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Late-Preterm Infants: A Population at Risk

Written by Crystal Karges, DTR, CLEC

During my pregnancy with my second child, the last thing I expected was to deliver prematurely; at 35 4/7 weeks’ gestation to be exact.  After the experience with the birth of my first child, who practically had to be coaxed from the womb at almost 41 weeks, I was not prepared for the challenges that came with having a late preterm baby.

Rushing to the hospital the night of my daughter’s birth, I remember praying earnestly for her precious life, unknowing of how her beginning moments would unfold.  She was born swiftly, weighing a whopping 7lbs of pure sweetness.  Unbeknownst by her size, however, the next couple days confirmed her vulnerability and immaturity as a late preterm, and much to my dismay, she struggled with hypoglycemia, hyperbilirubinemia, and poor feedings.

My greatest struggle lay in my inability to properly nourish her in those first critical days.  So eager was I to breastfeed, yet her feeding difficulties proved it much more complicated than I had ever imagined.  With the help of some fantastic lactation consultants and in my stubborn adamancy and determination, we formulated an effective plan to deliver my baby the vital nutrition she needed to combat the hypoglycemia and hyperbilirubinemia while assisting us in establishing breastfeeding-all so crucial in those first 72 hours.

“Late-preterm infants”, defined by birth at 34 0/7 through 36 6/7 weeks’ gestation, are a population at risk, particularly as they are less physiologically and metabolically mature than term infants.  As a result, late-preterm infants are at a higher risk than term infants of developing medical complications, resulting in higher rates of mortality and morbidity during the birth hospitalization. Though many late-preterm infants are frequently the size and weight of some term babies (as was the case with my own baby), there is the potential that they may be managed by caregivers and health professionals as though they are developmentally mature.  Herein lies the danger however, as studies have demonstrated the risks this special population faces, including higher rates of hospital readmission during the neonatal period (Engle, et al).

Perhaps one of the most challenging aspects of having a late-preterm, as I discovered with my own baby, are the unique obstacles that may be confronted with breastfeeding.  It is particularly crucial to educate mothers on how to evaluate feeding success and what signs to look for to detect dehydration and hyperbilirubinemia.  The American Academy of Pediatrics recommends that a formal evaluation of breastfeeding, including observation of position, latch, and milk transfer be undertaken and documented a least twice daily after birth along with a developed feeding plan that is understood by the family.  Helping mothers of the late-preterm infants understand the different needs her baby has, along with a targeted feeding plan of care, can help establish breastfeeding success in the short and long term.

I am deeply grateful to the Lactation Consultants who supported my desire to breastfeed while addressing the needs of my baby, who decided to enter the world a bit sooner than expected.  Through their gentle guidance, I was able to use a supplementary nursing system to feed her at breast to help promote and establish our breastfeeding relationship while ensuring she was receiving the nutrition she needed.  Fast forward five months, and we’re still going strong with exclusive breastfeeding.  I know the guidance and support I had in her early days of life were monumental in setting us up for success in the long run.

Lactation Consultants are a vital part of a comprehensive team that can address the unique needs of the late-preterm infant population.  What has been your experience in your practice working with late-preterm infants?  How have  you  helped a mother establish breastfeeding?

For more valuable resources on breastfeeding the late preterm baby, please refer to the following:


“Late-Preterm” Infants: A Population at Risk.  William A. Engle, Kay M. Tomashek and Carol Wallman.  Pediatrics 2007; 120; 1390.  DOI: 10.1542/peds.2007-2952

The Relationship of Brain Development and Breastfeeding in the Late-Preterm Infant.  Sunny G. Hallowell and Diane L. Spatz.  Journal of Pediatric Nursing 2012; 27: 154-162.


Implications of Obesity in Breastfeeding Women

Written by Crystal Karges, DTR, CLEC

With the growing concern of obesity in the United States, the implications for breastfeeding women are not completely understood. The frequency of obesity of adult women in the United States, particularly of those women who are considered to be within the reproductive age (20-39 years old), is increasing rapidly. A recent study has analyzed how a high fat diet may alter lactation outcomes, revealing possible complications for mothers who consume high-fat diets during pregnancy or who are overweight or obese.

