Prolonged Oropharyngeal Mother's Own Milk Administration to Extremely Preterm Infants: The POP-MOM Study – A Quasiexperimental Study

doi:10.21203/rs.3.rs-4701602/v1

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Research Article

Prolonged Oropharyngeal Mother's Own Milk Administration to Extremely Preterm Infants: The POP-MOM Study – A Quasiexperimental Study

https://doi.org/10.21203/rs.3.rs-4701602/v1

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Background: Previous studies have assessed the safety of short-term application of oropharyngeal colostrum to preterm infants for 5-7 days. These studies revealed no differences in necrotizing enterocolitis (NEC) rates, infection, death, or feeding at discharge.

Research aims: This study aimed to investigate the association between prolonged oropharyngeal mother's own milk (POP-MOM) administration (from birth to oral transition) and the prevalence of receiving mothers’ own milk and head growth at discharge or survival without morbidities in extremely preterm (EPT < 30 weeks) infants.

Methods: The study design is quasiexperimental, with an intervention group using POP-MOM administration and a historical control group before implementing this practice. The intervention group received POP-MOM as soon as it became available and continued until the oral transition of feedings was achieved. All EPT infants admitted to the NICU without contraindications to human milk were included. The main outcome measured was receiving any volume of the mother's own milk (MOM) at discharge. The secondary outcomes assessed were insufficient head growth (head circumference < P3) at discharge and preterm-related morbidities, including severe intraventricular hemorrhage (IVH≥3), chronic lung disease (CLD), necrotizing enterocolitis (NEC), sepsis, and cystic periventricular leukomalacia (PVL).

Results: The study included 217 EPT infants, 120 patients in the control group, and 97 in the intervention group. No antenatal or clinical differences were observed between the two groups. Of the total number of infants, 189 (87.0%) survived in the NICU, and at the time of discharge, 171 (90.4%) were breastfed at least once a day. After implementing the POP-MOM protocol, there was an increased likelihood of receiving any volume of MOM at discharge in extremely preterm infants (RR=1.10, 95% CI=1.02-1.21; p=0.01). The intervention group also had lower rates of insufficient head growth (RR=0.47; 95% CI 0.23-0.98; p=.04). We did not observe complications as a result of implementing this practice.

Conclusions: Prolonged administration of the oropharyngeal mother's milk protocol was associated with an increased frequency of infants receiving any MOM volume and improved head growth at NICU discharge.

Study registration: This study is registered under the number 61359516.1.0000.5330 at the Brazilian Federal Research Registration Platform.

Extremely Preterm Infants

Oropharyngeal Mother's Own Milk (POP-MOM)

Neonatal Intensive Care Unit (NICU)

Mother's Own Milk (MOM)

Head Growth

Necrotizing Enterocolitis (NEC)

Breastfeeding Outcomes

Preterm birth is the leading cause of death in children under five years old, with Brazil experiencing a 10% preterm birth rate among live births (1). Mortality is notably higher in infants born at less than 30 weeks of gestational age. Nutritional support, particularly the administration of human milk, notably maternal milk (MOM), is vital for reducing morbidities such as necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), and metabolic syndrome later in life, as well as mortality in extremely preterm infants (2) (3).

Colostrum, which is rich in immune components, offers crucial protection, especially in mothers of the least mature infants. Opened tight junctions in the mammary epithelium facilitate the transfer of these protective factors, which may persist longer after birth in mothers of preterm infants. Oropharyngeal administration of MOM stimulates an immune response (4) in oropharyngeal-associated lymphoid and gut-associated lymphoid tissues (5) (6), potentially offering significant benefits, including a shorter time to achieve full enteral feedings. Following preterm birth, the closure of tight junctions in the mammary epithelium may be delayed, resulting in prolonged availability of these protective products in the early postbirth period (Montagne, Cuillière, Molé, Béné, & Faure, 1999; Ronayne de Ferrer, Baroni, Sambucetti, López, & Ceriani Cernadas, 2000).

Several studies have explored the possible benefits of oropharyngeal colostrum (OPC) administration. A recent meta-analysis showed no significant differences in clinical outcomes, except for a shorter time to achieve full enteral feedings (Nasuf, Ojha, & Dorling, 2018). Most of those studies included infants who received OPC for 3 to 5 days, with only one study extending administration up to 30 weeks corrected gestational age (CGA) (7). This gap highlights the need for research on the long-term effects of prolonged oropharyngeal MOM (POP-MOM) administration.

