high priority for the wider staff team but encouraging direct breastfeeding was not: \\u003cem\\u003e\\u0026ldquo;Generally people are not so positive with breastfeeding, it\\u0026rsquo;s sort of seen as, \\u0026lsquo;Yes, if they want to breastfeed, that\\u0026rsquo;s fine.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e A01\\u003c/p\\u003e \\u003cp\\u003eLikewise at Units C and D, establishing breastfeeding was not seen as particularly important or even feasible, compared to bottlefeeding with expressed milk.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;I don\\u0026rsquo;t think we\\u0026rsquo;ve recently had many mums go home exclusively breastfeeding and I don\\u0026rsquo;t blame them to be honest, it\\u0026rsquo;s just really hard when you\\u0026rsquo;ve got a baby on the neonatal unit \\u0026hellip; I think most mums are happy if it\\u0026rsquo;s their milk to bottle feed anyway.\\u0026rdquo;\\u003c/em\\u003e C01\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec23\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eOvercoming separation of mothers and babies\\u003c/h2\\u003e \\u003cp\\u003e All of the units had transitional care rooms where parents could stay immediately before their baby was discharged, but none had space for all parents to routinely room-in. Staff at all four units said that having only limited facilities for parents to stay on site was particularly problematic at the point where the mother was trying to establish direct breastfeeding, and therefore needed to be with her baby as much as possible.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;If we had more facilities where the mums could room-in and establish breastfeeding 24/7 they might be more successful with exclusive breastfeeding, but we\\u0026rsquo;ve only got two parent bedrooms and the mum is only there at the time of discharge.\\u0026rdquo;\\u003c/em\\u003e C01\\u003c/p\\u003e \\u003cp\\u003eAt Unit A, night staff were reported to obstruct mothers\\u0026rsquo; attempts to spend time with their babies on the ward to breastfeed at night.\\u003c/p\\u003e \\u003cp\\u003e\\u0026ldquo;\\u003cem\\u003eThey don\\u0026rsquo;t want mums on the unit at night, because one of them even said to the mum, \\u0026lsquo;This is not a hotel, you can\\u0026rsquo;t come and go as you please.\\u0026rsquo;\\u0026rdquo;\\u003c/em\\u003e A03\\u003c/p\\u003e \\u003cp\\u003eAt Unit B, mothers were encouraged to room-in while they were establishing breastfeeding, but there could be competing needs for the limited rooms such as accommodating the parents of a critically ill baby. To avoid the problem of separation the unit had changed their discharge criteria so that mothers could establish breastfeeding at home with the support of an an outreach team:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;As soon as baby starts to show feeding cues for breastfeeding \\u0026hellip; we will get that mum to come in and stay until their baby goes home\\u0026hellip; It used to be the fact that [to be discharged] babies had to be having half and half, so half their requirements would be either by the bottle or by the breast, and then the other half could be down the tube \\u0026hellip; Things have now changed where [with] our outreach team, as soon as the baby is having at least one breastfeed a day and we can see effective feeding and mum recognises effective feeding, then we get that baby home for her then to establish her breastfeeding at home.\\u0026rdquo;\\u003c/em\\u003e B02\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec24\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eBreastfeeding as the only oral feeding\\u003c/h2\\u003e \\u003cp\\u003eAt all four units there was pressure from some staff for mothers to agree to give expressed milk or formula by bottle to babies who were developmentally ready to begin oral feeding, rather than continuing partial tube feeds while the mother and baby established breastfeeding. Staff typically proposed this as a solution when breastfeeding was slow to be established, or because of their desire to respond to the baby\\u0026rsquo;s feeding cues when the mother was not on the unit (and none of the units used cup feeding as an alternative).\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;If a baby\\u0026rsquo;s awake and rooting for a feed, we ask the mum would she consent to a bottle feed, because it\\u0026rsquo;s not nice tube feeding a baby that\\u0026rsquo;s awake and wanting a feed.\\u0026rdquo;\\u003c/em\\u003e C01\\u003c/p\\u003e \\u003cp\\u003ePressure to introduce bottles could also be driven by a lack of time or skills to support the transition to breastfeeding, which could be a long process for a very preterm baby.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Because of our short staffing the priority of most people is to do those things like basically keeping the babies alive, and although breastfeeding is an addition to helping them thrive, it's not in that moment going to keep them alive.\\u0026rdquo;\\u003c/em\\u003e D02\\u003c/p\\u003e \\u003cp\\u003eThis pressure could undermine mothers\\u0026rsquo; resolve to breastfeed, and some staff were also reported to make unhelpful critical comments to mothers who were trying to establish breastfeeding.