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The American Academy of Pediatrics recommends donor human milk (DHM) as the preferred feeding strategy for preterm infants when the milk of the mother is unavailable, based on conclusive evidence of lower rates of necrotizing enterocolitis with DHM feedings compared with preterm infant formula. The nutritional composition of DHM may differ from maternal milk for many reasons including differences in maternal characteristics, milk collection methods, and the impact of donor milk banking practices. The purpose of this systematic review is to examine the literature regarding research on the fat, protein, carbohydrate, vitamin, and mineral composition of DHM obtained through nonprofit milk banks or commercial entities. PubMed, CINAHL, and Scopus databases were searched for articles published between 1985 and 30 April, 2019. In total, 164 abstracts were screened independently by 2 investigators, and 14 studies met all inclusion criteria. Studies were predominantly small (<50 samples) and measured macronutrients. Few studies assessed vitamins and minerals. Information bias was prevalent due to the use of a variety of analytical methods which influence accuracy and cross-study comparisons. Other sources of information bias included missing information regarding methods for protein and calorie assessment. Despite these limitations, existing research suggests the potential for 2-fold and greater differences in the fat, protein, and energy composition of DHM, with mean values for energy and fat often below clinical reference values expected for human milk. Further research is warranted regarding the nutritional composition of DHM, with a prioritization on measuring macronutrients and micronutrients using established reference methods., (Copyright © The Author(s) 2020.)

Objective: To examine the effect of feeding type on microbial patterns among preterm infants and to identify feeding factors that promote the colonization of beneficial bacteria., Data Sources: PubMed, Cochrane Database of Systematic Reviews, Scopus, and the Cummulative Index of Nursing and Allied Health Literature were thoroughly searched for articles published between January 2000 and January 2017, using the keywords gut microbiome, gut microbiota, enteral microbiome, enteral microbiota, premature infant, preterm infant, extremely low birth weight infant, ELBW infant, very low birth weight infant, feeding, breast milk, breastfeeding, formula, prebiotic, probiotic, and long chain polyunsaturated fatty acid., Study Selection: Primary studies written in English and focused on the association between enteral feeding and gut microbiome patterns of preterm infants were included in the review., Data Extraction: We independently reviewed the selected articles and extracted information using predefined data extraction criteria including study design, study participants, type of feeding, type and frequency of biospecimen (e.g., feces, gastric aspirate) collection, microbiological analysis method, and major results., Data Synthesis: In 4 of the 18 studies included in the review, researchers described the effects of milk products (mothers' own milk, donor human milk, and formula). In 5 studies, the effects of prebiotics were assessed, and in 9 studies, the effects of probiotics on the gut microbiome were described. Mothers' own breast milk feeding influenced the compositional structure of preterm infants' gut microbial community and increased diversity of gut microbiota compared with donor human milk and formula feeding. The results of the use of prebiotics and probiotics varied among studies; however, the majority of the researchers reported positive bifidogenic effects on the development of beneficial bacteria., Conclusion: Mothers' own milk is considered the best form of nutrition for preterm infants and the gut microbial community. Variation in fatty acid composition across infant feeding types can affect microbial composition. The evidence for supplementation of prebiotics and probiotics to promote the gut microbial community structure is compelling; however, additional research is needed in this area., (Copyright © 2018 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Vulnerable preterm infants experience repeated and prolonged pain/stress stimulation during a critical period in their development while in the neonatal intensive care unit (NICU). The contribution of cumulative pain/stressors to altered neurodevelopment remains unclear. The study purpose was to investigate the impact of early life painful/stressful experiences on neurobehavioral outcomes of preterm infants in the NICU., Methods: A prospective exploratory study was conducted with fifty preterm infants (28 0/7-32 6/7weeks gestational age) recruited at birth and followed for four weeks. Cumulative pain/stressors (NICU Infant Stressor Scale) were measured daily and neurodevelopmental outcomes (NICU Network Neurobehavioral Scale) were examined at 36-37weeks post-menstrual age. Data analyses were conducted on the distribution of pain/stressors experienced over time and the linkages among pain/stressors and neurobehavioral outcomes., Results: Preterm infants experienced a high degree of pain/stressors in the NICU, both in numbers of daily acute events (22.97±2.30 procedures) and cumulative times of chronic/stressful exposure (42.59±15.02h). Both acute and chronic