Application of the Adverse Childhood Experiences Framework to the NICU.

BACKGROUND: Infants and families requiring neonatal intensive care unit (NICU) care often experience significant stress and trauma during the earliest period of the infant's life, leading to increased risks for poorer infant and family outcomes. There is a need for frameworks to guide clinical care and research that account for the complex interactions of generational stress, pain, toxic stress, parental separation, and lifelong health and developmental outcomes for infants and families. PURPOSE: Apply the Adverse Childhood Experiences (ACEs) framework in the context of the NICU as a usable structure to guide clinical practice and research focused on infant neurodevelopment outcomes and parental attachment. METHODS: An overview of ACEs is provided along with a detailed discussion of risk at each level of the ACEs pyramid in the context of the NICU. Supportive and protective factors to help mitigate the risk of the ACEs in the NICU are detailed. RESULTS: NICU hospitalization may be considered the first ACE, or potentially an additional ACE, resulting in an increased risk for poorer health outcomes. The promotion of safe, stable, and nurturing relationships and implementation of trauma-informed care and individualized developmental care potentially counter the negative impacts of stress in the NICU. IMPLICATIONS FOR PRACTICE AND RESEARCH: Nurses can help balance the negative and positive stimulation of the NICU through activities such as facilitated tucking, skin-to-skin care, mother's milk, and active participation of parents in infant care. Future research can consider using the ACEs framework to explain cumulative risk for adverse health and well-being in the context of NICU care.

Conditions that influence coping mechanisms in Latina mothers affected by incarceration: A secondary analysis using the vulnerability framework.

The objective of this study is to assess women's vulnerability to becoming involved with the legal system as it relates to their exposure, sensitivity, and resiliency to specific experiences associated with incarceration before, during, and after their confinement using the vulnerability framework. We sampled 12 women who self-identified as Latina mothers from local jail annexes, probation department offices, and substance use treatment centers in South Central Texas. We conducted a qualitative, secondary analysis. Three overarching themes emerged: (1) "[The abuse] just kept happening;" (2) "[Incarceration] was an excessive interference;" and (3) "I wasn't there back then [for my children], but now I can be [there for them] in some way." We also identified subthemes. More research and culturally tailored programming are needed to bridge services across legal system sites (jails, prisons, probation) that interact with this population of women to provide supportive services. PUBLIC CONTRIBUTION: We would like to recognize community stakeholders who work in the local jail, probation, and medication treatment centers who helped with the distribution of fliers and participant recruitment along with the women who shared their experiences following incarceration for the original study's data used in this secondary analysis.

Exploration of the effects of incarceration on the health of Latina women and their children using the life course theory.

OBJECTIVE: Use the Life Course Theory (LCT) to explore the effects of involvement with the justice system on the health of Latina women and their children. DESIGN: A supplementary analysis was conducted using data collected from the original study to answer a new research question. SETTING: South Central Texas. PARTICIPANTS: A primary qualitative data set from 12 Latina women involved with the justice system. METHODS: We applied LCT principles and used thematic content analysis as such we employed categoric distinction: lifespan development, time and place in individuals' lives, the timing of lives, human agency, and linked lives to analyze participants' narratives. RESULTS: Five themes emerged that aligned with LCT principles: (1) It feels like I'm living in my own prison; (2) What do I have to live for now; (3) It is like double punishment; (4) They made my choices; and (5) People didn't really understand. Participants felt helpless with few options to overcome their prior adversities, which affected their ability to make positive future choices. CONCLUSIONS: Findings highlight the potential, long-term, negative health consequences that may result from incarceration. Considering that justice system involvement can lead to more profound maternal and child health disparities, our findings suggest that greater advocacy from the nursing profession would increase accessibility to equitable and respectful maternity and women's health care services. Key points Involvement with the justice system can result in negative health consequences for women and their children. Maternal and child health disparities are often more profound after involvement with the justice system. Greater advocacy is needed from the nursing profession to ensure access to equitable and respectful maternity and women's health care services.