Undernutrition poses serious risks to preterm infants' developing brains, emphasizing the importance of MOM, which contains essential bioactive components crucial for modulating inflammatory responses and preventing infections. Longitudinal studies indicate neurodevelopmental benefits from human milk (8, 9), correlating with the duration of MOM provided during NICU stays. Encouraging MOM extraction and provision during NICU care can significantly improve preterm infants' outcomes. Therefore, implementing practices that promote the extraction of human milk and increase the provision of mothers' own milk (MOM) during neonatal intensive care unit (NICU) stays could benefit preterm infants.

This study aimed to examine whether the introduction of a prolonged oropharyngeal administration of mothers’ own milk (POP-MOM) protocol spanning from birth to oral transition, was associated with a greater incidence of receiving any volume of mothers’ own milk at the time of discharge and reduced preterm-related complications in extremely preterm (EPT < 30 weeks) infants. By addressing the gap in existing research on the long-term application of oropharyngeal MOM, this study seeks to contribute valuable insights into optimizing nutritional strategies for extremely preterm infants, thereby improving their survival and developmental outcomes.

Aim:

This study aimed to investigate the association between the implementation of a prolonged oropharyngeal administration of mothers’ own milk (POP-MOM) protocol and increased breastfeeding rates at NICU discharge, as well as reduced main morbidities in extremely preterm (EPT < 30 seeks) infants.

Design

We conducted a quasiexperimental study in a 27-bed level III private NICU in Porto Alegre, RS, Brazil. This study design was appropriate for investigating the association between implementing a POP-MOM protocol and increased breastfeeding rates at NICU discharge or reducing main morbidities in EPT infants. The study received approval from the Institutional Ethics Review Board for the protection of human subjects and is registered under the number 61359516.1.0000.5330.

Setting

The study took place at a private level III NICU located in the capital city of a southern state in Brazil. This city has a population of 1.5 million, making it the twelfth most populous city in the country. The majority of the population has European ancestry. The hospital is a recognized private nonprofit institution. It is distinguished by the Brazilian Ministry of Health as one of Brazil's five hospitals of excellence, serving as the sole representative from the country's southern region. Approximately 43% of the city's population has private insurance, and the hospital provides care only to patients covered by private insurance. The overall rate of exclusive breastfeeding at hospital discharge is approximately 90%.

During the study period, an average of 3,500 births occurred yearly, with 450 NICU admissions, including approximately 60 infants with very low birth weights. Feeding decisions, such as initiation, advancement, fortification, and discontinuation, were consistently made according to the unit's protocol and remained unchanged throughout the study. As the NICU does not have a milk bank and the commercialization of human milk is not permitted in Brazil, the mother's own milk (MOM) was the only available human milk source for all admitted preterm infants. In cases where MOM was not available, a preterm formula was prescribed. Enteral feedings were initiated as soon as MOM became available, and a bovine milk fortifier (FM 85®) was added to all infants according to the unit's protocol.

The NICU provided lactation support, education, and access to breast expression equipment. A schedule was implemented for mothers to share the available hospital-grade breast expression devices in a communal lactation room. Mothers were informed about the importance of the mother's milk, and trained staff supervised the operation of the expression devices and the handling and storage of the milk. Mothers were allowed to stay in the NICU without time restrictions, although they were encouraged to take breaks during the day and go home at night for sleep.

Once the infants reached 34 weeks postmenstrual age and achieved clinical stability, mothers were allowed to initiate breastfeeding during the day under supervision. If MOM was available at night, it was offered to the infants via bottle. In cases where MOM was unavailable, preterm milk formula was introduced.

Sample

The control group, which included patients born between 2013 and 2015, received mothers’ own milk (MOM) as the preferred feeding choice for all preterm infants. Parents were educated about the importance of mothers’ milk and provided support to initiate and maintain milk production throughout the NICU stay. As the NICU did not have a milk bank, all human milk offered was unpasteurized mother's own milk.