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;It\\u0026rsquo;s a difficult culture to change because the staff are quite fixated on \\u0026lsquo;The baby needs to bottle feed and if the baby\\u0026rsquo;s looking to suck, why are we not offering bottles\\u0026rsquo;?\\u0026rsquo; \\u0026hellip; [They] make the mum feel really bad about wanting to breastfeed or that she\\u0026rsquo;s not there in the evenings, so it makes it very difficult and very uncomfortable, then all the work that you have done before gets undone, and this has happened on numerous occasions.\\u0026rdquo;\\u003c/em\\u003e A02\\u003c/p\\u003e \\u003cdiv id=\\\"Sec25\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eMaintaining confidence without measuring volume\\u003c/h2\\u003e \\u003cp\\u003eSome parents and staff preferred to introduce bottles of expressed milk or formula rather than establish breastfeeding, because there was an objective measure of the volume of milk a baby had taken. Interviewees said they tried to reassure parents about other ways of assessing the efficacy of a breastfeed, but this was time-consuming.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Parents get very institutionalised with focusing on numbers, so if they can see that the baby\\u0026rsquo;s had a certain number [of ml] then they feel less anxious, whereas a breastfeed you're not seeing any numbers \\u0026hellip;You\\u0026rsquo;ve got to find other things to make them feel confident in what they're doing. It's time again, just spending time with them.\\u0026rdquo;\\u003c/em\\u003e B01\\u003c/p\\u003e \\u003cp\\u003eLess experienced staff might undermine mothers\\u0026rsquo; confidence by communicating their own desire for certainty:\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;On the NICU [neonatal intensive care unit] it\\u0026rsquo;s all about numbers, isn't it? \\u0026hellip; Some staff members, they\\u0026rsquo;re more interested in the figures, how many mls a baby has had. With more experience you know whether a baby has [breast]fed properly or not.\\u0026rdquo;\\u003c/em\\u003e C01\\u003c/p\\u003e \\u003cp\\u003eOnce a mother had begun direct breastfeeding, nurses typically used a time-based rating scale to assess the efficacy of a feed and thus the amount of top-up that would be given by tube. However, some interviewees said that that these mechanistic ways of assessing breast milk transfer were flawed, and again the key support was to build a mother\\u0026rsquo;s own confidence to assess a feed by observing the baby and her own bodily sensations.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;There's a general expectation that there's some kind of linear relationship between the length of a feed and how much milk has been taken in, and as many times as I tell them that\\u0026rsquo;s complete nonsense, [the nurses] still ask me. Because they want a plan \\u0026hellip; I talk to the parents about how their breasts are feeling before, during and after a feed, what the babies look like when they're feeding, are they actively feeding or are they having a few sucks and then drifting off to sleep?\\u0026rdquo;\\u003c/em\\u003e D03\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec26\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eReassurance about weight gain\\u003c/h2\\u003e \\u003cp\\u003eAll the interviewees were aware that it was normal for babies\\u0026rsquo; weight gain to falter briefly when they began to fully breastfeed, for several reasons: the baby would be using more energy on feeding and would be tired; the baby was now in control of feeding rather than being fed a predetermined amount of milk on a predetermined schedule; and whereas breast milk fortifier was usually added to expressed breast milk as a nutritional supplement, the baby did not receive these extra nutrients when feeding directly from the mother\\u0026rsquo;s breast. Interviewees tried to reassure parents that temporary slowing of growth was normal, but they described interactions where colleagues had undermined mothers\\u0026rsquo; confidence by telling them that that this was a sign that breastfeeding was not succeeding, so top-ups should be given.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Sometimes the difficulty has been where mum has mostly established breastfeeding, and the baby has maybe dropped 50g, and then [staff say], \\u0026lsquo;Oh well, you need to top up with a bottle or you need top up with a tube.\\u0026rsquo; And then it\\u0026rsquo;s all panic stations.\\u0026rdquo;\\u003c/em\\u003e A03\\u003c/p\\u003e \\u003cp\\u003eInterviewees had conflicting opinions about whether or not it was true that babies would go home a few days more quickly if they were bottlefed than if they were breastfed. These were linked to perceptions of babies\\u0026rsquo; ability to master these different feeding skills, how much time an individual mother was able to spend on the unit, and unit policies that required weight gain with oral feeding before a baby could be discharged.