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Flacking et al.
International Breastfeeding Journal (2021) 16:88 https://doi.org/10.1186/s13006-021-00435-8 R E V I E W Open Access Positive breastfeeding experiences and facilitators in mothers of preterm and low birthweight infants: a meta-ethnographic review Renée Flacking1* Uwe Ewald7 and Gill Thomson1,8 , Bente Silnes Tandberg2,3, Hannakaisa Niela-Vilén4, Rakel B. Jónsdóttir5, Wibke Jonas6, Abstract Background: Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences.
We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Methods: A systematic review using meta-ethnographic methods was conducted.

Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking.

The analysis involved a reciprocal level of translation and a line of argument synthesis.
Results: Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers.

A positive breastfeeding experience was identified as being ‘attuned’.

Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding.
‘Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed.

‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured.
‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant.

The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues.
Conclusions: This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding.

Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial.
The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices.

Keywords: Attunement, Breastfeeding, Breast milk, Feeding, Low-birthweight, Mother, Neonatal, NICU, Parent, Preterm * Correspondence: rfl@du.se 1School of Health and Welfare, Dalarna University, Falun, Sweden Full list of author information is available at the end of the article © The Author(s).
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Flacking et al.
Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 2 of 17 Background Over the last few decades, much attention has been paid to the intake of breast milk in preterm (< 37 gestational weeks) and low-birthweight infants (< 2500 g, LBW); breast milk provides nutritional, immunological, and neurological advan- tages compared to breast milk substitutes [1].
It has been suggested that even small changes in the prevalence of breast milk feeding may result in significant changes in health, healthcare costs, and economic productivity for preterm in- fants and their mothers [2].
Despite the overwhelming evi- dence of the value of breast milk for mothers and their preterm and/or LBW infants, there are wide variations in the initiation and duration rates of feeding breast milk [3–5], where preterm infants have shown to have a shorter breast milk feeding duration compared to term infants [6–8].

One of the major obstacles for breastfeeding (i.e., at breast) the preterm infant is the infant’s breastfeeding behaviour.
Preterm infants’ ability to breastfeed is a maturational process and until the infant can be breastfed exclusively, mothers who want to breastfeed need to express their breast milk by pumping.

In many settings, a range of non-evidence- based guidelines and care routines dictate that the infant should be of a certain gestational age when breastfeeding is initiated [9] or that the infant should tolerate full oral feeds before initiating breastfeeding [10].
Whereas a supportive neonatal unit context, including skin-to-skin contact, has been identified to facilitate the initiation and progression of breastfeeding for infants at lower gestational ages [11, 12].

Research has shown that infants maintain their physiological status when breastfed as early as 27 gestational weeks and can be exclusively breastfed at 32 weeks [13].

Thus, demon- strating that breastfeeding can be initiated despite an early gestational age.
Scheduled feeding is also still mandated in policy in some units/countries, although there are indications that scheduled feeding could be replaced with more individu- alized and appropriate practices [14].

In the context of neo- natal care, breastfeeding is often regarded as a productive process, with a primary focus on nutrition [15].
Such a focus fails to consider breastfeeding as being relational and valuable for emotional aspects such as comfort and pleasure, and can relegate breastfeeding into being an instrumental task based activity that is prone to problems and failure [16].
A few reviews have been conducted on parents’ experi- ences of breast milk feeding their preterm infants: parents’ experiences on factors that help or hinder breast milk supply [17]; factors that influence breastfeeding duration [18]; and mothers’ experiences with milk expression and breastfeeding [19].
Most qualitative research on breast milk feeding and breastfeeding the preterm infant has focused on negative in- sights, such as struggles with milk expression, conflicting ad- vice from health professionals, lack of privacy or inadequate support and encouragement [20–23].

Currently there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences.
We aimed to address this knowledge gap by searching the literature to identify positive indicators and enablers for positive breast- feeding.

We considered this approach to offer benefits to understand what a positive breastfeeding experience is, and how to facilitate this experience, emotionally and physically, for the mother and her infant.
The aim of this meta- ethnographic review was therefore to explore what character- izes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Methods Design We undertook a systematic review and used meta- ethnographic methods of Noblit and Hare to extract and analyse the findings [24].

A meta-ethnography is a com- monly used method to combine and interpret findings from different qualitative methodological approaches [25].
During the process of this review, we adhered to the eMERGe Reporting Guidance, which was developed to ensure com- prehensive and transparent reporting of meta-ethnographic research [25].

The review protocol was uploaded and pub- lished in PROSPERO [26].

Search strategy Search terms were identified using the PEO (Population; Exposure; Outcomes) structure.

The terms were devel- oped following scoping exercises and were agreed in col- Institutet, laboration with librarians Sweden.
An overview of the search string, according to the PEO structure, the inclusion and exclusion criteria and additional selection criteria (date of publication, study type and language) is presented in Table 1. at Karolinska Any study that described mothers’ experiences of breastfeeding their preterm (< 37 gestational weeks) or LBW (< 2500 g) infant were included.
A broad definition of breastfeeding was used [27] where all methods of feeding the infant breast milk, such as the breast, bottle, cup, tube (gavage), were of interest.

The experience of breastfeeding could relate to any time (from birth until weaning), and hence from neonatal units to at home after discharge.
All qualitative studies were to be in- cluded, i.e., exploratory descriptive, narrative, case study, phenomenology, grounded theory, ethnography as well as mixed-methods studies that included sufficient quali- tative data.

The authors native language allowed for the inclusion of original studies published in different lan- guages (i.e., English, Swedish, Norwegian, and Finnish).

Only studies published from 2008 onwards were to be included.
The rationale for this timeframe was based on the progression of family centred care and more neo- natal units offering single-family rooms, systematic use of skin-to skin contact and early discharge, all practices that potentially affect breastfeeding in a positive way.

Flacking et al.
International Breastfeeding Journal (2021) 16:88 Page 3 of 17 Table 1 Search terms and inclusion/exclusion criteria mapped to PEO framework Criteria Inclusion criteria Exclusion criteria Terms Mothers whose infants were not admitted to neonatal unit, infants not preterm or low birth weight mother* or maternal or women* low birth weight or preterm* or premature* Study population Exposure in context Mothers of preterm (< 37 weeks gestation) or low birth weight (< 2500 g) infants who have been admitted to a neonatal unit Neonatal unit = Neonatal Intensive Care Unit (NICU), Special Care Baby Unit (SCBU) Mothers’ experiences, perspectives, in neonatal units, in the transitional phase between hospital and home, or at home after discharge from neonatal unit Outcomes Data concerns experiences of feeding infants their own breast milk Never provided their own breast milk to their infant, experiences of expressing breast milk, experiences of providing bank milk Date 2008 to present Prior to 2008 Study type Qualitative studies, mixed-methods Purely quantitative based studies, clinical case studies, reviews, theses, opinion pieces, grey literature.
Language English, Finnish, Swedish, and Norwegian published articles Any other languages experience* or perception* or perspective* or view* breast feed* or breastfeed* or breast milk or breastmilk or breast pump* or breastpump* or human milk or lactation* or lactating limit to yr = “2008 -Current” ethnograph* or fieldwork or field work or focus group* or informant* or interview* or mixed method* or narration* or narrative* or open question* or participat* observation* or qualitative* or semi-structured or semistruc- tured or thematic analys* limit to english or finnish or norwegian or swedish A comprehensive search strategy was used on six bib- liographic databases: Medline (Ovid), Embase, Web of Science, PsycInfo (Ovid), CINAHL (Ebsco), and Global Index Medicus.
Citation tracking and reference checking was also performed.

Two librarians at Karolinska Insti- tute University Library search consultation group under- took the database searches.

All included papers from the searches were downloaded to an EndNote file and dupli- cates were removed.