In 2016, prolonged oropharyngeal mothers' milk (POP-MOM) was administered in the NICU. The protocol for obtaining and administering POP-MOM was initiated once mothers were deemed clinically stable to express milk. Mothers’ milk was collected from trained personnel in prelabeled sterile vials and stored at the Center of Special Food Processing in a common refrigerator for 12 hours. If the accumulated volume was not used, the sample was frozen and stored for 15 days. Each day, 1 ml syringes containing 0.2 ml of the mother's own milk were prepared. Before administration, the syringes were heated for 5 minutes in the infant's incubator. The nurse administered 0.1 ml on each side of the oral mucosa at every enteral feeding. Vital signs were monitored before and after POP-MOM administration, and any signs of tachycardia, bradycardia, tachypnea, bradypnea, or desaturations during and within 5 minutes after POP-MOM administration were reported to the on-call neonatologist.

The administration of oropharyngeal MOM, which involved giving 0.2 ml of the mother's own milk directly to the oropharyngeal mucosa, was offered alongside enteral feedings as prescribed by physicians. Parents were also invited to learn and administer POP-MOM to their infants, and the first semester focused on team training, prescription inclusion, and reporting adverse effects to the medical team. POP-MOM was prescribed to the patient's neonatologist consultants as an optional approach. In the second semester of 2016, the practice was evaluated and adjusted accordingly, and the prescription became mandatory.

The intervention group consisted of patients born between 2017 and 2019. Trained staff continued to supervise the operation of the expression devices and milk handling and storage. The assistant neonatologist decided to use enteral nutrition following the NICU feeding protocols. Trophic enteral feedings were initiated when the mother's milk became available. POP-MOM administration was interrupted only if the patient displayed signs of hemodynamic instability associated with the administration of vasopressor drugs. The POP-MOM implementation timeline is shown in Fig. 1.

Data collection

The maternal and infant data collected for analysis included mode of delivery, multiples, antenatal steroid administration, gestational age, birth weight, head circumference at birth, sex, and length of stay. The main outcome measured was receiving any volume of the mother's own milk (MOM) at NICU discharge, considering all diets offered within 72 hours before discharge. The secondary outcomes assessed were major preterm-related morbidities and insufficient head growth.

The major morbidities considered in the study were necrotizing enterocolitis (NEC), severe intraventricular hemorrhage (IVH ≥ 3), periventricular leukomalacia (PVL), and any late infection, defined as the presence of positive bacterial or fungal growth in blood or cerebrospinal fluid starting from the third day of life. Coagulase-negative Staphylococcus was classified as a true infection when accompanied by symptoms.

The definition of chronic lung disease (CLD) in infants < 33 weeks of gestation is based on an algorithm that is more accurate than the definition of oxygen at 36 weeks of gestation.

Insufficient head growth at discharge was diagnosed if the head circumference of the infants on the day of discharge was lower than the third percentile for gestational age and sex, as per the Fenton growth chart (Fenton & Kim, 2013). All maternal and infant demographic and medical data were collected following the definitions of the Vermont-Oxford Network database (Horbar, Soll, & Edwards, 2010).

The antenatal characteristics analysis included data from all extremely preterm (EPT) infants, while primary and secondary outcomes were calculated solely for patients who survived until discharge.

The data were collected from January 2013 to December 2019. Eligible patients were identified, and two neonatologists invited the parents or legal guardians to participate in the study. Informed consent was obtained from the parents or legal guardians to collect clinical data from medical records. The same two neonatologists followed the included patients every week until NICU discharge, prospectively gathering all maternal and infant demographic and medical information. If there was any disagreement regarding the data definition, a third neonatologist was consulted to resolve it. All collected data were deidentified and stored in password-protected files to ensure participant confidentiality.

Data Analysis

Statistical analyses were conducted using SAS software version 9.4 (SAS Institute Inc., 2013). A significance level of p < .05 was used to determine statistical significance. Descriptive statistics, including medians, 25th and 75th percentiles, means, standard deviations, counts, and percentages, were used to summarize the data.

Considering a confidence level of 95%, a power of 80%, and a previous prevalence of 80% of any MOM at discharge (nonpublished data), we calculated that a sample of 73 patients in each group would detect an increase in the primary outcome from 80% in the control group to 95% in the experimental group.

The study population was divided into two groups: Group 1 (control), which consisted of infants born before the implementation of the POP-MOM protocol, and Group 2 (intervention), which included infants born after the implementation and consolidation of the POP-MOM protocol. Patients born during the year of protocol implementation were not included.