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;They're absolutely desperate to get home, and it doesn\\u0026rsquo;t help that the chitchat in the unit and in the parents\\u0026rsquo; room is all about how they're quickest to feed when they're bottlefed \\u0026hellip; It's only a matter of days, but if you\\u0026rsquo;ve been in hospital for three months probably every day counts.\\u0026rdquo;\\u003c/em\\u003e D03\\u003c/p\\u003e \\u003cp\\u003eOn Unit B, fully breastfed babies could be given a \\u0026lsquo;shot\\u0026rsquo; of breast milk fortifier just before a breastfeed to help maintain their growth. As described above, this unit had an early discharge policy that did not require weight gain before discharge but enabled mothers to initiate breastfeeding on the unit, and their babies to be discharged primarily tube feeding, so that breastfeeding could be established at home with the support of an outreach team.\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eComparing the experiences and views of staff at four neonatal units in England has revealed substantial variation in support for breast milk feeding for very preterm babies across different time points in the neonatal feeding journey from pre-admission to discharge, despite the same guidance, quality improvement tools and accredited standards being available to all units (\\u003cspan additionalcitationids=\\\"CR17 CR18\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). Unit B, which had a higher rate of breast milk feeding at discharge compared with other neonatal units in England despite an average breastfeeding initiation rate in the local population, had committed leadership, a dedicated full time infant feeding specialist who saw mothers on the antenatal and postnatal wards as well as the neonatal unit, regular infant feeding training for all staff, and a culture of Family Integrated Care. Unit A, which had a higher rate of breast milk feeding at discharge that may have been influenced by an above average rate of breastfeeding initiation in its local population, had an infant feeding specialist with 15 hours a week of protected time. Staff at Unit A said that their high rate of breast milk feeding at discharge masked a low rate of direct breastfeeding, which was not an indicator measured by the National Neonatal Audit Programme, although it is recorded in neonatal electronic healthcare records.\\u003c/p\\u003e \\u003cp\\u003eUnits C and D had a lower rate of breast milk feeding at discharge and an average (Unit D) or below average (Unit C) breastfeeding initiation rate in the local population. There was minimal protected time allocated to the infant feeding specialist role (Unit D) or reliance on an infant feeding midwife from the postnatal ward (Unit C). Despite the commitment of individual members of staff, there was no strategic leadership or systematic support for breast milk feeding and breastfeeding across these units, and some staff were fatalistic in their perception that exclusive direct breastfeeding at discharge was an almost unattainable goal for a very preterm baby. These issues resulted in missed opportunities to support mothers effectively at each point on the feeding timeline, echoing the findings of Shattnawi (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e) that overworked neonatal staff saw breastfeeding promotion as \\u0026lsquo;a nicety instead of a necessity\\u0026rsquo; and abdicated the responsibility to support mothers to others.\\u003c/p\\u003e \\u003cp\\u003eTo achieve cultural change, Bliss recommends that each neonatal unit should have a dedicated lead professional to champion the issue and support mothers, and also that feeding should be seen as an issue for the multidisciplinary team, who should be trained on the benefits of breast milk, lactation physiology, and how to support parents (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). The experience of these four neonatal units illustrates the importance of these two recommendations being implemented together. Where the lead professional role existed but was under-resourced, inadequately trained staff would nonetheless treat support for breast milk feeding and breastfeeding as the responsibility of the lead, whether or not the lead was present on the ward. The support and information that staff gave parents was uncoordinated and inconsistent, and the time-critical optimal window for initiating lactation could be missed. By contrast, an adequately-resourced infant feeding lead could build an empathetic relationship with mothers that enabled her to give proactive, personalised, and consistent feeding support throughout the very preterm babies\\u0026rsquo; time on the neonatal unit. Where this role was part of a core infant feeding team and embedded in a multi-disciplinary staff team who regularly took part in infant feeding training that was specifically relevant to preterm babies, mothers could be effectively supported to initiate and sustain prolonged expressing and then to transfer to direct breastfeeding, which is associated with longer term breast milk feeding after leaving the neonatal unit (\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). The importance of protected time for the infant feeding lead role has been recognised in guidance (\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e), but current guidance does not specify specialist staffing levels (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e), leading to extreme variation in the allocated hours, banding and job descriptions between neonatal units in England (Personal communication from Karen Read, Neonatal Professional Lead for UNICEF Baby Friendly Initiative, shared with permission).