Applying a Reproductive Justice Lens to Enhance Research Engagement Among Systematically Underrepresented Childbearing Women.

BACKGROUND: Historically, childbearing women from diverse and systematically hard-to-reach populations have been excluded from nursing research. This practice limits the generalizability of findings. Maximizing research strategies to meet the unique needs of these populations must be a priority. OBJECTIVES: The aim of this study was to provide methodological context for the comprehensive application of reproductive justice strategies to guide research methods and promote engagement of underrepresented childbearing women while decreasing systemic bias. METHODS: In this article, we use a reproductive justice lens to characterize and define strategies for enhancing ethical and equitable engagement in research involving childbearing women who are often systematically underrepresented using a case study approach. Using a specific case study exemplar, the core tenets of reproductive justice are outlined and affirm the need to advance research strategies that create ethical engagement of diverse populations, transform oppressive social structures, and shift research paradigms so research objectives intentionally highlight the strengths and resiliency inherent to the targeted communities. RESULTS: We begin by describing parallels between the tenets of reproductive justice and the ethical principles of research (i.e., respect for persons, beneficence, and justice). We then apply these tenets to conceptualization, implementation (recruitment, data management, and retention), and dissemination of research conducted with childbearing women from diverse backgrounds who are systemically underrepresented. We highlight our successful research strategies from our case study example of women with histories of incarceration. DISCUSSION: To date, outcomes from our research indicate the need for multilevel strategies with a focus on respectful, inclusive participant and key community partner engagement; the time investment in local communities to promote equitable collaboration; encouragement of the patient's autonomous right to self-determination; and mitigation of power imbalances. Nurse researchers are well positioned to advance research justice at the intersection of reproductive justice and ethics to fully engage diverse populations in advancing health equity to support the best health outcomes.

A Scoping Review of Neonatal Opioid Withdrawal and the Infant Gut Microbiome: Does Human Milk Optimize Infant Outcomes?

BACKGROUND: While a growing body of literature has established the role of human milk as a mechanism of protection in the formation of the infant gut microbiome, it remains unclear the extent to which this association exists for infants with neonatal opioid withdrawal syndrome. PURPOSE: The purpose of this scoping review was to describe the current state of the literature regarding the influence of human milk on infant gut microbiota in infants with neonatal opioid withdrawal syndrome. DATA SOURCES: CINAHL, PubMed, and Scopus databases were searched for original studies published from January 2009 through February 2022. Additionally, unpublished studies across relevant trial registries, conference proceedings, websites, and organizations were reviewed for possible inclusion. A total of 1610 articles met selection criteria through database and register searches and 20 through manual reference searches. STUDY SELECTION: Inclusion criteria were primary research studies, written in English, published between 2009 and 2022, including a sample of infants with neonatal opioid withdrawal syndrome/neonatal abstinence syndrome, and focusing on the relationship between the receipt of human milk and the infant gut microbiome. DATA EXTRACTION: Two authors independently conducted title/abstract and full-text review until there was consensus of study selection. RESULTS: No studies satisfied the inclusion criteria, which resulted in an empty review. IMPLICATIONS FOR PRACTICE AND RESEARCH: Findings from this study document the paucity of data exploring the associations between human milk, the infant gut microbiome, and subsequent neonatal opioid withdrawal syndrome. Further, these results highlight the timely importance of prioritizing this area of scientific inquiry.

A Meta-Analysis of Breastfeeding Effects for Infants With Neonatal Abstinence Syndrome.