Several studies have demonstrated the negative effects of obesity on various physiological pathways. Such outcomes resulting from excessive weight gain during pregnancy include increased risk of developing breast cancer, increased birth weights in offspring, augmented probability of developing obesity or metabolic syndrome in their lifetime, development of gestational diabetes, and the possibility of delayed lactogenesis (failure to lactate for more than 72 hours postpartum). This is particularly important for the breastfeeding mother, as delayed onset of lactogenesis has also been correlated with overall shorter duration of breastfeeding. While it has been determined that obesity is a contributing factor to the interference of normal lactation cycles in mothers, the mechanisms within mammary glands that trigger delay of lactogenesis are yet to be understood.

In this recent study by Hernandez et al, the possible mechanisms by which high fat diets effect lactation outcomes were explored on rodent models. These researchers discovered that the mammary glands of rats ingesting a high fat diet had a significant reduction in the number of intact alveolar units within the mammary glands, which are critical for lactogenesis to occur normally. Additionally, it was also concluded from this study that within the mammary gland itself, there was a decline in genes corresponding with the uptake of glucose and development of milk proteins (an essential step for the synthesis of lactose), along with the increase in genes linked with the inflammatory process (a response activated by obesity). Based on these results, authors were able to determine that the consumption of a high-fat diet inhibits the normal functional ability of mammary parenchymal tissue, hindering its capability of manufacturing and secreting milk.

This information would be relevant to discussing with patients/clients in the prenatal period, particularly in encouraging pregnant mothers to consume a relatively low-fat diet with the goal of optimizing initiation and long-term duration of breastfeeding.

How does this information affect your scope of practice as a Lactation Consultant?

To be directed to the original study, please continue reading here.

Citation: Hernandez LL, Grayson BE, Yadav E, Seeley RJ, Horseman ND (2012) High Fat Diet Alters Lactation Outcomes: Possible Involvement of Inflammatory and Serotonergic Pathways. PLoS ONE 7(3): e32598. doi:10.1371/journal.pone.0032598

Crystal Karges, DTR, CLEC


Breastmilk Oligosaccharides and Their Effects on Necrotizing Enterocolitis

Written by Crystal Karges, DTR, CLEC

Just when the benefits of breastfeeding couldn’t seem to get any better, new research is revealing even more reasons for mothers to breastfeed.  Increased knowledge and understanding about the various properties and components of human breast milk, and the interaction with the newborn gut, make for profound evidence for its unsurpassed advantages.

A newly published study by Dr. Lars Bode, assistant professor in neonatal medicine and pediatric gastroenterology and nutrition at University of California San Diego (UCSD) School of Medicine’s Department of Pediatrics, has evaluated the effects of how a particular human milk oligosaccharide (HMO) can considerably decrease the risk of necrotizing enterocolitis.

One of the most recurrent and deadly intestinal disorders in premature infants is necrotizing enterocolitis (NEC), and it has been demonstrated that an estimated five percent of all premature infants born with a low birth weight acquire NEC.  While the mechanism behind NEC is not widely understood, the devastating effects are undeniably seen, with statics disclosing the fatality of this condition and the rigorous complications for survivors.

Amidst the difficulties associated with this complex condition, there are promising discoveries being made about the properties of breast milk that have been shown to counteract the outcomes correlated with NEC.  In his latest research findings, Dr. Bode and his colleagues discovered that out of the estimated 150 oligosaccharides unique to human milk alone, one oligosaccharide in particular (Disialyllacto-N-tetraose) is accountable for the advantageous effects of decreasing the risk of NEC in neonatal rats.  In contrast, infant formulas, which are supplemented with galactooligosaccharides (GOS), have a negligible influence on NEC in neonatal rats.

These findings not only elaborate on the numerous advantageous of human milk, but also illustrate how it functions in providing health benefits outside of nutrition and sustenance for the infant.  Sharing research such as this with clients and patients will continue to encourage and empower new mothers to breastfeed their infants.

For more information about Dr. Bode’s lab site, continue reading here.

About SPIN at UC San Diego

Premature infants who receive human breast milk have the best outcomes – medically, nutritionally, and developmentally. Within the Neonatology Division at UCSD’s Department of Pediatrics, the Supporting Premature Infant Nutrition (SPIN) program was developed to address the challenges of helping mothers produce sufficient breast milk for their premature infants, and to improve the manner in which neonatal intensive care units (NICUs) support optimal nutrition and growth in their most vulnerable population of patients.