\\u003c/p\\u003e \\u003cp\\u003eAlthough there has been a policy focus in England on improving information sharing and partnership working between midwives and health visitors in the community (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e), there has not been a similar focus on partnership between midwifery and neonatal care. This study has highlighted the gaps for mothers antenatally if the neonatal team were not aware of admissions of mothers at risk of very preterm birth, and postnatally if there was no joined-up working between midwives caring for the mother on the postnatal ward and the neonatal team caring for the baby, contrary to guidance from the Baby Friendly Initiative (BFI) standards (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). In some cases mothers were given directly contradictory advice by nurses and midwives about when or how to start expressing, or midwives were actively opposed to neonatal infant feeding staff supporting \\u0026lsquo;their\\u0026rsquo; mothers on the postnatal ward. Some neonatal units in Sweden offer \\u0026lsquo;couplet care\\u0026rsquo;, where mothers (including those with complex medical needs) stay on the neonatal ward from birth and receive postnatal care for their own recovery there (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). In this model it is the postnatal team who which moves around the hospital, rather than the mother. While most English neonatal units lack the space and resources to reorganise care this way, neonatal and maternity staff could commit to joint working to provide integrated care for the mother-baby dyad, recognising both the mother\\u0026rsquo;s own need to rest and recover and importance of the mother starting to express milk within two hours after very preterm birth in order to optimise her chance of reaching and maintaining a full supply (\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003ePrevious research on training neonatal nurses in breastfeeding support for preterm babies found that this significantly increased the rate of preterm babies who were exclusively breastfed at discharge (\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). This study indicates the importance of extending training to neonatal doctors and the whole multi-disciplinary team, and indeed to any health professionals involved in intrapartum care, fetal medicine and perinatal care, as recommended by the National Neonatal Audit Programme (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e). This can ensure that mothers who experience very preterm birth are given information about early initiation of expressing at the first appropriate opportunity by whichever health professional is caring for them; that they receive consistent information and support about sustaining expressing from any staff members they encounter; and that they are enabled to transfer to direct breastfeeding without being undermined by a focus on weight gain or inflexible discharge criteria. Training could also address the challenge for nurses of how to feed an older baby who is showing sucking behaviour but whose breastfeeding mother is not able to be on the unit for all of the baby\\u0026rsquo;s feeds.\\u003c/p\\u003e \\u003cp\\u003eIt is well established that physical separation of parents and their baby in neonatal care is one of the causes of breastfeeding difficulties as well as delays in establishing the parenting relationship (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e). Parents\\u0026rsquo; experiences are very different in units where they are able to stay with their babies all the time, either in a private single family room or with a cotside bed or reclining chair that they are encouraged to see as their own space (\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e). Accommodating parents on the neonatal unit can facilitate Family Integrated Care where the family is seen as a team led by the very preterm baby, and the role of staff is conceptualised as supporting and guiding the family team in their feeding process (\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e). It has, however, also been noted that sleeping next to their baby may compromise the quality of parents\\u0026rsquo; sleep because of staff activity and noise; therefore parents\\u0026rsquo; mental health may be better protected by being offered a sleep space that is near but not with their baby (\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e None of the units in this study had the space or facilities to routinely offer parents the ability to room-in with their babies until just before discharge. Staff said this both hampered the establishment of direct breastfeeding, and discouraged some mothers from even trying, because they believed their baby was likely to meet the discharge criteria about oral feeding and weight gain sooner if