Breastfeeding infants with special needs


ragnhildSince beginning her work as a neonatal nurse in 1990, Dr. Ragnhild Maastrup, RN, IBCLC, PhD has witnessed skin-to-skin contact change from “nice-to-do” to “need-to-do.” When Dr. Maastrup began working in the NICU, skin-to-skin contact was implemented for only one or two hours a day for stable preterm infants with Continuous Positive Airway Pressure (CPAP).

“But the day the infant was transferred from the incubator to a cot, the skin-to-skin contact stopped,” Dr. Maastrup says. “Today we facilitate early skin-to-skin contact. We tell the parents that their infant can ‘live on the parents’ chest’ with no time limits, and that skin-to-skin contact should continue at least until breastfeeding is established.”

Dr. Maastrup notes that in Denmark 81 percent of preterm infants in the NICU have initiated skin-to-skin contact within the first 24 hours of life, and 97 percent within the first week of life. Still, she says, daily duration of skin-to-skin contact can be improved; few infants get more than eight hours of daily skin-to-skin.

For the last decade, Dr. Maastrup has worked as a nursing researcher.  She is in charge of the Knowledge Centre for Breastfeeding Infants with Special Needs which gathers, systematizes, and develops knowledge on breastfeeding infants with special needs at Rigshospitalet and in Denmark and internationally. The Knowledge Centre makes the knowledge accessible for health professionals.

Dr. Maastrup explains that because preterm infants, infants with malformations, and infants who are sick for other reasons have special needs in regard to breastfeeding, the Knowledge Centre aims to develop practice and new knowledge in Rigshospitalet and Denmark so that care, treatment and counseling, in relation to breastfeeding infants with special needs, will be uniform, evidence-based and of high quality.

“The most common misconception about breastfeeding infants with special needs is that preterm infants need a certain weight or age to initiate breastfeeding,” Dr. Maastrup explains. “Breastfeeding should be initiated with infant stability as the only criterion.”

“I have supported mothers in placing their 800 grams baby at the breast to lick, taste and suck a little – and the babies did,” she goes on. “If the infants are physically stable with respiratory support, they can also suck while having CPAP.”

When asked to describe some of the most fascinating findings discovered through her main research areas– breastfeeding of preterm infants and skin-to-skin contact between preterm infants and their parents– Dr. Maastrup shares this:

We did a large cohort breastfeeding study in Denmark with participation of 1488 preterm infants, 68 percent were exclusively breastfed at discharge (breastfeeding defined as feeding at and from the breast.) We found that use of nipple shields for preterm infants was associated with a more than double risk of not being exclusively breastfed at discharge, and did not speed up the establishment of exclusive breastfeeding.


We also found that minimizing the use of a pacifier when the preterm infant should breastfeed more was positively associated with exclusive breastfeeding and speeded up the establishment of exclusive breastfeeding with one day.


Together with the cohort study we did a survey of breastfeeding support in Danish NICUs showing that breastfeeding is supported for example by recommendations of early initiation of breast milk expression and skin-to-skin contact, and that bottles rarely are used in preterm infants when exclusive breastfeeding is the goal.


I have also studied skin-to-skin contact in 22 extremely preterm infants with an average weight of 700 grams, and found that they tolerated the skin-to-skin contact without significant changes in skin temperature or physical stability. 


Dr. Maastrup’s thesis, Breastfeeding of preterm infants. Associated factors in infants, mothers and clinical practice, can be found at Lund University’s website:

A member of the Nordic and Quebec Working Group, Dr. Maastrup attended the First International Neo-BFHI Conference and Workshop, held in 2011 where participants from 24 nations gathered. The Second International Neo-BFHI Conference was held just this year with participants from 32 nations.

The aim of the Nordic and Quebec Working Group was to expand WHO/UNICEF’s BFHI Ten Steps to neonatal care by examining the evidence in relation to breastfeeding promotion, protection and support in neonatal wards; develop and adapt the BFHI’s standards and criteria; and develop and pilot test an assessment tool to evaluate neonatal units compliance with the criteria, Dr. Maastrup explains.

“To remain consistent with the WHO/UNICEF 2009 update of the BFHI standards, the expansion to neonatal wards closely follows the original Ten Steps to Successful Breastfeeding,” Dr. Maastrup says.  “Furthermore, to ensure that recommended practices focus on respect to mothers, a family-centered approach and continuity of care, the working group formulated three Guiding Principles meant to be basic tenets in all of the Ten Steps.”

The guiding principles cover all infants and families in the NICU regardless of breastfeeding or not, she adds.

“After the first conference many BFHI Country Coordinators and international experts from 20 countries have given their invaluable feedback to the Neo-BFHI Core document and performed pilot tests of the confidential Neo-BFHI External Assessment Tool,” Dr. Maastrup shares.

At the second conference, Dr. Maastrup and colleagues presented the final Neo-BFHI package which includes:

  • The Core document with recommended standards and criteria for Three Guiding Principles and Ten Steps to protect, promote and support breastfeeding in neonatal wards
  • A Self-Appraisal Tool to assess standards and criteria
  • Educational material for decision-makers and staff.
  • An External Assessment Tool (confidential, sent to the BFHI country coordinators.)

The Neo-BFHI package helps implement strategies in the neonatal intensive care units that will facilitate breastfeeding. The Neo-BFHI package can be found here.

At the 2016 International Breastfeeding Conference in Orlando, Fla., Dr, Maastrup will present Breastfeeding of Preterm Infants: Associated factors in infants, mothers, and clinical practice as well as co-present Neo BFHI: A Worldwide Expansion Project.

Dr. Maastrup says she is looking forward to sharing knowledge, being inspired, and becoming wiser at the International Breastfeeding Conference.
Register here for the opportunity to network and learn from Dr. Maastrup herself!

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