Crystal Karges, DTR, CLEC


Breastfeeding During a Disaster – Typhoon Washi

Written by Crystal Karges, DTR, CLEC

There is nothing more significant or essential during the occurrence of natural disasters or catastrophes than maintaining breastfeeding between a mother and her nursing baby.  The number of emergency situations occurring world-wide that have affected mothers and infants has increased over the last several years. This can prove to be both challenging and difficult as families who have survived such unpredictable incidences are often displaced from their homes and have suffered the loss of family and property.  Additionally, the incredible stress and anxiety resulting from experiencing such a trauma can undoubtedly be enough to sever a mother’s desire to continue breastfeeding. Perhaps the most susceptible victims in the repercussions of such calamities are infants, thus increasing the need to breastfeed during emergency situations.

Recently, residents of Cagayan de Oro City in the Philippines suffered the disastrous effects from Typhoon Washi, leaving countless families without homes or shelter and claiming many lives.   Amidst this tragic situation, mothers have regained hope by continuing to provide nourishment for their babies by sustaining breastfeeding.  One mother in particular, who survived the flashflood along with her husband and six-month old, shared of her decision in continuing to breastfeed her baby during this chaotic event: “I don’t feel shy or embarrassed breastfeeding in the evacuation center.”

Efforts from organizations such as UNICEF, have worked to promote breastfeeding during emergency situations, such as the devastating Typhoon Washi, by establishing breastfeeding areas within evacuation sites and conducting counseling for mothers to encourage continued breastfeeding or to assist with re-lactation.  Promoting such practices, along with the recommendations from ILCA (International Lactation Consultant Association), is critically important in ensuring that infants affected by these disasters will have adequate nutrition, as well as immunological protection.  IBCLCs, International Board Certified Lactation Consultants, can play a crucial role in humanitarian relief efforts to areas that have suffered natural disasters by implementing these necessary recommendations.

Though disastrous situations cannot be predicted, knowing the essentials on infant feeding in emergencies feeding can be life-saving.  Continue reading here for more information on ILCA’s Position of Infant Feeding in Emergencies.

What has been your experience in counseling the nursing mother during an emergency situation?

Crystal Karges, DTR, CLEC


Breastfeeding and Hypertension

Written by Crystal Karges, DTR, CLEC

Undoubtedly, the field of lactation continues to be an exciting subject of study, particularly as newfound evidence from developing research studies are confirming and fortifying the importance and benefits of breastfeeding. Knowledge of the latest research findings can be invaluable to the clinician who has the opportunity to encourage and educate the breastfeeding mother, particularly as they are able to assist in overcoming obstacles to breastfeeding that could make a difference in women’s health.

A recent study published in the American Journal of Epidemiology demonstrated that mothers who breastfed for a minimum of six months were less prone to developing hypertension over a 14 year period compared to those who bottle fed. These findings are contiguous with previous studies which have established that women who breastfeed have lower risks of diabetes, heart disease, and high cholesterol later in life.

In this latest study, researchers examined the relationship between breastfeeding and later risk of developing hypertension among approximately 56,000 American women who took part in this long-running study. All women participating in this research had at least one baby.

While findings included substantiation that an estimated 8,900 women from this study were ultimately diagnosed with high blood pressure over more than 20 years, data revealed that the probability women would develop hypertension were 22 percent higher in the incidence of not breastfeeding compared with women who exclusively breastfed for six months.

More specifically, this particular study concluded that never or abridged lactation was correlated with an increased risk of incident maternal hypertension, contrasted with the endorsed 6 months of exclusive or 12 months of total lactation per child. Researchers had also estimated that up to twelve percent of high blood pressure cases among women with children could be associated with “suboptimal” breastfeeding, including mothers who gave their babies formula or breastfed for less than three months. These findings are of utmost significance to the lactation consultant, who may make the difference in a mother’s long-term health by removing barriers that may prevent her from successfully breastfeeding.

To be directed to the original research study, please continue reading here.

Research findings such as these continue to give substantial support to the role of the lactation consultant in a mother and baby’s well being, particularly as the LC has the ability to empower a mother to create optimal health for herself.

What research findings do you find beneficial in sharing with your own clients?


Crystal Karges, DTR, CLEC


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