pain/stress experienced during early life significantly contributed to the neurobehavioral outcomes, particularly in stress/abstinence (p<0.05) and habituation responses (p<0.01), meanwhile, direct breastfeeding and skin-to-skin holding were also significantly associated with habituation (p<0.01-0.05)., Conclusion: Understanding mechanisms by which early life experience alters neurodevelopment will assist clinicians in developing targeted neuroprotective strategies and individualized interventions to improve infant developmental outcomes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To evaluate the effectiveness of an educational intervention on the breastfeeding knowledge and attitudes of female high school students living in Taiwan., Design: A prospective, two-group, quasi-experimental, repeated measure design., Setting: A high school in Taichung, Taiwan., Participants: Two hundred four female high school students., Methods: Data were collected through a self-administered questionnaire at baseline, after the intervention, and 1 month later. After administration of the questionnaire at baseline, the experimental group (n = 103) received a 30-minute breastfeeding education; the control group (n = 101) did not., Results: Findings showed that students in the experimental group had significantly greater breastfeeding knowledge immediately after the intervention and at 1 month postintervention. Also, compared with the control group, the experimental group had significantly greater positive breastfeeding attitudes after the intervention period, and the effect lasted at least 1 month., Conclusions: Breastfeeding interventions in schools improve adolescents' knowledge and attitudes. School nurses are well positioned to promote breastfeeding as a healthy lifestyle behavior within the school setting., (Copyright © 2016 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the effect of maternal body mass index (BMI) on infant breastfeeding behaviors (poor, steady, vigorous) and the transition of the mother-infant dyad to exclusive, direct breastfeeding during the first month of life., Design: Longitudinal descriptive investigation., Setting: Tertiary-level southeastern medical center and follow-up telephone calls., Participants: One hundred sixteen healthy, racially diverse, breastfeeding mother-infant dyads (77 full-term and 39 late-preterm infants)., Main Outcome Measure(s): Breastfeeding outcomes were classified as exclusive direct or partially breastfed. The effect of maternal BMI was compared to results from weekly mother's reports of infant breastfeeding behaviors., Results: Significant breastfeeding differences were observed based on maternal BMI and infant gestational age. Mothers with BMIs greater than 25 who described their infants as a vigorous breastfeeders were less likely to exclusively direct breastfeed (p < .002). Only 40% of mother-infant dyads had exclusive direct breastfeeding at any time point or gestational age with no significant increase at any time point after discharge. The BMIs of the woman made no difference in exclusive direct breastfeeding full-term infants compared to late-preterm infants., Conclusion: Maternal BMI had limited negative influence on exclusive direct breastfeeding during the first 4 weeks after discharge. Mothers should be educated that many infants need 3 to 4 weeks after discharge to learn how to breastfeed, infant feeding demands change during this time, and this time is important to the infant's neurologic and overall development., (© 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: To identify factors associated with skin injury during nasal continuous positive airway pressure (NCPAP) and describe differences in frequency, severity, and type of skin injuries when comparing nasal interfaces used during NCPAP in the preterm infant., Data Sources: Scientific databases were searched using provided key terms and yielded 113 articles., Study Selection: Forty-six articles were included in this integrative review: six case studies, 22 with identified aim of examining skin and nasal injury during NCPAP; 18 included skin care considerations during NCPAP., Data Extraction: Studies were categorized into four themes: types of nasal injuries; associated risk factors that increase incidence of injury; differences between NCPAP devices and/or nasal interface and corresponding rate and severity of nasal injury; and recommended prevention strategies to reduce iatrogenic cutaneous injury., Data Synthesis: Skin injury was a common theme during neonatal NCPAP with skin breakdown rates of 20% to 60%. Increased skin injury risk was associated with smaller infant size, gestational age, and duration of therapy. Nursing care strategies to improve skin integrity during NCPAP had little supportive evidence. Nursing practice is varied with reportedly little standardized care during NCPAP therapy. Recommendations for specific care strategies to reduce skin injury during NCPAP were supported by limited experimental studies., Conclusions: Risk factors during NCPAP include nasal injury and trauma secondary to tight-fitting nasal interfaces necessary to provide continuous distending pressure for respiratory stability. Identifying strategies to reduce skin breakdown will support noninvasive treatment success, reduce reintubation rates, reduce sepsis, reduce patient discomfort, and improve developmental outcomes