bottlefed, as also reported by Bonet et al (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e) for French and English neonatal units. Unit B had addressed this issue in two ways: firstly by encouraging mothers to start putting their babies to the breast much earlier so that the transition to breastfeeding was a gentle process of familiarisation and closeness long before there was any meaningful feeding; and secondly by changing their discharge criteria so that a baby could be discharged before oral feeding was fully established. This meant that mother and baby could establish breastfeeding at home without separation, with the support of an outreach team from the neonatal unit. This system contrasts with the policies in Italy reported by Bonet et al (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e), where very preterm babies were bottlefed on the neonatal unit before being discharged to begin breastfeeding at home. There is as yet no evidence on the impact of Unit B\\u0026rsquo;s approach on mothers\\u0026rsquo; ability to sustain longer term direct breastfeeding for very preterm babies, and this could be a topic for future research.\\u003c/p\\u003e \\u003cp\\u003eIrrespective of facilities for rooming in, the BFI standards require that parents should have 24-hour access to their babies, consistent with valuing them as partners in care, with policies in other paediatric settings, and with the Convention on the Rights of the Child article 9.1: \\u0026ldquo;a child shall not be separated from his or her parents against their will\\u0026rdquo; (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e). Although all four units adhered to this principle in theory, some night staff at Unit A were reported to create an unwelcoming environment for parents, whose presence they found annoying, similar to some staff observed by Shattnawi (\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). This underlines the importance of building a culture of support for feeding as part of Family Integrated Care throughout the whole neonatal team.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec28\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStrengths and limitations\\u003c/h2\\u003e \\u003cp\\u003e It was a strength of this study that it involved health professionals from a range of professional backgrounds, working in four different neonatal units of different types in England and with different local population breastfeeding rates, so giving insight into the successful and less successful implementation of national policy and practice recommendations. The interviewees included both staff with a lead responsibility for supporting feeding for very preterm babies and staff with general clinical responsibilities. It was a limitation that all the staff who volunteered to be interviewed had a positive personal attitude to breast milk feeding and breastfeeding, so information about staff with less positive attitudes relied on interviewees\\u0026rsquo; descriptions of colleagues.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThere are different challenges for health professionals in supporting mothers of very preterm babies at different stages of their feeding journey, but the variation in practice in this study shows that there is much to learn from neonatal units that have high rates of breast milk feeding at discharge. Effective support can be influenced by having a supernumerary post dedicated to infant feeding; strong leadership that champions breast milk feeding and breastfeeding within family integrated care; maintaining accountability by using existing quality improvement tools and accredited standards for neonatal units; and training for the whole multi-disciplinary team that encourages and enables every member of staff to take an appropriate share of responsibility for consistently informing and assisting mothers when the specialist is not available. National guidance could define recommended staffing levels for infant feeding support. Even when neonatal units do not have rooms for parents to live with their preterm babies throughout their stay, unit policies can support the transition to direct breastfeeding by encouraging mothers to start the process at the earliest opportunity, and minimise separation by supporting mothers to establish breastfeeding at home rather than requiring full oral feeding as a criterion of discharge. Joined-up working between staff on antenatal and postnatal wards and neonatal units can enable integrated feeding support for the mother-baby dyad, overcoming the risk of staff seeing the mother\\u0026rsquo;s and baby\\u0026rsquo;s needs as unconnected or opposed. The National Neonatal Audit Programme could consider reporting the rate of exclusive direct breastfeeding at discharge in addition to breast milk feeding, so that this transition is treated with equal importance.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eEthical approval and consent\\u003c/h2\\u003e\\n\\u003cp\\u003eThe Health Research Authority East of England \\u0026ndash; Essex Research Ethics Committee (reference 21/EE/0144) approved the study. \\u003cstrong\\u003eInformed consent was obtained from all subjects and all methods were carried out in accordance with relevant guidelines and regulations.