Study selection and appraisal All abstracts were screened by at least two members of the review team against inclusion/exclusion criteria and papers were subsequently identified for full text review.
All full text reviews were divided up across all members of the review team, and each paper was read in full by two reviewers.

Agreements for inclusion were made by consensus, and any disagreements regarding inclusion were discussed with a third reviewer.

The initial database searches were undertaken in October 2018, and again in June 2020.

All articles were quality appraised using the instru- ment developed by Walsh and Downe [28, 29].
The framework assesses studies against pre-defined criteria, and then allocates a score from A-D: A = no, or few flaws.
The study credibility, transferability, dependability and confirmability are high; B = some flaws, unlikely to affect the credibility, transferability, dependability and/or confirmability of the study; C = some flaws that may affect the credibility, transferability, dependability and/or confirmability of the study; D = significant flaws that are very likely to affect the credibility, transferability, de- the study.
Only pendability and/or confirmability of studies that scored C or higher were to be included in the final analysis.

Key data were extracted into a pre-designed template included study aims/research question, method- that ology, sample size, participant characteristics, data col- lection methods, key findings/themes, and the quality appraisal rating (Table 2).

Each paper was assigned to a lead reviewer (to extract the data) and a secondary re- viewer (to check that all key issues had been recorded).
Strategy for data synthesis An inductive and interpretative meta-ethnography ap- proach was used.

This approach distinguishes first, sec- ond and third order data [24, 25].

First order concerns participant quotes, second order the paper authors’ in- terpretations, and third order the review teams’ interpre- tations [24, 25].
Meta-ethnography involves identifying issues and concepts at the second order level, with this data then used by the review team to generate third order interpretations via mapping and organising the data into themes and associated sub themes; first order quotes were also extracted and used to authenticate and illuminate the interpretations.

This process also involves translation whereby similarities (reciprocal) and contra- dicting or disconfirming (refutational) data are identified.
Depending on the breadth of evidence identified, an overarching summary of all key issues (i.e., line of argu- ment synthesis) is produced [24, 25].

In this review, we aimed to describe what characterized and facilitated Flacking et al.
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International Breastfeeding Journal (2021) 16:88 Page 7 of 17 positive breastfeeding experiences, rather than negative and/or contradictory experiences.
Thus, our analysis fo- cused on providing a reciprocal level of translation and a line of argument synthesis.

The final themes and sub- themes were reviewed, refined and agreed by all authors.

Results In the original search, 1.644 hits were retrieved from the database searches and a further 130 during the updated search.

No papers were identified via additional search methods.
A total of 995 abstracts were screened against in- clusion/exclusion criteria, 73 were reviewed as full-texts and 17 included in the final review (see PRISMA, Fig.

1).

The study characteristics and quality appraisal grade of the included studies are presented in Table 2.

One of the studies was reported in three papers [34, 35, 42] and one study in two papers [36, 37], thus overall, the 17 articles comprised 14 studies.
The 14 studies were conducted in the US (n = 4) [43–46], Finland (n = 3) [39–41], Sweden (n = 2) [30, 34, 35, 42], Canada (n = 2) [31, 33], Norway (n = 1) [32], Sweden and England (n = 1) [36, 37], and Finland and US (n = 1) [38].

Overall, these studies represent the views of 697 mothers.

The focus for the papers were on breastfeeding ex- periences (n = 13) or the expression and provision of breast milk (n = 4).
Ten papers focussed on experiences during the infant’s hospitalization, five on both the hospitalization and after discharge home, and two on experiences at home, after discharge.

Although a broad definition of breastfeeding was used during the literature search and selection of papers, positive experiences of feeding the infant were described when the mother breastfed at breast.

All studies included preterm infants, with some born as early as 23 weeks gesta- tion.
In all studies but one, the infant’s age ranged from 1 day to 18 months at the time of data collection.

In the remaining Fig.

1 PRISMA flow diagram Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 8 of 17 study, the age of the infants ranged from newborn to 20 years of age [39].

Studies were conducted between 2008 and 2010 (n = 3), 2011–2015 (n = 6), and 2016–2019 (n = 3) and for two studies the year was not stated.
The data collection methods generally involved interviews, but written texts in surveys, a single open-ended question, narratives in social media, or observations were also employed.

In the next section we first provide the line of argument synthesis to define a positive breastfeeding experience.

We then detail the three themes and associated subthemes that describe the facilitators, situations and experiences that con- stitute and underpin positive attuned breastfeeding.
A positive breastfeeding experience – feeling attuned We defined a ‘positive breastfeeding experience’ as feel- ing attuned when breastfeeding.

Feeling attuned was an experience that could occur briefly, or for a longer period, at any time from birth, regardless of breast milk intake, frequency and/or duration achieved.
Mothers de- scribed attuned breastfeeding in terms of an emotional embodied connection [31, 38, 42], an experienced mu- tual interaction [36, 42], a “symbiosis” [41], or as a “pri- vate moment of intimacy” between them [41].

Attuned breastfeeding occurred when the mother trusted her body and what it could do, when the mother could be in the here and now and when she experienced mutual positive responses with her infant.
Attuned breastfeeding was a joint reciprocal activity where both the infant and the mother contributed to the experience, and an inter- action of psychological, social, physical and/or context related factors enabled the breastfeeding experience to be enjoyable and comfortable.

Below we present the three themes and associated sub-themes that describe how attuned breastfeeding experience can be facilitated (see Table 3).
Trusting the body and what it can do The theme of ‘trusting the body and what it can do’ comprises three subthemes, which describe how attuned breastfeeding is facilitated through understanding the bodily responses and capacity to produce breast milk (‘trusting the body’s capacity’), having faith and trust in the power of milk (‘transferring goodness’) and feeling comfortable with holding their infant and to breastfeed (‘trusting the ‘how to’).
Trusting the body’s capacity Five papers highlighted how women’s trust in their bod- ies was important for a pleasurable experience of breast- feeding [30, 31, 36, 37, 42].

Boucher described this as “the mother had to become more in tune with her body” [31].

The studies described how mothers discovered their own physical limitations and gained a deeper un- derstanding of how their mood, stress [31, 36, 39, 40, 43], and sleep [31, 33] impacted on their bodies ability to breastfeed.
One mother in Boucher et al.’s study described: “To me the best thing to ensure effective breastfeed- ing is to know how your body works and what sched- ule works best, know your own system, your own schedule … and where’s your sleep at.” [31].

Women’s trust in their bodies mainly related to their capacity to produce breast milk.

This was reflected by a mother in Ikonen et al.’s study who stated: “Beginning by expression was worth it.

I was able to breastfeed when the time came for me to do it.” [39].
In most studies the production of breast milk was seen as the initial start of a breastfeeding journey [31, 33, 35, 38–40, 42–44].

Mothers with very preterm infants described that it could take months until their infants had transitioned fully to breastfeeding and that this did not always occur during the infant’s hospitalization [32, 40].
The expres- sion of breast milk was therefore an important “stepping stone” [33] and the beginning of a temporary process [30, 35] that would hopefully lead to the ultimate reward of breastfeeding [31, 33, 39, 42–44].

A mother in Bujold et al.’s study [33] described: “Pumping my milk, well it is part of the breastfeed- ing process.

We’ve now started to feed him at the breast, it’s very motivating for me, it definitely makes me feel closer to my child.
(P01)” [33] Strategies that helped milk production and women’s trust in their capacity to produce breast milk was hold- ing the infant, having the infant skin-to-skin, or prac- ticing breastfeeding [33, 40, 43].

A mother in Niela- Vilen et al.’s study [40] stated: “I believe that the daily kangarooing was really im- portant because if the milk secretion didn’t start properly, but during kangarooing it started to flow.
(025)” [40] Being able to express near the baby or in privacy by using drapes or screens [30, 33, 39] and having func- tional and easy to use equipment [33, 39, 43, 45] were regarded as facilitative.