BACKGROUND: Neonatal abstinence syndrome (NAS) rates have dramatically increased. Breastfeeding is a nonpharmacological intervention that may be beneficial, reducing NAS symptom severity and thus the need for and duration of pharmacological treatment and length of hospital stay. OBJECTIVES: Conduct meta-analysis to determine whether breastfeeding results in better outcomes for NAS infants. Variables included symptom severity, need for and duration of pharmacological treatment, and length of hospital stay. METHODS: PubMed, Scopus, Embase, and Cochrane Library were searched from 2000 to 2020, and comparative studies examining breastfeeding for NAS infants were extracted. Randomized trials and cohort studies were included. Data were extracted and evaluated with Review Manager Version 5.3. A random-effects model was used to pool discontinuous outcomes using risk ratio and 95% confidence intervals. Continuous outcomes were evaluated by mean differences and 95% confidence intervals. RESULTS: Across 11 studies, 6,375 neonates were included in the meta-analysis. Using a random-effects analysis, breastfeeding reduced initiation of pharmacological treatment, reduced duration of pharmacological treatment, and reduced length of stay. No differences were detected for severity of NAS symptoms. Most studies only reported one to two variables of interest. For most studies, these variables were not the primary study outcomes. All studies were found to be of low risk and good quality based on the Cochrane Risk Assessment Tools. Varying breastfeeding definitions limit generalizability. DISCUSSION: Breastfeeding is associated with decreased initiation and duration of pharmacological treatment and length of stay.

Strategies to Improve Mother's Own Milk Expression in Black and Hispanic Mothers of Premature Infants.

BACKGROUND: Mother's own milk (MOM) is the gold standard of nutrition for premature infants. Yet, Hispanic and Black preterm infants are less likely than their White counterparts to receive MOM feedings. Evidence is lacking concerning potential modifiable factors and evidence-based strategies that predict provision of MOM among minority mothers of premature infants. PURPOSE: A review of the literature was conducted to answer the clinical question: "What evidence-based strategies encourage and improve mother's own milk expression in Black and Hispanic mothers of premature infants?" METHODS/SEARCH STRATEGY: Multiple databases including PubMed, Cochrane, and CINAHL were searched for articles published in the past 10 years (2010 through May 2020), reporting original research and available in English. Initial search yielded zero articles specifically addressing the impact of lactation interventions on MOM provision in minority mothers. Additional studies were included and reviewed if addressed breastfeeding facilitators and barriers (n = 3) and neonatal intensive care unit breastfeeding support practices (n = 7). FINDINGS/RESULTS: Current strategies used to encourage and improve MOM expression in minority mothers are based on or extrapolated from successful strategies developed and tested in predominantly White mothers. However, limited evidence suggests that variation in neonatal intensive care unit breastfeeding support practices may explain (in part) variation in disparities and supports further research in this area. IMPLICATIONS FOR PRACTICE: Neonatal intensive care unit staff should consider implementing scaled up or bundled strategies showing promise in improving MOM milk expression among minorities while taking into consideration the cultural and racial norms influencing breastfeeding decisions and practice. IMPLICATIONS FOR RESEARCH: Experimental studies are needed to evaluate the effectiveness of targeted and culturally sensitive lactation support interventions in Hispanic and Black mothers.

Differences in Neonatal Outcomes Among Premature Infants Exposed to Mother's Own Milk Versus Donor Human Milk.