Group differences were compared using Pearson's chi-square test with Yates' continuity correction. The normality of the data was assessed using the Shapiro‒Wilk test. For nonnormally distributed data, the Mann‒Whitney test was used as appropriate. Univariate relative risk (RR) estimates with 95% confidence intervals (CIs) were calculated.

During the study, 217 EPT infants were included, with 120 patients allocated to the control group and 97 patients allocated to the intervention group. Considering all the EPT infants included in the study, the median gestational age was 27 weeks (IQR 26–29), and all mothers received antenatal care. The median birth weight was 960 g (IQR 710–1210). Of the total number of infants, 189 (87.0%) survived hospitalization, and at the time of discharge, 171 (90.4%) were directly breastfed at least once a day. After the implementation period, the only adverse effect observed was excessive salivation in infants with birth weights < 1.000 g. When this was observed, POP-MOM administration was adjusted to every other enteral feeding administration until the patient achieved a weight of 1.000 g.

Table 1 displays the antenatal characteristics of all EPT infants included, and Table 2 contains continuous variables that were similar between the two groups. The only observed clinical difference between the groups was a slightly greater birth weight in Group 2, which was not statistically significant (Table 2).

Table 1

Antenatal Characteristics of **All** Extremely Preterm (GA < 30 weeks) Infant Participants Included (N = 217)
	Group 1 (Control) (n = 120)	Group 2 (Intervention) (n = 97)	X²
Variable	n (%)	n (%)	df = 1	p
Antenatal CE	107 (89.1)	89 (91.7)	0.19	0.65
Cesarian section	105 (87.5)	87 (89.6)	0.10	0.75
Male	64 (53.3)	50 (51.5)	0.06	0.79
Multiples	42 (35.0)	40 (41.2)	0.66	0.41
HC < p3	20 (16.6)	9 (9.2)	1.93	0.16
HC < p10	30 (25.0)	24 (24.7)	0.04	0.96
Survival	102 (85.0)	87 (89.6)	1.05	0.30
GA = gestational age; CE = corticosteroids; HC = head circumference

Table 2

Comparisons of Continuous Variables Grouped According to Exposure to Prolonged Oropharyngeal Colostrum (POPC) among **All** Extremely Preterm (GA < 30 Weeks) Infant Participants Included (N = 216)
	Group 1 (Control) (n = 119)	Group 2 (Intervention) (n = 97)
Variable	M (IQR)	M (IQR)	W	p
BW (grams)	920 (700–1205)	1045 (845–1270)	1916	0.05
GA (weeks)	27 (26–28)	28 (26 − 20)	2126	0.28
LOS (days)	72 (51–92)	74 (55–98)	15566	0.16
BW = birth weight; GA = gestational age; LOS = length of stay

Table 3 shows the outcomes of the EPT infants who survived to discharge. Analysis of the main and secondary outcomes in infants who survived discharge revealed an increase in the likelihood of receiving any volume of the mother's own milk at discharge after the implementation of the POP-MOM protocol (RR = 1.10, 95% CI 1.02–1.21; p = .01). Patients in the intervention group had less insufficient head growth (RR = 0.47; 95% CI 0.23–0.98; p = 0.04).

Table 3

Outcomes of Extremely Preterm (GA < 30 weeks) Infant Participants Who **Survived** to Discharge (N = 189)
	Group 1 (Control) (n = 102)	Group 2 (Intervention) (n = 87)
Variable	n (%)	n (%)	RR	95%IC
Sepsis	41 (40.2)	35 (40.2)	1.00	0.70–1.41
NEC	14 (13.7)	14 (16.0)	1.17	0.59–2.32
Surgical NEC	2 (1.9)	2 (2.3)	0.85	0.12–5.92
IVH ≥ 3	11 (10.7)	5 (5.7)	0.53	0.19–1.47
PVL	9 (8.8)	3 (3.4)	0.39	0.10–1.39
CLD	14 (13.7)	17 (19.5)	1.42	0.74–2.71
Any MOM	88 (86.2)	83 (95.4)	1.10	1.02–1.21
HC < p10	31 (30.3)	33 (37.9)	1.24	0.83–1.85
HC < p3	22 (21.5)	9 (10.3)	0.47	0.23–0.98
GA = gestational age; NEC = necrotizing enterocolitis; IVH = intraventricular hemorrhage; PVL = periventricular leukomalacia; CLD = chronic lung disease; MOM = mother’s own milk; HC = head circumference; p3 = percentile 3

