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Breastfeeding of Pre-term Infants

By Helen Harrison

The evidence that breastfeeding makes a major difference is so much stronger than the evidence for any other type of intervention, including EI and all the remedial therapies, yet breastfeeding receives far less support. I think it is time to reexamine our priorities.

The documented advantages in IQ (8 - 9 IQ points) resulted from simply providing breastmilk to the babies during the NICU period. It *may* turn out that longer periods of breastmilk feedings are even more beneficial, but this hasn't yet been proven.

I think mothers who don't/can't nurse should also be supported. I think banked donor breast milk should be the food of choice for their babies, and I think it is sad that countries like New Zealand which are so supportive of breastfeeding are not using this important resource. I think breastmilk (from whatever source) can be every bit as important to the health and well-being of preemies as donated blood and should be given the same degree of emphasis. I would also like to add that my book The Premature Baby Book has been highly criticized over the years for being TOO supportive of bottle-feeding mothers and because I honestly acknowledged the many daunting difficulties of trying to breastfeed a preemie.

Supplying breastmilk (via bottles or gavage) appears to provide the same benefits as nursing. Much of the research has, in fact, involved giving breastmilk (from donor mothers) by gavage and/or bottle to preemies whose mothers did not want to nurse or couldn't nurse. The studies were an attempt to sort out whether there was a benefit in the nutritional content of the milk itself (nature) or whether the benefit came from enhanced maternal/infant bonding and better parent/child relationships (nurture). The research showed that the benefit was in the milk itself. The improved outcomes of the infants receiving breastmilk was due to superior nutrition and "a beneficial effect of human milk on neurodevelopment." (1) (2)

Here are the Australian study's conclusions (3): "Adverse distractibility and cognitive outcomes are common in very premature infants (below 33 weeks gestational age). Intracranial pathology [IVH grades 3 or 4 and/or PVL] has a strong effect on IQ outcome. Social class and male sex are the dominant influences on IQ once intracranial pathology has been excluded. Decreasing gestation is associated with low IQ but has no effect on distractability/hyperactivity (D/H). Breastfeeding has beneficial effects on both low IQ and high D/H. Strategies to encourage and support breastfeeding may have a large impact on outcomes in very preterm infants"

Although breastfeeding seems to prevent nutritionally based brain deficits, there are, unfortunately, many other factors that contribute to disabilities among preemies such as IVH, PVL and/or ventricular enlargement, hydrocephalus, poor brain growth in-utero, disordered neuronal migration, poor myelination, etc. Although the last two factors *might* be helped by breastfeeding the rest of it probably can't be, so breastmilk should never be considered a panacea. Nevertheless, if there were one intervention that parents and staff should be working on to improve outcomes, the supplying of breastmilk and eventual breastfeeding would be where I would suggest making all-out commitments of time, support, parental encouragement and resources.

At any rate, here is the abstract from New Zealand on breastfeeding(4):

Introduction: Over the past two decades there has been increasing evidence suggesting that breast milk may be associated with small but detectable improvements in childhood cognitive and educational achievement. It is likely that any nutrient factors in breastmilk may be of most benefit in preterm infants. We aimed to examine the relationship between the receipt of breastmilk and cognitive ability at 7-8 years in a national cohort of very low birthweight infants (BW <1500g)

Methods: 298 children (96% of the surviving children living in NZ) were assessed at a home visit. Parents were asked a comprehensive questionnaire on their child's health, schooling, behavior and family background. Children were tested on the Revised Wechsler Intelligence Scale for Children.

Results: 73% of mothers elected and were able to provide breastmilk for their infants following birth; 36% of infants received breastmilk for less than 4 months; 16% for 4-7 months; and 21% for more than 8 months. There was a clear and significant dose response relationship between duration of breastfeeding and WISC-R IQ scores at age 7-8 years. Children who received breastmilk for 8 months or longer had mean verbal IQ scores 10 points higher and performance IQ scores 6 points higher than the mean scores for children of mothers who chose not to breast feed. These differences were substantially reduced after statistical control for social, family, and perinatal factors associated with the mother's decision to provide breastmilk. Nevertheless, even after controlling for confounding factors, there remained a significant (p.<.05) association between duration of breastfeeding and verbal IQ; children who received breastmilk for 8 months or longer had adjusted mean IQ scores that were 8 points higher than the scores of children who did not receive breastmilk.

Conclusion: These data, from a national cohort of VLBW infants, add to the accumulating evidence that exposure to breast milk may be of long term benefit in respect of cognitive abilities in former preterm infants."

Research Citations

1. Lucas et al. A randomised multicentre study of human milk versus formula and later development in preterm infants. Archives of Disease in Childhood.1994;70:F141-146.
2. Lucas et al. Breast milk and subsequent intelligence quotient in children born preterm. Lancet. 1992; 339:261-264.
3. Hagan et al. Breast feeding, distractibility, and IQ in very preterm infants. _Pediatric Research_ 1996; 39:266A.
4. "Receipt of Breast Milk and Subsequent Cognitive Ability at 7 - 8 Years Amongst a National Cohort of VLBW Infants. Brian Darlow , L. John Horwood, Nina Mogridge, Dept of Paediatrics, Christchurch School of Medicine, Christchurch, New Zealand. Pediatric Research 1998; 43:211A, abstract 1233.

Helen Harrison is the well known author of The Premature Baby Book, often referred to as the "Bible of Prematurity" by older preemie parents. These observations are excerted with permission from posts to the prematurity parents support internet mailing lists on prematurity: Preemie-child and Preemie-L.

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