BACKGROUND: Growing evidence supports the superior benefits of exposure to mother's own milk (MOM) in reducing prematurity-related comorbidities. Neonatal exposure to donor human Milk (DHM) is a suitable alternative when MOM is insufficient or unavailable. However, the same protective composition and bioactivity in MOM are not present in DHM. Additional evidence is needed to justify and inform evidence-based practices increasing MOM provision while optimizing adequate use of DHM for premature infants. PURPOSE: A systematic review of the literature was conducted to determine differences in neonatal outcomes among premature infants exposed to predominately MOM versus DHM. METHODS/SEARCH STRATEGY: Databases including PubMed, CINAHL and Cochrane were searched (2020-2021) using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines. Evidence was classified using the John Hopkins evidence-based practice levels and quality of evidence. RESULTS: Eleven studies met inclusion criteria. Studied neonatal outcomes included ( a ) growth parameters (n = 8), ( b ) neonatal morbidities (n = 6), and ( c ) gut microbiome (n = 4). Overall, evidence suggests DHM exposure is beneficial but not equivalent to MOM feeding. Compared with DHM, greater doses of MOM are ideal to enhance protection primarily related to infant growth, as well as gut microbiome diversity and richness. IMPLICATIONS FOR PRACTICE: Standardized and evidence-based practices are needed to clearly delineate optimal use of DHM without undermining maternal and neonatal staff efforts to support and promote provision of MOM. IMPLICATIONS FOR RESEARCH: Additional evidence from high-quality studies should further examine differences in neonatal outcomes among infants exposed to predominately MOM or DHM in settings using standardized and evidence-based feeding practices.

Systemic inequities and depressive symptomology in Hispanic mothers: A path analysis model.

BACKGROUND: Hispanic mothers are one of the largest groups to give birth. They also experience high rates of morbidity and mortality; however, there is limited data related to their health inequities. PURPOSE: The purpose of this study was to evaluate systemic inequities associated with discrimination using the Reproductive Justice Framework to observe factors that influenced depressive symptomology in Hispanic women. METHODS: A path analysis was conducted to evaluate systemic inequities that influenced postpartum depression using the public database, Listening to Mothers III (LMIII). The sub-sample consisted of n = 406 Hispanic mothers. Data was initially collected between the years 2011 and 2013. RESULTS: Hispanic mothers were more likely to experience occurrences of perceived discrimination while seeking perinatal healthcare. These occurrences of discrimination led to lower trust in their healthcare providers, lower satisfaction with care, more instances of unwanted medical procedures, the need to feel to hold back comments about their health which ultimately resulted in higher rates of self-reported postpartum depression. The model fit indices supported the model's plausibility (χ2 /df ratio = 3.16, Comparative Fit Index = 0.91, Root Mean Square Error of Approximation = 0.06). CONCLUSIONS: This data supported our hypothesis that the pathway of discriminatory barriers Hispanic mothers experience during pregnancy influence postpartum depression.

Neonatal Intensive Care Unit Admission Temperatures of Infants 1500 g or More: The Cold Truth.

BACKGROUND: Smaller preterm infants often receive extra attention with implementation of additional thermoregulation interventions in the delivery room. Yet, these bundles of interventions have largely remained understudied in larger infants. PURPOSE: The purpose of this study was to evaluate initial (or admission) temperatures of infants born weighing 1500 g or more with diagnoses requiring admission to the neonatal intensive care unit (NICU). METHODS: Retrospective medical record review of 388 infants weighing 1500 g or more admitted to the NICU between January 2016 and June 2017. RESULT: In total, 42.5% of infants weighing 1500 g or more were admitted hypothermic (<36.5°C), 54.4% with a normothermic temperature, and 2.8% were hyperthermic. Of those infants admitted hypothermic, 30.4% had an admission temperature ranging from 36°C to 36.4°C and 12.1% had an admission temperature of less than 36°C. When compared with infants weighing less than 1500 g, who were born at the same institution and received extra thermal support interventions, there was a statistically significant difference (P < .001) between admission temperatures where infants less than 1500 g were slightly warmer (36.8°C vs 36.5°C). IMPLICATIONS FOR PRACTICE: Ongoing admission temperature monitoring of all infants requiring NICU admission regardless of birth weight or admission diagnosis is important if we are going to provide the best support to decrease mortality and morbidity for this high-risk population. IMPLICATIONS FOR RESEARCH: While this study examined short-term outcomes, effects on long-term outcomes were not addressed. Findings could be used to design targeted interventions to support thermal regulation for all high-risk infants. CONCLUSION: Neonates admitted to the NICU weighing 1500 g or more are at high risk for developing hypothermia, similar to smaller preterm infants.