This study aimed to investigate the associations between the use of a prolonged oropharyngeal mother's own milk (POP-MOM) administration protocol and the prevalence of any mother's own milk (MOM) at NICU discharge, head growth at discharge and survival without major morbidities in EPT infants. The results offer valuable insights into the potential benefits of the POP-MOM protocol in improving breastfeeding rates and certain outcomes in an extremely preterm infant population.

Our study revealed a high incidence of breastfeeding at discharge (90.4%) and an increase in the likelihood of receiving any volume of MOM at discharge following the implementation and consolidation of the POP-MOM protocol. This finding highlights the potential benefit of the protocol in promoting the provision of mothers’ milk to the most vulnerable and premature infants, who are at greater risk of adverse outcomes.

A similar finding was reported in a prospective, randomized clinical trial including 99 preterm (< 32 weeks) infants (10). Although their results did not show statistically significant differences for receiving any fortified breastmilk at discharge or any unfortified breastmilk at discharge between infants receiving OPC and controls, when combining these outcomes, OPC administration was associated with increased rates of any MOM at discharge (p = .04)

Another notable finding was that the proportion of infants in the intervention group whose head circumference was below the 3rd percentile for gestational age at discharge decreased, indicating improved head growth. The control group had a 16.3% prevalence of HC < p3 at birth, and it increased to 21.3% at discharge. The POP-MOM group, on the other hand, had an HC < p3 at birth of 12.9%, which decreased to 10.3% at discharge. This suggests that the POP-MOM protocol may also positively affect head growth, an important indicator of brain development. We hypothesize that this finding might be connected to a longer duration of MOM exposure in the intervention group.

The results of this study align with previous research highlighting the importance of mothers' own milk in improving outcomes for preterm infants. Recently, Lund et al. reported a positive association between increased MOM intake and HC growth from birth to 32 weeks postmenstrual age (3). Human milk has been associated with better neurodevelopment outcomes. Belfort et al. (8) reported better IQ and learning ability performance at 7 years in a large cohort of preterm infants who received > 50% enteral intake of breast milk. More recently, Blesa et al. (9) showed that greater exposure to breast milk was associated with improved structural connectivity in preterm MRI studies. Ottolini et al. (11) also showed that early feeding of breast milk is associated with greater cerebral volume, which may explain better neurodevelopment outcomes. Furthermore, the study's focus on head growth as an outcome measure is noteworthy.

While head circumference may be an essential indicator of neurodevelopmental outcomes, other studies have also examined the impact of breastfeeding on other morbidities in preterm infants, such as necrotizing enterocolitis and sepsis (12). A systematic review by Miller et al. (2) revealed that the use of human milk was associated with a reduced risk of late-onset sepsis, severe ROP, and severe NEC in preterm infants. In contrast, the current study did not find significant differences in morbidities between the control and intervention groups. These discrepancies may be attributed to the fact that the NICU where the study was conducted has an elevated breastfeeding rate at discharge, which may have contributed to diluting the influence of implementing the POP-MOM protocol on other outcomes.

Mothers’ milk also contains essential bioactive factors that modulate inflammatory responses, prevent infections, and contribute to brain development. Therefore, providing POP-MOM offers noninvasive mechanisms that allow vulnerable preterm infants to benefit from the advantages of MOM. Martín-Álvarez (13) showed that the administration of OPC for 15 days decreased the proinflammatory state of preterm infants. Although we did not find differences in outcomes related to the inflammatory response, our study adds to the existing evidence by specifically investigating the impact of the OPC protocol on breastfeeding rates and outcomes in VLBW infants. Additionally, we studied the effects of POP-MOM protocol implementation, not specifically how this impacted MOM volume.

Future research should focus on conducting larger randomized controlled trials in diverse clinical settings to further evaluate the effectiveness of the POP-MOM protocol. Additionally, exploring long-term neurodevelopmental outcomes and evaluating the impact of the protocol on the incidence of major morbidities such as necrotizing enterocolitis, intraventricular hemorrhage, and chronic lung disease would provide a more comprehensive understanding of the benefits of the intervention.