Staff or peer supporters encour- agement, shared experiences, and support made mothers feel hope and security [30, 35, 43] in their bodies’ capaci- ties and served as powerful motivators to initiate and sustain breast milk expression [33, 43, 45, 46].
Transferring goodness A key facilitator for a positive breastfeeding experience was the belief or feeling that the provision of breast milk Flacking et al.
International Breastfeeding Journal (2021) 16:88 Page 9 of 17 Table 3 Themes and subthemes linked to the individual papers A positive breastfeeding experience – feeling attuned Themes Trusting the body and what it can do Subthemes Trusting the body’s capacity Transferring goodness Trusting the “how to” Being emotionally present – in the here and now Feeling relaxed Feeling reassured Experiencing mutual positive responses Seeing and interpreting the infant’s cues Responding to infant’s cues Seeing a positive response from the infant Bjork et al., 2012 [30] Boucher et al., 2011 [31] Breivold et al., 2019 [32] Bujold et al., 2018 [33] Ericson et al., 2017 [34] Ericson and Palmér, 2019 [35] Flacking and Dykes, 2013 [36] Flacking and Dykes, 2017 [37] Holdren et al., 2019 [38] Ikonen et al., 2016 [39] Niela-Vilen et al., 2015 [40] Niela-Vilen et al., 2019 [41] Palmér and Ericson, 2019 [42] Parker et al., 2018 [43] Radtke Demirci et al., 2015 [44] Rossman et al., 2011 [45] Rossman et al., 2013 [46 was a ‘transfer of goodness’.
Mothers described that they had faith in the power of milk to increase their infant’s health, mitigate complications and help the infant grow [31, 32, 39, 41, 43, 44, 46].

Breast milk was described as a “lifeline” [39] and that providing milk was equivalent to “giving life” [46].

A mother in Rossman et al.’s study stated: “I’m giving him life, medicine, food, and a part of me, all in a feeding every 2 hours.” [46].
These beliefs mainly stemmed from the staff providing information and demonstrating positive attitudes towards breast milk and breastfeeding [40, 46], a positive breastfeeding infants, for most of culture, and the encouragement and support from the woman’s family or peers [33, 43, 45].

Mothers separated the initially or from their hospitalization, described that by expressing breast milk they had a purpose in being a mother and thereby felt connected [33, 38, 39, 41, 43, 46].
One mother stated: “I think the breast milk—it’s me.

I feel connected ‘cause my breast milk is a part of me.

I mean, I’m makin’ this milk.” [46].

Mothers often felt that producing breast milk was the only thing they could do and that providing breast milk was the only thing they could give [38, 39, 46].

For Flacking et al.
For Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 10 of 17 these women, expressing breast milk reminded them that they were a mother [41], and that they played a vital role in contributing to their infant’s care [33, 38, 39, 43].
Trusting the ‘how to’ An embodied feeling of trust in ‘how to’ breastfeed, in- cluding how to hold their infant and the techniques in breastfeeding, were reported in a number of studies [31, 35–38, 42, 44]: “It’s all about holding your breast; it’s really the techniques.

You need to know [your breast].

And you have to feel comfortable with it."

[31] Mothers needed to feel comfortable with holding their infant in order to experience a positive breastfeeding ex- perience [31, 35, 36, 42, 44].
Some mothers described that they held their infant “instinctively” and felt com- fortable with it [36], and while multiparous mothers found holding and breastfeeding easier [31], for others the feeling of being comfortable and secure progressed with time [31, 36].

In most studies, how to hold and how to breastfeed was practised in different degrees during the infant’s hospitalization.
It was often a process that was balanced between the presence of staff providing support and ad- vice, and mothers being able to do things in their own way; to “stand on her own two feet” [30].

For the support supportive, during the infants’ to be perceived as hospitalization, the transition to home or after discharge, staff needed to be attuned to the mother as an individual and provide support based on the mother’s needs and her infant’s needs [30, 32, 34, 35, 40].
Staff needed to be knowledgeable in breastfeeding preterm infants and pro- vide information and practical guidance in a sensitive and timely manner; providing more and more pieces of information on e.g., different positions, how to manipu- late the breasts or how to assess a proper latch [30–32, 34, 35, 37, 38, 40].
Mothers felt supported when staff were proactive, responsive (e.g., listened, showed inter- est), respectful (e.g., not judging or putting demands on the mother) [30–32, 34, 35], when they provided positive feedback and gave hope, and made mothers feel safe [30–32, 34].

A mother in Ericson et al.’s study stated: “If I had questions, they could answer them and they were very attuned.

I thought the whole conversation was modelled after me.

.

like the questions I had .

and what problems I had and so on.


Then there was the encouragement.

Sometimes you might not be so eager so many months of tube feeding and pumping to just get that encouragement, a little pat on the shoulder.

(Inter- view 20)” [34] to continue breastfeeding after Being emotionally present – in the here and now In order to experience attuned breastfeeding, mothers need to feel emotionally present; that they can be in the here and now.
Two subthemes describe the importance of physical closeness and privacy and the reassurance by staff and others for feeling emotionally present (‘feeling relaxed’ and ‘feeling reassured’).

Feeling relaxed Mothers referred to how they needed to feel relaxed to achieve a state of attuned breastfeeding [30, 32, 36–38, 40, 42].

Feeling relaxed became easier by increased phys- ical closeness and privacy [30], such as through having a single family room [36, 38].
In Flacking and Dykes study, one of the mothers stated: “In there [the nursery], it’s a bit noisy and people are coming and going.

She seems to have a better go if it’s quieter and I am relaxed.” [36].

A private, familiar and safe space enabled mothers to act more freely and to immerse themselves in the breast- feeding experience [36, 38].

Holdren et al.
Holdren et al.

described that by having a “space to process their emotions and begin to get to know their infant” [38 p. 6], mothers learnt to take care of themselves and their infant and become more autonomous: .

“It kinda felt like you can do .

.

what you want more freely...because things like, like talking to the baby or singing to the baby .

.

.

even though it kinda feels like the most normal thing, but when you have someone else in the room you kind of feel a bit more self conscious.
And bursting into tears uhh next to someone who you don’t know .

.

it’s not like the most, the most, most comfortable thing.

(F2)” [38] .

For other mothers, the closeness and privacy did not occur until they came home to a familiar environment, “a safe haven” [32].

Feeling reassured Another factor that enabled women to be in the here and now and to experience positive breastfeeding was the reassurance from staff and others that all was “going well”.
Positive feedback from staff contributed to a feel- ing of security and calmness during hospitalization [30, 34, 35, 37] and at home [32, 34].

For some mothers, hav- ing the staff outside their private space, monitoring the infants, and entering their space when needed was re- assuring [36].

A mother in Björk et al.’s study wrote: “It was very positive that the health professional was so calm and encouraging but not too pushy and stayed in the background.
It is important that they step forward now and then and give advice but at the same time let me try on my own.” [30] Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 11 of 17 This sense of reassurance was not only linked to breastfeeding per se but also to other aspects of being a mother of a preterm or LBW infant.

Such reassurance could derive from staff [34, 35] but also from other par- ents of preterm infants who had “walked in my shoes” [45].
Thus, peer supporters through their “mothering the mother” [45] approach facilitated a state of calm and wellbeing [45, 46]: “They are really big on talking about postpartum depression and the counseling services available if I’m feeling stressed.

So, they help with more than just breastfeeding.

the whole package of dealing with having a baby in the NICU.

“ [45] It’s kind of Experiencing mutual positive responses A sense of mutuality was a key facet of an attuned breastfeeding experience.
Three subthemes describe this, where the mother recognise (‘seeing and interpreting the infant’s cues’), respond (‘responding to infant’s cues’), and then experience the infant’s response (‘seeing a positive response from the infant’).