Correlates and Trajectories of Preterm Infant Sucking Patterns and Sucking Organization at Term Age.

BACKGROUND: Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions. PURPOSE: Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age. METHODS: Sucking performance of 88 preterm infants born between 24 and 34 weeks of post-menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant's quartile location from baseline to term. RESULTS: A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000). IMPLICATION FOR PRACTICE: Infants with the weakest sucking pressures at 34 weeks of post-menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post-menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems. IMPLICATIONS FOR RESEARCH: Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency.

Recovering Together: Mothers' Experiences Providing Skin-to-Skin Care for Their Infants With NAS.

BACKGROUND: Over the past 2 decades, the prevalence of neonatal abstinence syndrome (NAS) has increased almost 5-fold. Skin-to-skin care (SSC), a method of parent-infant holding, is a recommended nonpharmacologic intervention for managing NAS symptoms. SSC has the potential to reduce withdrawal symptoms while positively influencing parent-infant attachment. Yet, little is known about the SSC experiences of mothers of infants with NAS. PURPOSE: The purpose of this study was to explore the SSC experiences of mothers of infants with NAS, including perceived barriers to SSC in the hospital and following discharge home. METHODS: A qualitative descriptive design was used to obtain new knowledge regarding the experience of SSC of mothers of infants with NAS. Purposive sampling was used to recruit participants eligible for the study. We conducted semistructured individual interviews with postpartum mothers of infants with NAS. Data were analyzed using thematic analysis. FINDINGS/RESULTS: Thirteen mothers participated in the study. Four themes emerged from the data analysis: "a little nerve racking"; "she needed me, and I needed her"; dealing with the "hard times"; and "a piece of my puzzle is missing." SSC was described as a conduit for healing and bonding; in addition, several barriers to SSC were reported. IMPLICATIONS FOR PRACTICE AND RESEARCH: These findings highlight the inherent benefits of SSC for infants with NAS and demonstrate the unique challenges of these mother-infant dyads. Critical changes in hospital practices are needed to create an environment supportive of SSC for this patient population. In addition, research regarding implementation of interventions to increase SSC usage in this population is warranted.

Parental Decision-Making in Pediatric Intensive Care: A Concept Analysis.

The development of nursing knowledge requires a close relationship between theory, research, and practice. The purpose of the analysis of the concept of "parental decision-making in pediatric critical care" is to facilitate nurses' therapeutic care of critically ill children and their families. To construct, structure, and give meaning to the concept, we use our experience in the field, critical reading of the literature, and careful analysis of data that have emerged about parental decision-making in pediatric intensive care. Several factors affect parent's ability to act as decision-makers: the psychosocial and physical disorders they develop, the subordination of their parental roles by the health care team, and the child's critical state of health. While different disciplines, including nursing, have well described the decision-making concept, parental decision-making in the context of pediatric intensive care has not been as well delineated. Nursing science recognizes the importance of decision-making and has incorporated the concept as an essential domain of its philosophical and disciplinary interests. Following the method proposed by Walker and Avant, the concept was analyzed, attributes, background, and consequences described. A model case was presented and discussed. An operational definition emerges, providing knowledge for professional nursing practice and will be the basis for an essential theoretical development around this phenomenon. Parents' recognition, the promotion of family-centered care, and shared decisions are ideal for encouraging parental participation.

Marital Satisfaction of Infertile Couples Using Natural Procreative Technology (NaProTECHNOLOGY).

ABSTRACT: Infertility affects one in 16 married women in the United States where 12.7% of these seek treatment. The stress of infertility and treatment is known to impact marital satisfaction, which can be further complicated by personal and religious beliefs regarding the ethics of some assistive reproductive technologies. A morally acceptable approach to infertility diagnosis and treatment is natural procreative technology or NaProTECHNOLOGY (NPT) using the Creighton Model FertilityCare™ System. A quantitative, descriptive study utilizing demographic surveys and the Index of Marital Satisfaction found that couples using NPT reported marital satisfaction.