during NCPAP use., (© 2013 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: To compare maternal competence and responsiveness in mothers of late preterm infants (LPIs) with mothers of full-term infants., Design: A nonexperimental repeated-measures design was used to compare maternal competence and responsiveness in two groups of postpartum mothers and the relationship of the theoretical antecedents to these outcomes., Setting: Urban academic medical center., Participants: Mothers of late preterm infants (34-36, 6/7-weeks gestation) and mothers of term infants (≥37-weeks gestation), including primiparas and multiparas. Data were collected after delivery during the postpartum hospital stay and again at 6-weeks postpartum., Methods: Descriptive and inferential analysis., Results: A total of 70 mothers completed both data collection periods: 49 term mothers and 21 LPI mothers. There were no differences between the two groups related to their perception of competence or responsiveness at delivery or 6-weeks postpartum. At 6-weeks postpartum, none of the assessed factors in the model was significantly related to competence or responsiveness., Conclusions: The results, which may have been limited by small sample size, demonstrated no difference in the perceptions of LPI and term mothers related to competence or responsiveness. Maternal stress and support were significantly related to other factors in the model of maternal competence and responsiveness., (© 2013 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: To confirm content validity of GutCheck(NEC) , a risk index for necrotizing enterocolitis (NEC) and to determine the level of agreement among experts about NEC risk factors in premature infants., Design: Electronic Delphi method (e-Delphi)., Setting: Online electronic surveys and e-mail communication supported by an interactive study website., Participants: Nurses and physicians (N = 35) from four countries and across the United States who rated themselves as at least moderately expert about NEC risk., Methods: e-Delphi involved three rounds of surveys and qualitative thematic analysis of experts' comments. Surveys continued until criteria for consensus and/or stability were met., Results: Of 64 initial items, 43 were retained representing 33 risk factors (final GutCheck(NEC) Content Validity Index [CVI] = .77). Two broad themes about NEC risk emerged from 242 comments: the impact of individual physiologic vulnerability and variation in neonatal intensive care unit (NICU) clinicians' practices. Controversy arose over the impact of treatments on NEC, including probiotics, packed red blood cell (PRBC) transfusions, and patent ductus arteriosus (PDA) management using indomethacin., Conclusion: GutCheck(NEC) achieved borderline content validity for a new scale. The e-Delphi process yielded a broad perspective on areas in which experts share and lack consensus on NEC risk. Future testing is underway to reduce the number of risk items to the most parsimonious set for a clinically useful risk tool and test reliability., (© 2013 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: To synthesize findings from the published empirical literature on parent satisfaction with care provided in the neonatal intensive care unit (NICU)., Data Sources: Electronic databases including CINAHL, Medline, Embase, PsycInfo, Sociological Abstracts, the Cochrane Library, and the Campbell Library were searched for relevant research dating from January 1990 to the beginning of October 2011. The reference lists of all studies were reviewed and the personal files of the authors were also searched for relevant studies., Study Selection: Twelve studies (nine quantitative descriptive, two qualitative descriptive, and one mixed methods) were identified that met the review inclusion criteria. Only studies written in English were selected., Data Extraction: Whittemore and Knafl's methodology for integrative reviews guided the data extraction and subsequent analysis. Studies meeting the review inclusion criteria were analyzed sequentially. Data were extracted and organized under the following headings: author, year, and country; study purpose and design; sample size and setting; study variables and data collection; study findings; and limitations., Data Synthesis: Studies examining parent satisfaction with the care provided in the NICU were synthesized under four main themes: (a) parents' degree of satisfaction with care, (b) factors associated with parents' satisfaction with care, (c) elements of care parents view as important, and (d) discrepancies between parent expectations and actual ratings of care., Conclusions: The vast majority of parents were highly satisfied with the care they and their infants received in the NICU. However, other evidence points to less-than-optimal NICU care that is not meeting parents' expectations. These findings provide some direction as to what is important and satisfying to parents whose children must reside in the NICU. However, given the quality and dearth of the evidence, gaps remain in our understanding, and additional, more rigorous research is needed., (© 2013 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Objective: To evaluate existing evidence on long-term developmental outcomes of late-preterm infants (LPI; infants born 34-36 6/7 weeks gestation)., Data Sources: Computerized bibliographic databases and hand