Seeing and interpreting the infant’s cues Several studies described the importance of mothers being able to recognise their infant’s pre-feeding sig- nals [31, 36–38, 40, 44] and their state of sleep- wakefulness [36, 37, 44].
Mothers described that being able to interpret their infant’s abilities, instincts and responses accurately made them feel that breastfeed- ing was a shared responsibility where they managed breastfeeding together as a team [30, 32, 38].

Boucher et al.

described this as becoming “an expert on ob- serving and interpreting her infant’s behaviour” [31].

One mother reported: “You’ve got to learn how to read your baby .

.

.
.

.

know exactly how much milk she’s getting, learn if she’s eating effectively, if she’s latching properly.

.

I thought that everything with motherhood clicks in- stinctively.

It doesn’t.” [31] .

.

Early positive feeding experiences, such as for mothers of infants with a low gestational age, related to ‘joyful’ and ‘fantastic’ experiences.
Mothers were surprised by their infant’s competence and capacity the first time at the breast [30, 38], and the subtle, yet evident, cues their infants showed: “Well, of course it was really, well just fantastic .

.

.

And even the first times that, well, not even breast- feeding, but when they said that you could like bring him next to your breast, and kind of like smell, and maybe lick a little bit.

So that was for me kind of the experience.


(F2)” [38] However, mothers also needed to have an awareness that the infant’s maturation to breastfeed would take time and that infants could not be rushed.

This was described by a mother from Radtke-Demirci et al.’s study [44]: "[The connection between breastfeeding and bonding] is different since he’s not in that sleepy mode.

Before I don’t even know if I saw it more as, like, nurturing.

I’m just like, ‘This is just what I’m to do.


He just needs to be held.’ He was supposed to still be inside of me, so of course I loved holding him then, but now I feel like it’s more of like a bonding .

.

.

."

[44].

The mothers understanding of the infant’s developing breastfeeding behaviour and interpreting signals were fa- cilitated by staff describing infants’ cues and behaviour [30, 31, 34, 35, 38].
The studies that described this phenomenon referred to this as a ‘transfer of knowledge’, and how this reflected a staff member’s individual ‘trait’ rather than a joint unit responsibility.

Some mothers also emphasized that continuity of care was needed to extend from hospital to soon after discharge via different forms of support e.g., proactive telephone support, domiciliary care provided by the neonatal unit and staff at other healthcare facilities [32, 34, 35].
Responding to infant’s cues Mothers also needed to be able to respond to their in- fants’ pre-feeding signals or sleep-wakefulness cues [30, 31, 36, 38].

One mother in Flacking and Dykes (2013) study described her abilities and her twins’ cues: “They are lying with me so I know they get what they need.

They relax more when they’re on me, in the sack [kangaroo wrapping].

But when they’re like this [in front of her] I can see them.

Then it’s easier to see their signs of them being hungry.
I try not to breastfeed less than every other hour.

Sometimes they want to eat every hour.

And sometimes, when I have put them down, they start to squirm and then I breastfeed again,” [36].
Mothers’ abilities to respond to their infants’ signals was highly dependent on being physically present, hav- ing skin-to-skin contact, and being enabled or allowed to breastfeed when their infants’ signalled [30, 36, 38, 40], which created “a window of opportunity for feeding in correspondence to the baby’s cues” [36].

Mothers in Flacking and Dykes’s study [36] described how rooming- in meant that they did not miss their infant’s “periods of awakeness” [36].
One mother described how she and her Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 12 of 17 partner became attuned to their infant when assigned a room of their own: “We withdrew from everything.

We focused on him and it was peace and quiet and we could hear him.

I saw that he was searching so I just put him at the breast and he started to suck and he hadn’t before.

It was the breakthrough.

There were just a few hours in between feedings.

I was enabled freedom.


I didn’t look at the clock but I did as he wanted.

God how great!

We were attuned to him.

(MB6)” [36] Mothers described that when breastfeeding could be provided on an on-demand basis, breastfeeding was more enjoyable [30, 31, 44].

A mother in Flacking and Dykes’s study [37] described how staff wanted her to use a nipple shield in order for her infant to “learn quicker”.
She refused as she felt that learning should happen on an individual basis, and that it was more important for her infant to “suck and lick as he wants it” [37].

With time, mothers’ and infants’ abilities to respond to each other was enhanced.

A mother in Holdren et al.’s study stated: “We kept practicing and we both improve [d] a lot.

(F3)” [38].
(F3)” [38].

A mother in Niela-Vilen et al.’s study described her experiences of feeding her infant be- tween the age of three to twelve months: “Breastfeeding is definitely one of the best things I have ever done.

Both I and my baby enjoy and we will continue for a long time [at 3 months].

Breast- feeding is wonderful.

The longer we breastfeed, the more pleasant it becomes.
There is a special bond between me and my baby because of breastfeeding, and I wouldn’t change it for anything in the world [at 6 months].

It still is very comfortable, the baby enjoys as well [at 12 months]” [41].

Seeing a positive response from the infant The third facet of mutuality was the infant’s positive re- sponse.

When this mutuality occurred, breastfeeding was perceived to be an enjoyable experience for both the mother and her infant [30, 31, 36, 37, 40–42, 44].
The interpretation of an infant’s response to breastfeeding depended on the mother’s previous experiences of breastfeeding, the mother’s knowledge about infants’ de- veloping breastfeeding behaviours, and/or trust in her infant’s instincts [30, 40, 44].

A mother in Björk et al.’s study wrote: "With some arrangement with pillows and so on it started to work.

My son started to look for the nipple and suck.

Even though it was not for a long time I was at that moment thinking 'Yes he knows what to do'.
And then the nervousness disappeared."

[30].

Mothers described a positive infant response during breastfeeding as being calm, alert, active, and that the in- fant sucked and swallowed [37, 40, 44] or fed “efficiently” [37, 42].

A more subtle experience was that infants enjoyed it [37, 38, 40, 41].

A mother in Holdren et al.’s study described: “.

.. and umm, and I feel like she was really enjoying it even though she didn’t get much out of it yet (F3)” [38].
Discussion This systematic review and meta-ethnography aimed to define what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Insights into positive breastfeeding experi- ences were derived from 14 studies conducted in six countries.

By using reciprocal translation, we identified characteristics of what constitutes a positive breastfeed- ing experience, an experience that we described as being ‘attuned’.
Data was synthesized into three themes, ‘trust- ing the body and what it can do’, concerns how attuned breastfeeding is facilitated through understanding the bodily responses and capacity to produce breast milk, having faith and trust in the power of milk, and feeling comfortable with holding the infant and to breastfeed.
‘being emotionally present – in the The second theme, here and now’ describes the importance of feeling re- laxed and reassured through closeness, privacy, the sup- port from staff, peers, and others for feeling emotionally present.

The third theme, ‘experiencing mutual positive responses’, concerns how a feeling of mutuality arises when the mother recognises and interprets her infant’s cues, when she is enabled to respond to those signals and when she receives a positive response from her in- fant.
In the following sections we first discuss attuned feeding drawing on key insights from the three themes, followed by a discussion on the three major facilitators for attuned feeding.

The phenomenon of attunement has been studied ex- tensively, where the primary focus has been on behav- ioural, emotional and biological synchrony or mutuality between the mother and infant [47–50].
Our findings re- flect those of Stern in terms of how attunement com- prises, from the parental perspective, a sensitivity and responsiveness to infant cues and attentional states, and from the infant perspective the biological preparedness to engage in and also to anticipate attuned interactions, leading to exchanges of infant-parent mutually positive emotions [51].
The quality of parent-infant interaction and communi- cation is an ongoing process that affects and contributes to the neurobiological regulation of the other [47, 52].

Breastfeeding is a key maternal activity, and the quality of this experience makes a substantial contribution to biological, social-emotional, and cognitive well-being Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 13 of 17 [53, 54].
During embodied interactions such as breast- feeding, the mother and the infant need to coordinate their behaviours and bodies, both contributing to attune- ment.