Neonatal Nurses' Self-reported Practices, Knowledge, and Attitudes Toward Use of Maternal Voice for Preterm Infants.

BACKGROUND/SIGNIFICANCE: Infants born extremely premature (<1500 g) often experience lengthy stays in the challenging environment of the neonatal intensive care unit (NICU) separated from their parents. PURPOSE: The purpose of this study was to explore nurses' knowledge, attitude, and use of maternal voice as a therapeutic intervention for preterm infants in the NICU. METHODS: Neonatal nurses (n = 117) completed an online survey about the use of maternal voice in their individual units. Questions included: (1) previous knowledge surrounding use of maternal voice in the NICU; (2) their attitudes about using maternal voice recordings and/or live maternal speech as an intervention; (3) whether their unit had the necessary equipment and environment conducive to using the therapy; (4) average amount of time parents were in the NICU with their neonate; and (5) in what situations they would personally encourage the use of maternal recordings (during procedures, rounds, etc). RESULTS: Of those responding, 73.3% of nurse (n = 117) respondents agreed they were willing to incorporate maternal recordings into caregiving, with 80.8% indicating they were open to learning and employing different therapies to improve parental involvement in infant care. IMPLICATIONS FOR PRACTICE: When the appropriate equipment is available, neonatal nurses are interested and willing to use alternative therapies that incorporate parental participation into direct caregiving as well as utilizing maternal voice recordings. IMPLICATIONS FOR RESEARCH: Further research with larger, more diverse samples is needed to determine the current knowledge, attitudes, and practices of maternal voice recordings by NICU nurses. Future research can also focus on barriers to utilization of the therapy during daily care.

What Are the Effects of the Maternal Voice on Preterm Infants in the NICU?

BACKGROUND/SIGNIFICANCE: Premature infants often experience extended stays in the neonatal intensive care unit (NICU) as opposed to home with parents. This prolonged separation creates a strain for both parents and infants, decreasing attachment and parental caregiving. One strategy to combat this shared stress is increasing parental participation, particularly through the use of their voices whether parents are present or not. PURPOSE: This Evidence-Based Practice Brief column explores the connection between mother and child, specifically the effects of maternal voice on infant autonomic stability, weight gain, and behavioral states. METHODS: A systematic search of CINAHL, PubMed, and PsycInfo was used to identify studies involving the use of maternal voice intervention with preterm infants in the NICU. RESULTS: Fifteen studies were identified. Three intervention categories emerged: (1) live maternal speech, (2) recorded maternal speech (subcategories included whether intervention content was prescribed or not), and (3) recorded maternal speech that was combined with biological maternal sounds (heart rate). Within each category, studies were organized chronologically to reflect how knowledge has changed overtime. IMPLICATIONS FOR PRACTICE: Maternal voice has physiological as well as behavioral and emotional effect on preterm infants. Several studies found that maternal voice increased autonomic stability improving (heart rate and respirations) as well as weight gain. No negative effects were identified. Given these findings, incorporating different types of maternal voice into routine care by the bedside nurse can assist the mother in feeling more involved in her infant's care without seemingly being a distraction or obstacle to providers. IMPLICATIONS FOR RESEARCH: A major limitation for generalizability was sample size; more research is needed with larger sample sizes replicating interventions types to discern best outcomes.Video Abstract available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?videoId=31&autoPlay=true.

Testing Evidence-Based Strategies for Clinical Ladder Program Refinement.