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ch2\\u003eConsent to publish\\u003c/h2\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003ch2\\u003eAvailability of data and materials\\u003c/h2\\u003e\\n\\u003cp\\u003eThe datasets generated during the current study are not publicly available due to the consent process but are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003ch2\\u003eConflict of interest\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors declare they have no competing interests.\\u003c/p\\u003e\\n\\u003ch2\\u003eFunding\\u003c/h2\\u003e\\n\\u003cp\\u003eThis research is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Maternal and Neonatal Health and Care, PR-PRU-1217-21202. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\\u003c/p\\u003e\\n\\u003ch2\\u003eAuthors\\u0026rsquo; contributions\\u003c/h2\\u003e\\n\\u003cp\\u003eJM, FA, CG and JK designed the study. \\u0026nbsp;JM conducted the interviews and analysed the data, and FA and AA analysed a subset of the data. JM wrote the first draft, and all authors reviewed and agreed the final version of the manuscript.\\u003c/p\\u003e\\n\\u003ch2\\u003eAcknowledgements\\u003c/h2\\u003e\\n\\u003cp\\u003eThank you to the staff who took part in this study, and to our PPPI contributors: Josie Anderson (BLISS), Jane Denton (Multiple Births Foundation), and Janet Rimmer (Twins Trust).\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMenon G, Williams TC. Human milk for preterm infants: why, what, when and how? Archives of Disease in Childhood -. Fetal Neonatal Ed. 2013;98(6):F559.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTudehope DI. Human Milk and the Nutritional Needs of Preterm Infants. J Pediatr. 2013;162(3):S17\\u0026ndash;25.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eIkonen R, Paavilainen E, Kaunonen M. Preterm Infants' Mothers' Experiences With Milk Expression and Breastfeeding: An Integrative Review. Adv Neonatal Care. 2015;15(6):394\\u0026ndash;406.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBonet M, Blondel B, Agostino R, Combier E, Maier RF, Cuttini M, et al. Variations in breastfeeding rates for very preterm infants between regions and neonatal units in Europe: results from the MOSAIC cohort. Archives Disease Child - Fetal Neonatal Ed. 2011;96(6):F450.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMerewood A, Brooks D, Bauchner H, Macauley L, Mehta SD. 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Child (Basel Switzerland). 2021;9(1).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNational Neonatal Audit Programme. 2019 annual report on 2018 data. RCPCH:London; 2019.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLandridge D. Phenomenology and Critical Social Psychology: Directions and Debates in Theory and Research Soc. Personal Psychol Compass. 2008;2(3):1126\\u0026ndash;42.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePidgeon N, Henwood K. Using grounded theory in psychological research. In: Hayes N, editor. Doing qualitative analysis in psychology. Hove: Psychology; 1997.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNational Neonatal Audit Programme. 2019 report on 2018 data, data file. 2019.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNHS England. NHS England Statistical Release Breastfeeding Initiation, Quarter 4 2016/17. 2017.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHealth Innovation West of England. PERIPrem undated [ \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.healthinnowest.net/our-work/transforming-services-and-systems/periprem/\\u003c/span\\u003e\\u003cspan address=\\\"https://www.healthinnowest.net/our-work/transforming-services-and-systems/periprem/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNHS England. Saving babies\\u0026rsquo; lives: version 3 2023 [ \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.england.nhs.uk/long-read/saving-babies-lives-version-3/\\u003c/span\\u003e\\u003cspan address=\\\"https://www.england.nhs.uk/long-read/saving-babies-lives-version-3/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePublic Health England DoH. Health visiting and midwifery partnership \\u0026ndash; pregnancy and early weeks. 2015.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePublic Health England. Care continuity between midwifery and health visiting services: principles for practice. 2021.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWestrup B. Family-centered developmentally supportive care: the Swedish example. Arch Pediatr. 2015;22(10):1086\\u0026ndash;91.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLi X, Li Y, Qian L, Han P, Feng H, Jiang H. Mothers' experiences of breast milk expression during separation from their hospitalized infants: a systematic review of qualitative evidence. BMC Pregnancy Childbirth. 2024;24(1):124.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFlacking R, Dykes F. Being in a womb\\u0026rsquo; or \\u0026lsquo;playing musical chairs\\u0026rsquo;: the impact of place and space on infant feeding in NICUs. BMC Pregnancy Childbirth. 2013;13(1):179.