Embodied interactions in early life emerges from the dynamic interplay between signals arising inside the body and through affective exchanges [55].

As we identi- fied within the review, trusting the body is crucial for attuned breastfeeding.
Breastfeeding presents a situation of closeness and proximity, in which the mother feels attuned when she is emotionally present and in the here and now.

When mothers feel relaxed during breastfeed- ing, the stress levels are reduced and infant behaviour during breastfeeding as well as in other behaviours such as sleep are positively affected [56].
But when mothers are preoccupied or have unresolved trauma they are less attuned to their infant’s cues during feeding, compared with those considered secure [57].

This was evident within the included papers in terms of how positive breastfeeding was associated with mothers who were emotionally present and felt connected.

Mother’s ability to see, interpret and respond to in- fant’s cues have mainly been explored in mothers of term infants.
Biologically pre-programmed behaviours have been described by Widström and colleagues [58] and Matthiesen and colleagues [59] showing that when term infants are placed in skin-to-skin contact with their mothers immediately after birth, they interact both be- haviourally and physiologically leading up to breastfeed- ing within one or two hours.

Thus, this set of behaviours requires maternal attention, availability and physiological and psychological responsiveness.
In the preterm dyad, more subtle movements and signs are present and there- fore breastfeeding attunement requires a greater level of responsiveness to the infant’s cues and behaviours.

Pre- feeding cues in preterm infants, just as in term infants, are not only cues of actual hunger but also an innate need to suck [60].

Breastfeeding can thus be the appro- priate response to hunger but also to distress and pain [61] or to the infant’s need for increased pleasure [62].
Attuned breastfeeding may therefore be viewed as a comforting activity for in addition to the outcomes of feeding.

the mother-infant dyad, Facilitators Across the papers, three major facilitative factors were identified to enable attuned breastfeeding.

First, being in closeness; holding the infant or having the infant skin- to-skin enabled mothers to trust their bodies, become relaxed, and to see and respond to their infant’s signals.
Montirossi and McGlone describe in their review [55], that the infant meets the mother’s body before (s) he meets the mother’s mind and the mother meets her in- fant’s body before the infant’s mind.

Thus, the body interaction, which comes first in the mother-infant highlights the importance of physical proximity.
Their review suggests that mother-infant interactions fluctuate between attuned and misattuned states, in which the lat- ter can be repaired through e.g., skin-to-skin and affec- tionate touch and by a maternal sense of their internal bodily states.

Skin-to-skin contact entails numerous physiological, physical, and psychological benefits for parents and infants, of which one is the evident positive short and long-term outcomes for breastfeeding [12].
The second major facilitator was the staff’s support and interpersonal relationship with the mother.

Schmied et al.’s findings from their meta-synthesis of women’s experiences of breastfeeding support [63], showed that mothers of term infants want staff to be ‘au- thentically present’ and have a ‘facilitative style’ in breastfeeding support.

The findings from our study were similar.


We found that mothers of preterm/LBW infants experienced good support when staff were attuned and responsive to mother’s and infant’s needs; reassuring, re- spectful, and encouraging; when they provided informa- tion and practical guidance in a sensitive and timely manner; and had a positive attitude towards breast milk and breastfeeding.
Mothers from the included studies also described that staff needed to have specific know- ledge in the breastfeeding behaviours of preterm infants and possess skills and knowledge in breastfeeding pre- term terms [64].

As nurses in neonatal units provide support for breastfeeding during every shift [65], it is im- portant to include all nurses in breastfeeding training programs to ameliorate the support provided to mothers and infants term infants, [66].
Unlike mothers of mothers of preterm/LBW infants have a much longer hospital stay with more staff encounters, which places a larger responsibility on staffs’ communication skills [67] and to ensure continuity and meaningful relationships [68].

Further, mothers need to be empowered by staff to be ‘in charge’ of breastfeeding and not become passive [69].
Within settings recipients of care and support where mothers are separated from their infants, it is hard for mothers to take active control to act freely and to gain trust in their capabilities [15]; this is contrary to units where the mother-infant dyad can spend unending time in close physical proximity [5].

However, regardless of the environmental features, staff support is crucial for breastfeeding preterm/LBW infants [70, 71].
The third major facilitator for attuned breastfeeding was being enabled to breastfeed when their infant signalled.

By changing neonatal designs to include more private spaces and single-family rooms, the opportunities for mothers to support the infants’ resources and capacities (e.g., limited periods in alert behavioural state, strengths, muscle tone) unfolds.
In line with the values from family centred care [72], an individual and dyadic ap- proach to promote a more (neuro) developmental infants’ Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 14 of 17 supportive breastfeeding context is needed.
Cue-based feeding [73–78], responsive feeding [14, 79] and infant driven feeding [80–82], are all synonyms for a view that the infant’s signals (i.e., behavioural responses and physio- logical signals) should guide the process towards full breastfeeding or any oral feeding.

However, these ap- proaches to support the infant’s developing (breast) feed- ing behaviour have mainly been described as ‘suggestions’ in qualitative research or through quality improvement projects.
Such approaches require more knowledge and support from the staff to guide mothers on their infant’s individual feeding development, and most of all a willing- ness to evaluate established practices, such as rigid sched- uled feeding routines, that are potentially not conducive for mothers and infants.

Strengths and limitations The strengths of this review are the comprehensive search strategy, and a minimum of two reviewers being involved in each stage to enhance the rigour and trust- worthiness.
An evident limitation is that most studies were conducted in the Nordic countries.

There are sev- eral potential reasons for this; the Nordic countries hav- ing a history of being pro-breastfeeding cultures and also that the progression towards family centred care has potentially moved faster than in other countries.

An- other limitation is that few papers have been published on positive experiences.
Although a broad definition of breastfeeding was used during the literature search and selection of papers, positive experiences of feeding the infant were only described when the mother breastfed at breast in all papers.

One reason for this could be that in many settings the norm and goal is to feed the infant directly at breast [5, 8].

When mothers do not achieve this goal but instead feed the infant by alternative means, i.e., a bottle, the overall experience becomes negative.
Another reason could be that researchers regard ‘breast- feeding at breast’ as the focus of their paper and there- fore not pay attention to positive experiences by other feeding methods.

We would argue that attuned feeding occur irrespective of what method is used.

Another limi- tation is the ‘staff-centeredness’ in many of the papers.
A few of the papers described significant others’ (e.g., rela- tives, fathers, other mums in the neonatal units) atti- tudes towards breast milk and breastfeeding as being influential, but not in terms of actual support they pro- vided.
This could be due to the authoritative and institu- tionalised environment that neonatal units represent, in combination with a ‘medicalization’ of breastfeeding pre- term infants, which reinforces staffs’ power and oppor- tunities to assess, judge and evaluate the breastfeeding performance.

As shown, no single study contributed to all the sub-themes, but the studies collectively enabled into what in-depth richer and more insights characterizes and facilitates a positive breastfeeding ex- perience.
Future research should focus on what consti- tutes attuned breastfeeding in different neonatal unit contexts, with different populations (e.g., from lower/ middle income settings).

Maybe more importantly, there is a need to evaluate different strategies and interven- tions in early breastfeeding, where the infants’ and mothers’ emotional and physical needs and capacities are acknowledged.
Conclusions This systematic review and meta-ethnographic methods identified positive breastfeeding experiences as being ‘attuned’.

Attuned breastfeeding occurred when the mother trusted her body and what it could produce, when she could be emotionally and physical present in the here and now and when she experienced mutual positive re- sponses with her infant.
The most prominent facilitating factors for experiencing attuned breastfeeding were being in close physical proximity with the infant, meaningful and sensitive staff support and positive staff-mother inter- personal relationships, and being enabled to breastfeed when the infant signalled.
This study offers new insights into how staff and gatekeepers in neonatal units can facili- tate and enable mothers to achieve more positive breast- feeding experiences with a more prominent focus on the relational aspects of breastfeeding.

