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Breastfeeding outcomes in European NICUs: impact of parental visiting policies
  1. Marina Cuttini1,
  2. Ileana Croci1,
  3. Liis Toome2,3,
  4. Carina Rodrigues4,
  5. Emilija Wilson5,
  6. Mercedes Bonet6,7,
  7. Janusz Gadzinowski8,
  8. Domenico Di Lallo9,
  9. Lena Carolin Herich1,
  10. Jennifer Zeitlin6
  11. on behalf of the EPICE Research Group
    1. 1 Clinical Care and Management Innovation Research Area, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
    2. 2 Department of Neonatal and Infant Medicine, Tallinn Children’s Hospital, Tallinn, Estonia
    3. 3 Department of Pediatrics, University of Tartu, Tartu, Estonia
    4. 4 EPI Unit, Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
    5. 5 Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
    6. 6 Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Centre for Epidemiology and Biostatistics (U1153), Inserm UMR 1153, Paris, France
    7. 7 Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
    8. 8 Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
    9. 9 Hospital Network Planning and Research Area, Lazio Regional Health Authority, Rome, Italy
    1. Correspondence to Dr Marina Cuttini, Clinical Care and Management Innovation Research Area, Bambino Gesù Children’s Hospital, IRCCS, Rome 00146, Italy; marina.cuttini{at}


    Objective The documented benefits of maternal milk for very preterm infants have raised interest in hospital policies that promote breastfeeding. We investigated the hypothesis that more liberal parental policies are associated with increased breastfeeding at discharge from the neonatal unit.

    Design Prospective area-based cohort study.

    Setting Neonatal intensive care units (NICUs) in 19 regions of 11 European countries.

    Patients All very preterm infants discharged alive in participating regions in 2011–2012 after spending >70% of their hospital stay in the same NICU (n=4407).

    Main outcome measures We assessed four feeding outcomes at hospital discharge: any and exclusive maternal milk feeding, independent of feeding method; any and exclusive direct breastfeeding, defined as sucking at the breast. We computed a neonatal unit Parental Presence Score (PPS) based on policies regarding parental visiting in the intensive care area (range 1–10, with higher values indicating more liberal policies), and we used multivariable multilevel modified Poisson regression analysis to assess the relation between unit PPS and outcomes.

    Results Policies regarding visiting hours, duration of visits and possibility for parents to stay during medical rounds and spend the night in unit differed within and across countries. After adjustment for potential confounders, infants cared for in units with liberal parental policies (PPS≥7) were about twofold significantly more likely to be discharged with exclusive maternal milk feeding and exclusive direct breastfeeding.

    Conclusion Unit policies promoting parental presence and involvement in care may increase the likelihood of successful breastfeeding at discharge for very preterm infants.

    • very preterm infants;
    • parental involvement
    • maternal milk

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    • Contributors MC conceived this work, supervised statistical analyses and drafted the paper. She contributed to designing the data collection instrument, and coordinated data collection in the Emilia Romagna and Marche regions. IC carried out statistical analyses and contributed to the interpretation of the findings. She made substantial contributions to data collection in Emilia Romagna and Marche regions. LT contributed to designing the data collection instrument, coordinated data collection in Estonia and critically revised the paper for important intellectual content. CR coordinated data collection in Portugal regions and participated in the preparation of the manuscript and interpretation of findings. EW contributed to designing the data collection instrument and to the acquisition of the data in Sweden; she participated in drafting the paper and in the interpretation of the findings. MB participated in designing the data collection instrument and in creation of the study database. She critically reviewed the paper for important intellectual content, and contributed to the interpretation of the findings. JG contributed to designing the data collection instrument, coordinated the study in Poland, critically revised the paper and contributed to finalise it. DDL contributed to designing the data collection instrument, coordinated the study in the Lazio region, participated in the interpretation of the results and critically revised the manuscript. LCH made substantial contributions to data analyses and interpretation and participated in drafting the paper. JZ initiated and coordinated the project at the international level, drafted the data collection instrument, made substantial contributions to the interpretation of the results and participated in drafting and finalising the paper. All authors have seen and approved the submission of this version of the manuscript, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The EPICE project was funded by the European Union’s Seventh Framework Programme (FP7/2007-2013), under Grant Agreement n° 259882. Additional funding was received in the following regions: France (French Institute of Public Health Research/Institute of Public Health and its partners the French Health Ministry, the National Institute of Health and Medical Research, the National Institute of Cancer and the National Solidarity Fund for Autonomy; grant ANR-11-EQPX-0038 from the National Research Agency through the French Equipex Program of Investments in the Future; and the PremUp Foundation); Poland (2012–2015 allocation of funds for international projects from the Polish Ministry of Science and Higher Education); Portugal (funds from The Portuguese Foundation for Science and Technology to the Epidemiology Research Unit of the Institute of Public Health of the University of Porto (UID/DTP/04750/2013) and for the individual grant SFRH/BD/111794/2015 to CR); Sweden (regional agreement on medical training and clinical research -ALF- between Stockholm County Council and Karolinska Institutet, and by the Department of Neonatal Medicine, Karolinska University Hospital); UK (funding for The Neonatal Survey from Neonatal Networks for East Midlands and Yorkshire & the Humber Regions).

    • Disclaimer The funders had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report or in the decision to submit the article for publication.

    • Competing interests None declared.

    • Patient consent Parental/guardian consent obtained.

    • Ethics approval Hospital or Regional Ethics Committees of participating regions according to national legislation.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Collaborators BELGIUM: Flanders (E. Martens, G. Martens, P. Van Reempts); DENMARK: Eastern Region (K. Boerch, A. Hasselager, L. Huusom, O. Pryds, T. Weber); ESTONIA (L. Toome, H. Varendi); FRANCE: Burgundy, Ile-de France and Northern Region (P.Y. Ancel, B. Blondel, A. Burguet, P.H. Jarreau, P. Truffert); GERMANY: Hesse (R.F. Maier, B. Misselwitz, S. Schmidt), Saarland (L. Gortner); ITALY: Emilia Romagna (D. Baronciani, G. Gargano), Lazio (R. Agostino, D. DiLallo, F. Franco), Marche (V. Carnielli), M. Cuttini; NETHERLANDS: Eastern & Central (C. Koopman-Esseboom, A. Van Heijst, J. Nijman); POLAND: Wielkopolska (J. Gadzinowski, J. Mazela); PORTUGAL: Lisbon and Tagus Valley (L.M. Graça, M.C. Machado), Northern region (C. Rodrigues, T. Rodrigues), H. Barros; SWEDEN: Stockholm (A.K. Bonamy, M. Norman, E. Wilson); UK: East Midlands and Yorkshire and Humber (E. Boyle, E.S. Draper, B.N. Manktelow), Northern Region (A.C. Fenton, DWA Milligan); INSERM, Paris (J. Zeitlin, M. Bonet, A. Piedvache).