BACKGROUND: Institutional objectives for clinical ladder program (CLP) implementation often focus on improving job satisfaction, retention rates, and patient outcomes. Local inconsistency in CLP implementation seemed to be contributing to decreased job satisfaction and nurse retention rates. PURPOSE: The aim of this study was to use current evidence and prevailing perceptions of bedside nurses and nurse managers to refine an existing CLP. METHODS: Pretest/posttest design was used to evaluate differences in perceptions of existing CLP (baseline) and perceptions 6 months after CLP refinements were initiated (post). RESULTS: Baseline perceptions of CLP implementation were significantly different for bedside nurses and managers. Bedside nurses were more dissatisfied than nurse managers. Perceptions became more similar across groups as initiatives were implemented to improve CLP understanding and as CLP implementation became more consistent across the organization. CONCLUSIONS: Targeted strategies tailored to increase understanding and consistent CLP implementation can be effective in improving CLP satisfaction and increasing bedside nurse professional behaviors.

Cup Feeding as a Supplemental, Alternative Feeding Method for Preterm Breastfed Infants: An Integrative Review.

Background The benefits of human milk for the preterm infant are well established. Preterm infants have lower breastfeeding rates and often face breastfeeding challenges. It is important that feeding practices for preterm infants optimize their chances of breastfeeding. Objective The purpose of this integrated review is to synthesize and critically analyze research related to the safety and efficacy of cup feeding as an alternative, supplemental feeding method for breastfed infants. Data Sources The electronic data bases of PubMed, CINAHL and were used to identify studies published in English from 1998- 2017. Design Using inclusion and exclusion criteria, 27 articles were initially assessed. After further screening 19 articles were included in the full review and of these 5 more were excluded. Lastly, an in-depth review of these 14 studies resulted in 2 more exclusions, for a total of 12 studies that met full inclusion and exclusion criteria. Review Methods Studies were examined for information on safety and efficacy of cup feeding as an alternative, supplemental feeding method for preterm breastfed infants. Studies were grouped into categories of outcomes that included (a) safety and physiologic properties; (b) breastfeeding outcomes. Results Use of cup feeding resulted in more stable heart rate and oxygen saturation than bottle feeding with similar weight gain. Additionally, breastfeeding rates were higher at discharge with continued higher rates at 3 and 6 months post-discharge for cup fed infants. Conclusions Premature infants face more breastfeeding obstacles than term infants. The potential for cup feeding as an alternative to bottle-feeding for breast fed preterm infants is positively supported by these results It is fundamentally important for NICU professionals to establish a protocol, education and training for the potential use of this feeding method for this vulnerable population.

What Is the Evidence for Use of a Supplemental Feeding Tube Device as an Alternative Supplemental Feeding Method for Breastfed Infants?

BACKGROUND: According to the Healthy People 2020 goals, the sustainability of breastfeeding duration rates within the United States has not been achieved. To increase these rates, it is important that women with breastfeeding difficulties receive the support needed to continue breastfeeding. When supplementation occurs, it is essential that the breastfeeding relationship be preserved. Various methods of supplementation are often recommended including use of the supplemental feeding tube device (SFTD). PURPOSE: The question guiding this brief is "What evidence exists to support the use of an SFTD as a method of supplementation for breastfed infants?" SEARCH STRATEGY: The PubMed and CINAHL databases were queried for original research published in English from 1990 through July 2016. Search terms included "supplemental feeding tube," "breastfeeding," "term infants," "premature infants," "Supplemental Nursing System," "Lact-aid," and "supply line." FINDINGS: Very limited research exists on the use of SFTDs as a method of supplementation for breastfed infants; however, existing research suggests that an SFTD may be useful as a supplementation method for breastfed infants. High-quality research is needed to evaluate the efficacy of using an SFTD for supporting exclusive and all breastfeeding rates. IMPLICATIONS FOR PRACTICE: Nurses and providers need to be educated and trained in the use of SFTDs as well as all supplemental feeding methods. Information on efficacy and SFTD use should also be included in policies related to breastfeeding and human milk use. IMPLICATIONS FOR RESEARCH: Further research should determine best methods of supplementation for breastfed infants and should examine differences in breastfeeding rates when using the SFTD for supplementation.