Positive breastfeeding support requires a favourable environment which en- hances mother-infant dyads closeness and trust in the mother’s and infant’s capacities.
Acknowledgements We extend thanks to Heather Trickey for valuable comments in the early phase of the study and to Magdalena Svanberg and Sabina Gillsund at Karolinska Institutet’s Library for obtaining the literature search.

This project was undertaken on behalf of the SCENE network (https://sites.utu.fi/scene/).
Authors’ contributions The study was designed by RF and GT, RF directed and coordinated the work, GT provided conceptual and methodological guidance, all authors participated in the review, data extraction and quality appraisals, RF wrote the original draft, GT was a major contributor in writing the manuscript, all authors commented on the manuscript and all authors read and approved the final manuscript.

Funding No funding was received for the research.

Open Access funding provided by Dalarna University.
Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

Declarations Ethics approval and consent to participate Not applicable.

Consent for publication Not applicable.

Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 15 of 17 Competing interests The authors declare that they have no competing interests.

Author details 1School of Health and Welfare, Dalarna University, Falun, Sweden.
2Department of Paediatric and Adolescent Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.

3Lovisenberg Diaconal University College, Oslo, Norway.

4Department of Nursing Science, University of Turku, Turku, Finland.

5Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavik, Iceland.

6Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden.

7Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden.
8School of Community Health & Midwifery, Maternal and Infant Nutrition and Nurture (MAINN) research unit, University of Central Lancashire, Preston, UK.

Received: 7 March 2021 Accepted: 11 November 2021 References 1.

Taylor SN.

Solely human milk diets for preterm infants.

Semin Perinatol.

2019;43(7):151158. https://doi.org/10.1053/j.semperi.2019.06.006.

2.

Mahon J, Claxton L, Wood H. Modelling the cost-effectiveness of human milk and breastfeeding in preterm infants in the United Kingdom.
Health Econ Rev.

2016;6(1):54. https://doi.org/10.1186/s13561-016-0136-0.

Bonet 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.

Arch Dis Child Fetal Neonatal Ed.

2011;96(6):450–2.

https://doi.org/10.1136/adc.2009.179564.

3.

4.

Wilson E, Edstedt Bonamy AK, Bonet M, Toome L, Rodrigues C, Howell EA, 7.

5. et al.
5. et al.

Room for improvement in breast milk feeding after very preterm birth in Europe: results from the EPICE cohort.

Matern Child Nutr.

2018;14(1): e12485.

https://doi.org/10.1111/mcn.12485.

Grundt H, Tandberg BS, Flacking R, Drageset J, Moen A.

Associations between single-family room care and breastfeeding rates in preterm infants.

J Hum Lact.

2021;37(3):593–602.

https://doi.org/10.1177/0890334420962709.

6.

Michels KA, Ghassabian A, Mumford SL, Sundaram R, Bell EM, Bello SC, et al.
Breastfeeding and motor development in term and preterm infants in a longitudinal US cohort.

Am J Clin Nutr.

2017;106(6):1456–62.

https://doi.

org/10.3945/ajcn.116.144279.

Flacking R, Nyqvist KH, Ewald U.

Effects of socioeconomic status on breastfeeding duration in mothers of preterm and term infants.

Eur J Pub Health.

2007;17(6):579–84.

https://doi.org/10.1093/eurpub/ckm019.


Jonsdottir RB, Jonsdottir H, Orlygsdottir B, Flacking R. A shorter breastfeeding duration in late preterm infants than term infants during the first year.

Acta Paediatr.

2021;110(4):1209–17.

https://doi.org/10.1111/apa.1 5596.

Reyna BA, Pickler RH, Thompson A.

A descriptive study of mothers' experiences feeding their preterm infants after discharge.

Adv Neonatal Care.

2006;6(6):333–40.

https://doi.org/10.1016/j.adnc.2006.08.007.

10.


Callen J, Pinelli J, Atkinson S, Saigal S. Qualitative analysis of barriers to breastfeeding in very-low-birthweight infants in the hospital and postdischarge.

Adv Neonatal Care.

2005;5(2):93–103.

https://doi.org/10.1016/ j.adnc.2004.12.005.

9.

8.

11.

Nyqvist KH, Sjoden PO, Ewald U.

The development of preterm infants' breastfeeding behavior.

Early Hum Dev.

1999;55(3):247–64.

https://doi.org/1 0.1016/S0378-3782(99)00025-0.

12.
12.

Mekonnen AG, Yehualashet SS, Bayleyegn AD.

The effects of kangaroo mother care on the time to breastfeeding initiation among preterm and LBW infants: a meta-analysis of published studies.

Int Breastfeed J.

2019; 14(1):12. https://doi.org/10.1186/s13006-019-0206-0.

Lucas RF, Smith RL.

When is it safe to initiate breastfeeding for preterm infants.

Adv Neonatal Care.

2015;15(2):134–41.

https://doi.org/10.1097/ANC.

0000000000000167.

13.

14.


Watson J, McGuire W. Responsive versus scheduled feeding for preterm 15. infants.

Cochrane Database Syst Rev.

2016;8(8):CD005255.

https://doi.org/1 0.1002/14651858.CD005255.pub5.

Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to “becoming a mother” and to reciprocal breastfeeding.

Stories of mothers of very preterm infants at a neonatal unit.

Soc Sci Med.

2006;62(1):70–80.

https://doi.org/10.1016/j.socscimed.2005.05.026.

16.
16.

Dykes F, Flacking R. Encouraging breastfeeding: a relational perspective.

Early Hum Dev.

2010;86(11):733–6.

https://doi.org/10.1016/j.earlhumdev.201 0.08.004.

17.

Alves E, Rodrigues C, Fraga S, Barros H, Silva S. Parents' views on factors that help or hinder breast milk supply in neonatal care units: systematic review.

Arch Dis Child Fetal Neonatal Ed.

2013;98(6):F511–7.

https://doi.org/10.113 6/archdischild-2013-304029.

18.
18.

Briere CE, McGrath J, Cong X, Cusson R. An integrative review of factors that 19. influence breastfeeding duration for premature infants after NICU hospitalization.

J Obstet Gynecol Neonatal Nurs.

2014;43(3):272–81.

https:// doi.org/10.1111/1552-6909.12297.

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.

https://doi.org/10.1097/A NC.0000000000000232.

20.
20.

Morelius E, Kling K, Haraldsson E, Alehagen S. You can't flight, you need to fight-a qualitative study of mothers' experiences of feeding extremely preterm infants.

J Clin Nurs.

2020;29(13–14):2420–8.

https://doi.org/10.1111/ jocn.15254.

21.

Palmquist AEL, Holdren SM, Fair CD.

“It was all taken away”: lactation, embodiment, and resistance among mothers caring for their very-low-birth- weight infants in the neonatal intensive care unit.

Soc Sci Med.
Soc Sci Med.

2020;244: 112648. https://doi.org/10.1016/j.socscimed.2019.112648.

22.

Cescutti-Butler L, Hemingway A, Hewitt-Taylor J.

“His tummy's only tiny” - scientific feeding advice versus women's knowledge.

Women's experiences of feeding their late preterm babies.

Midwifery.

2019;69:102–9.

https://doi.

org/10.1016/j.midw.2018.11.001.

23.

Dosani A, Hemraj J, Premji SS, Currie G, Reilly SM, Lodha AK, et al.
Breastfeeding the late preterm infant: experiences of mothers and perceptions of public health nurses.

Int Breastfeed J.

2016;12(1):23. https:// doi.org/10.1186/s13006-017-0114-0.

25.

24.

Noblit GW, Hare RD.

Meta-ethnography: synthesizing qualitative studies.

London: Sage Publications; 1988. https://doi.org/10.4135/9781412985000.

