The feeding process in preterm infants is a difficult process for both infants and mothers due to adverse factors such as neonatal morbidities, poor contact with parents, delayed breastfeeding, and other factors (23). In order to manage this process correctly, mothers should have knowledge about feeding of the preterm infant and be able to make effective and reliable practices. Therefore, it was aimed to examine the knowledge, attitude, and practice of mothers about feeding their preterm infants. In this current study, majority of mothers had high level of knowledge and practice about infant feeding, and also had positive attitudes about feeding their infants.
More than half (58.6%) of the preterm infants in our study were bottle-fed, and the proportion of infants fed by breastfeeding was very low. In a study conducted with preterm infants, similar to our study, the rates of feeding with breastfeeding were very low, and therefore, the success rate could increase with specific interventions and better support (23).
In addition, most of the preterm infants had a history of orogastric tube feeding during NICU stay. McCain et al. reported that feeding methods alternative to oral feeding are used when preterm infants cannot achieve sucking-swallowing-respiratory coordination (24). Raol et al. reported that sucking-swallowing-respiratory coordination was achieved in the 34th week of gestation (25). Most of the preterm infants in this study had a history of orogastric tube feeding may be associated with an average of 30 weeks of gestation.
Most of the mothers in the present study were young and first-time mothers, and majority of them (80.5%) were trained during discharge from the NICU. Rohana et al. conducted a KAP study in mothers of preterm infants about the sudden infant death syndrome, it was revealed that mothers mostly obtained information by doing research on the Internet (26). Therefore, considering the information pollution in the internet environment, it would be more appropriate for mothers to be educated by health professionals, as in our study, instead of getting information from the Internet.
In our study, 58.5% of the mothers of preterm infants had a high level of knowledge, and mothers evaluated their own level of knowledge as high. Meier et al. reported that feeding problems of preterm infants are often caused by the lack of knowledge and practice. In addition, it has been reported that mothers generally receive advice from friends and families rather than healthcare professionals, and these recommendations are not suitable for preterm infants or infants at risk. It was emphasized that a standardized education should be given to mothers by a NICU nurse (13). In our study, the majority of the mothers received feeding training during NICU discharge. Thereby, it was thought that NICU training contributes to the knowledge level of mothers about feeding.
Lewallen et al. reported that mothers usually received feeding education and support during the NICU stay, however most were not supported at home. They reported that mothers of preterm infants should also be educated about feeding after discharge (27). In our study, a low-to-moderate relationship was found between feeding education and the level of knowledge. Thus, it can be concluded that training programs aimed at educating preterm infant mothers on feeding should be supported.
Ahmed et al. provided 5 sessions of feeding education to mothers of preterm infants and the training program not only improved the practices of mothers, but also increased their knowledge about feeding and prematurity (28). In our study, a strong relationship was found between the level of knowledge and practice. Thus, it can be concluded that if the mothers have a good level of knowledge about infant feeding, they make more effective and safe practices.
Another favorable finding in the current study was the positive attitudes of mothers regarding feeding. Mothers thought that preterm infants are in a group that needs attention in terms of feeding and swallowing. They stated that adequate feeding of preterm infants is an important issue that should be followed up to prevent developmental problems, and mothers should be knowledgeable about feeding for maintaining better practices. The positive attitude of mothers of preterm infant is crucial to provide a quality care. It was known that preterm infants have problems in oral feeding due to differences in muscle tone, sucking-swallowing-respiratory coordination, regulation and endurance (29-31). These often cause malnutrition in preterm infants, and feeding is associated with long-term motor, cognitive and neurodevelopmental outcomes (32). It is known that the mothers’ knowledge and attitudes are important for maintaining better practices (13).
In general, feeding practices of mothers that support knowledge and attitude results were also seen as appropriate and good. Lubbe et al. reported that mothers performed better practices when they learned to understand hunger, satiety, and stress cues about their infants (14). In our study, presence of feeding education was found to be related to the level of practice. As a result, the feeding education given by the health professional may enable mothers to practice feeding effectively and safely.
In our study, the mothers had a mild level of momentary and a moderate level of long-lasting anxiety. After NICU discharge, parents are asked to take responsibility for the daily care of their high-risk infants at home, which causes stress on parents. Studies have reported that the anxiety experienced while providing care increases after discharge, and can persist for 6 months or longer for mothers of preterm infants (33, 34).
Lubbe et al. reported that mothers who applied the cue-based feeding method had better care skills, which result in decreased stress related to feeding (14). Pickler et al. reported that the infant's weight gain increased, the hospital stay was shortened with the cue-based feeding method, and thereby, the parental workload decreased, care skills increased, and stress levels decreased (32). In our study, it was found that as the level of knowledge increased, the level of practice of the mothers increased, and the level of anxiety of the mothers decreased as the level of knowledge and practice increased. Based on this, it is thought that the effective and correct practice performed with appropriate knowledge reduces the mother's workload and anxiety level.
This present study is the first to reveal the KAP of mothers with preterm infants in terms of feeding, and to investigate the relationship between these factors and anxiety levels. In future studies, the KAP and concerns of mothers who received feeding education and support both in the NICU and after discharge can be evaluated. The key points of the study and our recommendations are:
Mothers of preterm infants should be trained by health professionals about infant feeding.
Infant feeding counseling and education should be given not only during and discharge from NICU, but also continue after discharge.
Mothers' anxiety levels and workload can be decreased by effective and correct practice performed with knowledge. In addition, mothers should be supported in coping with anxiety.