Of the 678 cases screened, 400 infants were recruited after obtaining informed consent. A total of 364 cases were eligible for complete data analysis after exclusion of eight infants and 28 mothers due to refusal of consent and loss to follow-up (Fig. 1). The baseline demographic details of the neonates and parents are presented in Table 1.

Table 1 Baseline data for neonates and mothersFeeding practices at discharge, at 4 weeks and at 8 weeks

Figure 2 shows the rates of exclusive breastfeeding, exclusive infant formula feeding and any breastfeeding at the time of NICU discharge, at 4 weeks and at 8 weeks. The rates of exclusive breastfeeding were 20% at discharge (73 / 364; 95% CI 16.2, 24.4), 54% at 4 weeks (197/364; 95% CI 48.9, 59.1) and 42% at 8 weeks (153 / 364; 95% CI 37, 47.1). The rates of any breastfeeding were 64% (233 / 364; 95% CI 58.9, 68.7), 40% (146 / 364; 95% CI 35.2, 45.2) and 43% (157 / 364; 95% CI 38.1, 48.2) at discharge, 4weeks and 8 weeks, respectively. The rates of exclusive formula feeding were 16% (58 / 364; 95% CI 12.5, 20), 6% (21 / 364; 95% CI 3.8, 8.6) and 15% (54 / 364; 95% CI 11.5, 18.8) at discharge, 4 weeks and 8 weeks, respectively.

Fig. 2

Feeding practices at discharge, 4-week follow-up and 8-week follow-up

Feeding practices compared with neonatal and maternal parameters

The breastfeeding rates at discharge, 4 weeks and 8 weeks were compared with gestational age, duration of NICU stay, mode of delivery, parity, language, maternal educational level, occupational status, and family income. These data are shown in Table 2.

Table 2 Feeding practices and neonatal and maternal parameters

Term gestation predominated in the study population, and the median was 38 weeks. When comparing different gestational age groups and the breastfeeding type and rate of feeding, it was observed that neonates who had a lower gestational age had better breastfeeding rates at the time of discharge (exclusive breastfeeding for preterm birth < 34 weeks was 66% (31 / 47) and for gestation > 35 weeks was 13% (42 / 317)), but multivariable analysis did not show a statistically significant association between the gestational age and mode of feeding at the time of NICU discharge or during follow-up at 4 weeks and 8 weeks (Table 3).

Table 3 Adjusted analysis for exclusive breastfeeding vs. nonexclusive breastfeeding at discharge, 4 weeks and 8 weeks, with various neonatal and maternal parameters

The duration of the NICU stay had a wide range from one to 55 days, with a median of 3 days. When comparing breastfeeding type and rates with the duration of NICU stay, neonates who had NICU stays less than 4 days had exclusive breastfeeding rates of only 7.4% (14 / 188) (Table 2). Adjusted analysis showed higher exclusive breastfeeding rates at the time of NICU discharge for neonates with NICU stays longer than 1–3 days. Adjusted odds of exclusive breastfeeding for NICU stays of 4–7 days were 3.000 (95% CI 1.25, 7.198) compared with the reference group of NICU stays of 1–3 days; NICU stays of 8–14 days had an AOR of 11.679 (95% CI 3.19, 42.69); NICU stays > 15 days had AOR 30.648 (95% CI 6.62, 141.89). However, this association between feeding types and the duration of the NICU stay was no longer significant at 8 weeks (Table 3).

When compared with other neonatal and maternal parameters by multivariable regression analysis, there was no significant relation between the age of parents, educational status of mothers or income group and the method of feeding at NICU discharge or during the four-week and eight -week follow-ups. However, employed mothers were found to have lower exclusive breastfeeding at 8 weeks (AOR 0.51; 95% CI 0.29, 0.87).

Neonates delivered by lower segment cesarean section (LSCS) were noted to have higher infant formula feeding rates at the time of NICU discharge (23%; 42 / 187 vs. 9%; 16 / 177), but multivariable regression analysis did not show a statistically significant association (Tables 2 and 3). Similarly, Arabic-speaking mothers were noted to have higher exclusive infant formula feeding practices at the eight-week follow-up (22%; 29 / 130 vs. 10%; 24 / 234), but this observation was not statistically significant by multivariable regression analysis.

Feeding practices in relation to breastfeeding education and support

Feeding education and its relationship with the mode of feeding are summarized in Table 4.

Table 4 Feeding practices and breastfeeding education and support

Ninety-five percent (347 / 364) of mothers said that they were advised and recommended to breastfeed, but only 48% (167 / 347) said that this education was given prepartum and 86.4% (301 / 348) said that it was given by a verbal method only. Ninety-one percent (331 / 364) of mothers said that they received family support for breastfeeding, 61% (222 / 364) said they received support from hospital staff, and 20% (72 / 364) said they received support from friends. We used logistic regression to calculate the AOR to find the association of exclusive breastfeeding with breastfeeding education and support. We did not find a statistically significant relationship between exclusive breastfeeding and the mode of education and support (odds ratios of various parameters are presented in Table 5).

Table 5 Adjusted analysis for exclusive breastfeeding vs. nonexclusive breastfeeding at discharge, 4 weeks and 8 weeks, for mode of educationBreastfeeding attitudes

During the four-week follow-up, mothers were asked about their attitudes and beliefs about breastfeeding and their preferences for infant formula milk. Although 82% (298 / 364) said that formula milk could lead to overfeeding, 16% (58 / 364) of mothers believed that formula milk was healthier. Whereas 33% (120 / 364) preferred formula milk for night-time feeding and for travel, 13% (46 / 364) believed that their baby’s crying may have been due to low breast milk and opted for formula milk feeding during that time. A total of 16.5% (60 / 363) of mothers felt that formula milk was better for employed mothers.