France EF, Cunningham M, Ring N, Uny I, Duncan EAS, Jepson RG, et al.

Improving reporting of meta-ethnography: the eMERGe reporting guidance.

BMC Med Res Methodol.


2019;19(1):25. https://doi.org/10.1186/s12874-018- 0600-0.

Flacking R, Thomson G, Trickey H, Silnes Tandberg B, Niela-Vilen H, Ewald U, et al.

A meta-ethnographicstudy of facilitators for positive breastfeeding experiences and the needs for breastfeeding support in mothers ofpreterm and/or low-birth-weight infants.

PROSPERO, 2018, CRD42018108310 Available from:https://www.crd.york.ac.uk/prospero/display_record.php?ID= CRD42018108310.

26.

27.
26.

27.

World Health Organization & United Nations Children's Fund.

Global Strategy for Infant and Young ChildFeeding.

2003, Geneva, ISBN: 9241562218.

28.

Walsh D, Downe S. Appraising the quality of qualitative research.

Midwifery.

2006;22(2):108–19.

https://doi.org/10.1016/j.midw.2005.05.004.

29.

Downe S WS, Walsh D, Simpson L, Steen M. Template for metasynthesis.

Contact: sdowne@uclanacuk 2009.

30.


Bjork M, Thelin A, Peterson I, Hammarlund K. A journey filled with emotions--mothers' experiences of breastfeeding their preterm infant in a Swedish neonatal ward.

Breastfeed Rev.

2012;20(1):25–31.

31.

Boucher CA, Brazal PM, Graham-Certosini C, Carnaghan-Sherrard K, Feeley N. Mothers' breastfeeding experiences in the NICU.

Neonatal Netw.

2011;30(1): 21–8.

https://doi.org/10.1891/0730-0832.30.1.21.

32.

Breivold K, Hjaelmhult E, Sjostrom-Strand A, Hallstrom IK.
Mothers' experiences after coming home from the hospital with a moderately to late preterm infant - a qualitative study.

Scand J Caring Sci.

2019;33(3):632–40.

https://doi.org/10.1111/scs.12656.

33.

Bujold M, Feeley N, Axelin A, Cinquino C. Expressing human milk in the NICU: coping mechanisms and challenges shape the complex experience of closeness and separation.

Adv Neonatal Care.

2018;18(1):38–48.

https://doi.

org/10.1097/ANC.0000000000000455.


Ericson J, Flacking R, Udo C. Mothers' experiences of a telephone based breastfeeding support intervention after discharge from neonatal intensive care units: a mixed-method study.

Int Breastfeed J.

2017;12(1):50. https://doi.

org/10.1186/s13006-017-0142-9.

Ericson J, Palmer L. Mothers of preterm infants' experiences of breastfeeding support in the first 12 months after birth: a qualitative study.

Birth.

2019;46(1):129–36.


https://doi.org/10.1111/birt.12383.

34.

35.

Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 16 of 17 36.

37.

Flacking R, Dykes F. 'Being in a womb' or 'playing musical chairs': the impact of place and space on infant feeding in NICUs.

BMC Pregnancy Childbirth.

2013;13(1):179. https://doi.org/10.1186/1471-2393-13-179.
Flacking R, Dykes F. Perceptions and experiences of using a nipple shield among parents and staff - an ethnographic study in neonatal units.

BMC Pregnancy Childbirth.

2017;17(1):1. https://doi.org/10.1186/s12 884-016-1183-6.

38.

Holdren S, Fair C, Lehtonen L. A qualitative cross-cultural analysis of NICU 39. care culture and infant feeding in Finland and the U.S. BMC Pregnancy Childbirth.

2019;19:345.
2019;19:345.

Ikonen R, Paavilainen E, Kaunonen M. Trying to live with pumping: expressing milk for preterm or small for gestational age infants.

MCN Am J Matern Child Nurs.

2016;41(2):110–5.

https://doi.org/10.1097/NMC.

0000000000000214.

40.

Niela-Vilen H, Axelin A, Melender HL, Salantera S. Aiming to be a breastfeeding mother in a neonatal intensive care unit and at home: a thematic analysis of peer-support group discussion in social media.

Matern Child Nutr.

2015;11(4):712–26.


https://doi.org/10.1111/mcn.12108.

41.

Niela-Vilen H, Axelin A, Salantera S, Melender HL.

A typology of breastfeeding mothers of preterm infants: a qualitative analysis.

Adv Neonatal Care.

2019;19(1):42–50.

https://doi.org/10.1097/ANC.

0000000000000542.

42.

Palmer L, Ericson J.

A qualitative study on the breastfeeding experience of mothers of preterm infants in the first 12 months after birth.

Int Breastfeed J.
Int Breastfeed J.

2019;14(1):35. https://doi.org/10.1186/s13006-019-0229-6.

43.

Parker MG, Lopera AM, Kalluri NS, Kistin CJ.

“I felt like I was a part of trying to keep my baby alive”: perspectives of Hispanic and non-Hispanic black mothers in providing milk for their very preterm infants.

Breastfeed Med.

2018;13(10):657–65.

https://doi.org/10.1089/bfm.2018.0104.

44.

Radtke Demirci J, Happ MB, Bogen DL, Albrecht SA, Cohen SM.
Weighing worth against uncertain work: the interplay of exhaustion, ambiguity, hope and disappointment in mothers breastfeeding late preterm infants.

Matern Child Nutr.

2015;11(1):59–72.

https://doi.org/10.1111/j.1740-8709.2012.00463.x.

45.

Rossman B, Engstrom JL, Meier PP, Vonderheid SC, Norr KF, Hill PD.

"They've walked in my shoes": mothers of very low birth weight infants and their experiences with breastfeeding peer counselors in the neonatal intensive care unit.

J Hum Lact.

2011;27(1):14–24.


https://doi.org/10.1177/089033441 0390046.

47.

46.

Rossman B, Kratovil AL, Greene MM, Engstrom JL, Meier PP.

"I have faith in my milk": the meaning of milk for mothers of very low birth weight infants hospitalized in the neonatal intensive care unit.

J Hum Lact.

2013;29(3):359– 65. https://doi.org/10.1177/0890334413484552.

Leclere C, Viaux S, Avril M, Achard C, Chetouani M, Missonnier S, et al.
Why synchrony matters during mother-child interactions: a systematic review.

PLoS One.

2014;9(12):e113571.

https://doi.org/10.1371/journal.pone.0113571.

Feldman R, Greenbaum CW, Yirmiya N. Mother-infant affect synchrony as an antecedent of the emergence of self-control.

Dev Psychol.

1999;35(1):223– 31. https://doi.org/10.1037/0012-1649.35.1.223.

48.

49.

Ruttle PL, Serbin LA, Stack DM, Schwartzman AE, Shirtcliff EA.
Adrenocortical attunement in mother-child dyads: importance of situational and behavioral characteristics.

Biol Psychol.

2011;88(1):104–11.

https://doi.org/10.1016/j.

biopsycho.2011.06.014.

51.

50.

Morelius E, Brostrom EB, Westrup B, Sarman I, Ortenstrand A.

The Stockholm neonatal family-centered care study: effects on salivary cortisol in infants and their mothers.

Early Hum Dev.

2012;88(7):575–81.

https://doi.org/10.101 6/j.earlhumdev.2011.12.033.


Stern D. The interpersonal world of the infant: a view from psychoanalysis and developmental psychology.

New York: Basic Books; 1985.

Trout M. Presence and attunement in health care: a view from infancy research.

Creat Nurs.

2011;17(1):16–21.

https://doi.org/10.1891/1078-4535.1 7.1.16.

52.

53.

Bowlby J. Attachment and Loss Vol.1 Attachment.

London: Random House; 1969.

54.


Hemmi MH, Wolke D, Schneider S. Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis.

Arch Dis Child.