Mothers’ own milk is the first choice for preterm infants, and there is a well-documented dose-dependent effect on decreasing morbidity in the most vulnerable preterm infants (2). Healthcare professionals must be educated to recognize human milk feeding as a cost-effective strategy to reduce complications related to prematurity, especially in middle- and low-income countries (MICs and LICs). Implementing a protocol such as the POP-MOM is a simple and feasible strategy for starting, supporting, and promoting the duration of the MOM. The fact that it can be started as soon as mothers are clinically stable may help to overcome the difficulty preterm mothers have in coming to volume, as described by Hoban et al. (14). Being able to maintain mothers breastfeeding their preterm infants to NICU discharge is important because data show that breastfed groups have better neurodevelopmental outcomes despite a slower weight gain (15).

Limitations

While the findings are encouraging, certain limitations of the study must be

considered. The quasiexperimental design might introduce potential confounding factors and

limit the ability to establish causality. Additionally, the study was conducted in a single

private NICU, with a population with socioeconomic characteristics that might not reflect reality in public settings. This may limit the generalizability of the findings to other settings.

This study provides evidence supporting the implementation of the prolonged oropharyngeal mother's own milk (POP-MOM) administration protocol as a potential strategy to improve head growth and enhance the provision of the mother's own milk (MOM) to extremely preterm infants. The findings underscore the importance of promoting breastfeeding and optimizing nutritional care for EPT infants, which can have significant implications for their short- and long-term outcomes. The main findings in this study are the implementation of the POP-MOM protocol was associated with a high incidence of breastfeeding at discharge, indicating its potential to enhance the provision of MOM to EPT infants. The study also found a decrease in the proportion of infants with head circumference below the third percentile at discharge in the intervention group, suggesting a positive impact on head growth, an important indicator of brain development.

The results highlight the critical role of mother’s own milk in improving the health outcomes of preterm infants. The POP-MOM protocol, by promoting the use of MOM, offers a non-invasive, cost-effective intervention that can be easily implemented in NICUs. This approach not only supports the immediate nutritional needs of EPT infants but may also contributes to their neurodevelopmental outcomes, potentially reducing the risk of adverse morbidities associated with prematurity. This study’s findings advocate for broader adoption of the POP-MOM protocol, emphasizing the need for healthcare professionals to prioritize and support breastfeeding practices in NICUs.

BPD: Bronchopulmonary Dysplasia

CGA: Corrected Gestational Age

CI: Confidence Interval

CLD: Chronic Lung Disease

EPT: Extremely Preterm

HC: Head Circumference

IVH: Intraventricular Hemorrhage

LIC: Low-Income Country

MIC: Middle-Income Country

MOM: Mother's Own Milk

NEC: Necrotizing Enterocolitis

NICU: Neonatal Intensive Care Unit

OPC: Oropharyngeal Colostrum

POP-MOM: Prolonged Oropharyngeal Mother's Own Milk

PVL: Periventricular Leukomalacia

RR: Relative Risk

VLBW: Very Low Birth Weight

Ethics approval

This study received approval from the Institutional Ethics Review Board for the protection of human subjects and is registered at the Federal Platform for Resesarch registration under the number 61359516.1.0000.5330.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

"The authors declare that they have no competing interests" in this section.

Funding: None.

Authors' contributions:

FMG contributed to the conception, design, interpretation, and drafted the work.

DFVV contributed to the conception and revision of the manuscript.

MFCS contributed to the conception, acquisition, interpretation, and revision of the manuscript.

CTF contributed to the analysis, interpretation of data, and revision of the manuscript

MGO contributed to the conception, design, acquisition, analysis, and interpretation of data and was a major contributor to writing the manuscript.

All authors read and approved the final manuscript.

Acknowledgements

We thank the medical and nursing staff, patients, and their parents at Moinhos de Vento for cooperating. Thanks to the Research Support Division for their epidemiological and statistics contribution. Special thanks to Ângela Viau and Jessica Minho, who contributed to the initial steps of this project.

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No competing interests reported.

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Prolonged Oropharyngeal Mother's Own Milk Administration to Extremely Preterm Infants: The POP-MOM Study – A Quasiexperimental Study

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