search for English language articles published between January 1995 and November 2010 yielded 817 articles., Study Selection: Twelve studies (10 cohort and two cross-sectional) were identified that defined late-preterm (LP) birth as 34 to 36 6/7 weeks gestation and addressed growth and neurodevelopmental outcomes in LPI., Data Extraction: Using a modified Downs and Black scale for assessing the quality of experimental and observational studies, two reviewers who were blind to each other's ratings assessed study quality. Ratings ranged from 12.5 to 14 with moderate to very good interrater agreement. Kappa (κ) values were 0.83 (reporting), 0.63 (external validity), 0.73 (internal validity), and 0.83 (design) for the four subscales and 0.56 for the whole scale, with no major systematic disagreements between reviewers., Data Synthesis: Studies were divided into five categories to include the following developmental outcomes: neurodevelopment, behavioral, cognitive, growth, and function. Using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines, synthesis of the findings is provided as an integrative review., Conclusion: Significant variations in study populations, methodology, and definition of LP exist. Due to paucity and heterogeneity of the existing data especially in infants born 34 to 36 6/7 weeks, there is no clear characterization of the long-term risks, and future research is needed., (© 2011 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

Background: Parent perception of child vulnerability (PPCV) and parent overprotection (POP) are believed to have serious implications for age appropriate cognitive and psychosocial development in very low birth weight preterm children., Aim: With recent concerns about suboptimal developmental outcomes in late-preterm children, this study was aimed at examining the relationship between history of late-preterm birth (34-36 6/7 weeks gestation), and PPCV, POP, and healthcare utilization (HCU)., Study Design: This was a cross-sectional observational design., Participants: Study participants were mothers of 54 healthy singleton children recruited from community centers including Women and Children Clinics (WIC), primary care clinics and daycare centers in the upper Midwest region., Outcome Measures: Outcome measures included Forsyth Child Vulnerability Scale (CVS), Thomasgard Parent Protection Scale (PPS) scores, and healthcare utilization (HCU). Potential covariates included history of life-threatening illness, child and maternal demographics, and maternal stress and depression using the Center for Epidemiologic Studies Depression Scale (CESD)., Results: HCU (p=0.02) and the PPS subscales of supervision (p=0.003) and separation (p=0.03) were significant predictors of PPCV in mothers of 3-8 years old children with late-preterm history. Age of the child (p=0.008) and CVS scores (p=0.005) were significant predictors of POP. Maternal age (p=0.04), stress (p=0.04), and CVS scores (p=0.003) were significant predictors of HCU. Dependence, a subscale of the PPS, correlated with the child's age and gender even after controlling for age., Conclusion: History of late-preterm did not predict MPCV, MOP, or HCU in healthy children. Future research is needed in larger more diverse samples to better understand causal relationships and develop strategies to lessen risks of MPCV and MOP., (Published by Elsevier Ireland Ltd.)

Objective: To compare and contrast the clinical usefulness and psychometric properties of existing self-report instruments designed to assess maternal breastfeeding attitudes, experience, satisfaction, and confidence., Data Sources: CINAHL, PsycINFO, MEDLINE, PubMed databases from 1990 through 2009, and reference lists from selected articles were included in the search. Only published research articles written in English that provided reliability and validity of the self-report instruments for breastfeeding assessment were reviewed., Study Selection: A total of 301 articles were retrieved according to the initial selection criteria; 24 articles met the final inclusion criteria., Data Extraction: Data extracted from research studies addressing the purpose of the review and demonstrating psychometric properties were presented., Data Synthesis: Seven breastfeeding assessment tools were identified, and each tool demonstrated acceptable reliability and validity., Conclusion: Seven self-report instruments were found to be valid, reliable, and feasible measures for assessing breastfeeding relationships. But two of the seven self-report instruments were only tested in one study, and only one study used a self-report instrument (the Breastfeeding Attrition Prediction Tool-BAPT) to test the effectiveness of an intervention. It is recommended that researchers consider using the existing self-report instruments in future experimental studies to test the feasibility and effectiveness of breastfeeding interventions. Moreover, it is important to continue to conduct more well designed research to further test and refine these self-report instruments in a variety of diverse populations and ethnic groups and to further examine their psychometric properties. Clinical applications have not been well addressed and need to be considered in the design of these future works. Understanding how to best support the breastfeeding mother must be the long-term outcome of instrument development in this area.