2011;96(7):622–9.

https://doi.org/10.1136/adc.2010.191312.

55.

Montirosso R, McGlone F. The body comes first.

Embodied reparation and the co-creation of infant bodily-self.

Neurosci Biobehav Rev.

2020;113:77–87.

https://doi.org/10.1016/j.neubiorev.2020.03.003.

56.
56.

Mohd Shukri NH, Wells J, Eaton S, Mukhtar F, Petelin A, Jenko-Praznikar Z, et al.

Randomized controlled trial investigating the effects of a breastfeeding relaxation intervention on maternal psychological state, breast milk outcomes, and infant behavior and growth.

Am J Clin Nutr.

2019;110(1):121–30.

https://doi.org/10.1093/ajcn/nqz033.

57.

Messina S, Reisz S, Hazen N, Jacobvitz D. Not just about food: attachments representations and maternal feeding practices in infancy.

Attach Hum Dev.
Attach Hum Dev.

2020;22(5):514–33.

https://doi.org/10.1080/14616734.2019.1600153.

58.

Widstrom AM, Brimdyr K, Svensson K, Cadwell K, Nissen E. Skin-to-skin contact the first hour after birth, underlying implications and clinical practice.

Acta Paediatr.

2019;108(7):1192–204.

https://doi.org/10.1111/apa.14754.

59.

Matthiesen AS, Ransjo-Arvidson AB, Nissen E, Uvnas-Moberg K. Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking.

Birth.

2001;28(1):13–9.


https://doi.org/10.1046/j.1523-536x.2001.

00013.x.

60. de Vries JI, Visser GH, Prechtl HF.

The emergence of fetal behaviour.

I Qualitative aspects.

Early Hum Dev.

1982;7(4):301–22.

https://doi.org/10.101 6/0378-3782(82)90033-0.

62.

61.

Benoit B, Newman A, Martin-Misener R, Latimer M, Campbell-Yeo M. The influence of breastfeeding on cortical and bio-behavioural indicators of procedural pain in newborns: findings of a randomized controlled trial.

Early Hum Dev.
Early Hum Dev.

2021;154:105308. https://doi.org/10.1016/j.earlhumdev.2021.105308.

Silva GA, Costa KA, Giugliani ER.

Infant feeding: beyond the nutritional aspects.

J Pediatr.

2016;92(3 Suppl 1):S2–7.

https://doi.org/10.1016/j.jped.201 6.02.006.

Schmied V, Beake S, Sheehan A, McCourt C, Dykes F. Women's perceptions and experiences of breastfeeding support: a metasynthesis.

Birth.

2011;38(1): 49–60.

https://doi.org/10.1111/j.1523-536X.2010.00446.x.

63.

64.

Blatz MA, Huston AJ, Anthony MK.


Influence of NICU nurse education on intention to support lactation using tailored techniques: a pilot study.

Adv Neonatal Care.

2020;20(4):314–23.

https://doi.org/10.1097/ANC.

0000000000000702.

Froh E, Dahlmeier K, Spatz DL.

NICU nurses and lactation-based support and care.

Adv Neonatal Care.

2017;17(3):203–8.

https://doi.org/10.1097/ANC.

0000000000000370.

65.

66.


Maastrup R, Rom AL, Walloee S, Sandfeld HB, Kronborg H. Improved exclusive breastfeeding rates in preterm infants after a neonatal nurse training program focusing on six breastfeeding-supportive clinical practices.

PLoS One.

2021; 16(2):e0245273.

https://doi.org/10.1371/journal.pone.0245273.

67.

Bry K, Bry M, Hentz E, Karlsson HL, Kyllonen H, Lundkvist M, et al.
Communication skills training enhances nurses' ability to respond with empathy to parents' emotions in a neonatal intensive care unit.

Acta Paediatr.

2016;105(4):397–406.

https://doi.org/10.1111/apa.13295.

Sigurdson K, Profit J, Dhurjati R, Morton C, Scala M, Vernon L, et al.

Former NICU families describe gaps in family-centered care.

Qual Health Res.

2020; 30(12):1861–75.

https://doi.org/10.1177/1049732320932897.


Ericson J, Palmer L. Cessation of breastfeeding in mothers of preterm infants-a mixed method study.

PLoS One.

2020;15(5):e0233181.

https://doi.

org/10.1371/journal.pone.0233181.

68.

69.

70.

Nyqvist KH, Haggkvist AP, Hansen MN, Kylberg E, Frandsen AL, Maastrup R, et al.

Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations.

J Hum Lact.

2013;29(3):300–9.


https://doi.org/10.1177/ 0890334413489775.

71.

Gerhardsson E, Hildingsson I, Mattsson E, Funkquist EL.

Prospective questionnaire study showed that higher self-efficacy predicted longer exclusive breastfeeding by the mothers of late preterm infants.

Acta Paediatr.

2018;107(5):799–805.

https://doi.org/10.1111/apa.14229.

Thomson G, Moran VH, Axelin A, Dykes F, Flacking R. Integrating a sense of coherence into the neonatal environment.

BMC Pediatr.
BMC Pediatr.

2013;13(1):84. https://doi.org/10.1186/1471-2431-13-84.

Fry TJ, Marfurt S, Wengier S. Systematic review of quality improvement initiatives related to cue-based feeding in preterm infants.

Nurs Womens Health.

2018;22(5):401–10.

https://doi.org/10.1016/j.nwh.2018.07.006.

Lubbe W. Clinicians guide for cue-based transition to oral feeding in preterm infants: an easy-to-use clinical guide.

J Eval Clin Pract.

2018;24(1): 80–8.

https://doi.org/10.1111/jep.12721.

72.

73.

74.

75.
72.

73.

74.

75.

Newland L, L'Huillier MW, Petrey B.

Implementation of cue-based feeding in a level III NICU.

Neonatal Netw.

2013;32(2):132–7.

https://doi.org/10.1891/ 0730-0832.32.2.132.

Shaker CS.

Cue-based feeding in the NICU: using the infant's communication as a guide.

Neonatal Netw.

2013;32(6):404–8.

https://doi.

org/10.1891/0730-0832.32.6.404.

76.

Flacking et al.

International Breastfeeding Journal (2021) 16:88 Page 17 of 17 77.
Thoyre S, Park J, Pados B, Hubbard C. Developing a co-regulated, cue-based feeding practice: the critical role of assessment and reflection.

J Neonatal Nurs.

2013;19(4):139–48.

https://doi.org/10.1016/j.jnn.2013.01.002.

78.

Whetten CH.

Cue-based feeding in the NICU.

Nurs Womens Health.

2016; 79.

20(5):507–10.

https://doi.org/10.1016/j.nwh.2016.08.006.

Theurich MA, McCool-Myers M, Koletzko B.

Supporting breastfeeding of small, sick and preterm neonates.

Semin Perinatol.
Semin Perinatol.

2020;45(2):151387. https://doi.org/10.1016/j.semperi.2020.151387.

80.

Dalgleish SR, Kostecky LL, Blachly N. Eating in "SINC": safe individualized nipple-feeding competence, a quality improvement project to explore infant-driven oral feeding for very premature infants requiring noninvasive respiratory support.

Neonatal Netw.

2016;35(4):217–27.

https://doi.org/10.1 891/0730-0832.35.4.217.

81.

Gianni ML, Sannino P, Bezze E, Plevani L, Esposito C, Muscolo S, et al.
Usefulness of the infant driven scale in the early identification of preterm infants at risk for delayed oral feeding independency.

Early Hum Dev.

2017; 115:18–22.

https://doi.org/10.1016/j.earlhumdev.2017.08.008.

Settle M, Francis K. Does the infant-driven feeding method positively impact preterm infant feeding outcomes.

Adv Neonatal Care.

2019;19(1):51–5.

https://doi.org/10.1097/ANC.0000000000000577.

82.


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