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWhite RD, Consensus Committee on Recommended Design Standards for Advanced Neonatal C. Recommended standards for newborn ICU design, 9th edition. Journal of perinatology: official journal of the California Perinatal Association. 2020;40(Suppl 1):2\\u0026ndash;4.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBonet M, Forcella E, Blondel B, Draper ES, Agostino R, Cuttini M, et al. Approaches to supporting lactation and breastfeeding for very preterm infants in the NICU: a qualitative study in three European regions. BMJ Open. 2015;5(6):e006973.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eUnited Nations. Convention on the Rights of the Child. 1989.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-pregnancy-and-childbirth\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"prch\",\"sideBox\":\"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/prch/default.aspx\",\"title\":\"BMC Pregnancy and Childbirth\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Neonatal unit, very preterm, breastfeeding, expressing, qualitative, staff experiences, barriers, facilitators\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4593940/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4593940/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eBreast milk has significant benefits for preterm babies, but \\u0026lsquo;very preterm\\u0026rsquo; babies born before 32 weeks are less likely to receive their mother\\u0026rsquo;s milk than babies born at later gestation, as mothers have to initiate and sustain lactation through expressing their milk for tube feeding until their babies can feed orally. There are wide disparities between neonatal units in England in rates of breast milk feeding at discharge. This study explored health professionals\\u0026rsquo; experiences of barriers and facilitators to their role in supporting breast milk feeding and breastfeeding for very preterm babies.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003e12 health professionals were interviewed, from four neonatal units in England with high or low rates of breast milk feeding at discharge. Interviews were analysed using comparative thematic analysis.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThere were notable differences between neonatal units. Five themes were developed: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e)\\u0026lsquo;The role of the infant feeding specialist\\u0026rsquo; with subthemes \\u0026lsquo;Time allocated to infant feeding support\\u0026rsquo;, \\u0026lsquo;Supportive relationships and proactive, personalised support\\u0026rsquo;, and \\u0026lsquo;Shared responsibility for feeding support\\u0026rsquo;; (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e)\\u0026lsquo;Achieving a whole team approach to breast milk feeding\\u0026rsquo; with subthemes \\u0026lsquo;Leadership and the feeding culture\\u0026rsquo;, \\u0026lsquo;Using external standards as levers\\u0026rsquo;, and \\u0026lsquo;Training for the multi-disciplinary team\\u0026rsquo;; (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e)\\u0026lsquo;Supporting initiation of breastfeeding\\u0026rsquo; with subthemes \\u0026lsquo;Attitudes to early initiation\\u0026rsquo; and \\u0026lsquo;Joined up working with postnatal ward\\u0026rsquo;; (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e)\\u0026lsquo;Supporting long-term expressing\\u0026rsquo; with subthemes \\u0026lsquo;Positive feedback\\u0026rsquo;, \\u0026lsquo;Troubleshooting challenges\\u0026rsquo; and \\u0026lsquo;Provision of breastpumps and facilities\\u0026rsquo;; (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e)\\u0026lsquo;Supporting the transition to breastfeeding\\u0026rsquo; with subthemes \\u0026lsquo;Attitudes to breastfeeding\\u0026rsquo;, \\u0026lsquo;Overcoming separation of mothers and babies\\u0026rsquo;, \\u0026lsquo;Breastfeeding as the only oral feeding\\u0026rsquo;, \\u0026lsquo;Maintaining confidence without measuring volume\\u0026rsquo;, and \\u0026lsquo;Reassurance about weight gain\\u0026rsquo;.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eEffective support can be influenced by having a supernumerary post dedicated to infant feeding; strong leadership that champions breast milk feeding and breastfeeding within Family Integrated Care; maintaining accountability by using existing quality improvement tools and accredited standards for neonatal units; and training for the whole multi-disciplinary team that encourages and enables every member of staff to take an appropriate share of responsibility for consistently informing and assisting mothers with expressing and breastfeeding. Joined-up working between staff on antenatal and postnatal wards and neonatal units is important to enable integrated feeding support for the mother-baby dyad.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Differences between neonatal units with high and low rates of breast milk feeding for very preterm babies at discharge: a qualitative study of staff experiences\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-07-16 22:15:08\",\"doi\":\"10.21203/rs.3.rs-4593940/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision 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