Iran Journal of Nursing

Introduction
Preterm birth is a challenging issue for the healthcare system of countries, which has several complications for newborns such as nutritional disorders that are considered a serious threat to the growth and development of premature infants. These babies often lack the coordination and strength needed to suck and swallow efficiently from the mother’s breast, making breastfeeding a difficult task. The post-discharge period is a critical time for mothers when careful monitoring and follow-up are needed to detect complications early and enhance premature infants’ health. It is important to pay attention to eliminating nutritional deficiencies of infants in the post-discharge period. Failure to address nutritional deficiencies in the post-discharge period leads to weight loss and growth disorders in premature infants, affecting their long-term development. 
Despite various interventions to promote breastfeeding, the exclusive breastfeeding rate in Iran is still below the ideal levels. Efficient breastfeeding requires continuous strengthening of the breastfeeding knowledge and skills in mothers. Breastfeeding self-efficacy is important for assessing maternal nutritional capabilities. Regular monitoring under the supervision of healthcare providers and continuous education can increase the breastfeeding ability of mothers. Follow-up after discharge can make the mother feel efficient in meeting the nutritional needs of her baby. Readmission after discharge is another challenge for premature infants, which is often due to maternal care deficiencies, the infant’s weak immune system, and improper breastfeeding. A 2014 study in Iran reported a 15.3% prevalence of hospital readmission within the first year of life for premature infants. 
Telenursing technology for remote nursing care is an innovative, accessible, and cost-effective solution. This method can link healthcare professionals to mothers, providing essential guidance, education, and emotional support to address their breastfeeding challenges after discharge. Previous studies highlighted the positive impact of telenursing on breastfeeding outcomes. Nevertheless, there is a lack of comprehensive investigations that consider both maternal and infant-related variables. The study aims to investigate the effect of telenursing on breastfeeding self-efficacy, infant weight gain, and readmission to neonatal intensive care units (NICUs) in mothers of premature infants.

Methods
This quasi-experimental study was conducted in three NICUs of Shahid Beheshti, Al-Zahra and Imam Hossein hospitals affiliated to Isfahan University of Medical Sciences in October and November 2022 for eight weeks. A convenience sampling method was used to select 60 eligible mothers with premature infants aged >33 weeks, divided into two groups of 30, including intervention and control. The control group received routine post-discharge face-to-face follow-ups, while the intervention group received eight weeks of online Telenursing care via local mobile messengers (Eitaa and Soroush).
Telenursing interventions focused on addressing specific problems of mothers, including breastfeeding problems, infant feeding problems and other highlighted principles in infant care including infection prevention, screenings, signs and routine neonatal care. Telenursing experts provided recommendations online using video calling, texting, photos, or videos. A multidisciplinary team, including nurses and medical specialists, facilitated 24-hour telenursing support. In-person visits were coordinated when necessary, and clinical and paraclinical examinations were addressed by neonatologists. 
Before and after intervention, the mothers’ breastfeeding self-efficacy, infant weight and re-admission rate were evaluated. Dennis’ 33-item breastfeeding self-efficacy scale was used to measure the mothers’ breastfeeding self-efficacy. The infant weight at the time of discharge was considered the initial weight and the weight measured by growth monitoring centers later was considered the final weight. Data analysis was conducted using descriptive statistics, Kolmogorov-Smirnov test (for testing the normality of data distribution), chi-square test (for testing homogeneity of demographic factors) and t-test (for breastfeeding self-efficacy and infant weight comparisons within and between groups). The NICU readmission rate was reported using descriptive statistics. 

Result
The chi-square test results indicated no significant differences in demographic variables between the two groups (P>0.05). The majority of mothers had age <30 years with infants aged 35-37 weeks. For breastfeeding self-efficacy, the independent t-test results revealed no significant difference in pretest scores between the control and intervention groups (P>0.05). However, following the intervention, a significant difference was found (P<0.05). Furthermore, within-group comparison using paired t-tests demonstrated a significant increase in self-efficacy scores for both control and intervention groups after intervention (P<0.05).
Regarding the infant weight, the independent t-test results demonstrated no significant differences between the control and experimental groups before and after the intervention (P>0.05). However, the paired t-tests within each group revealed a significant increase in weight gain for both control and intervention groups after intervention (P<0.05).
There was only one readmission to the NICU in the control group (3.33%) and zero in the intervention group, indicating the potential positive impact of telenursing intervention on reducing the frequency of readmission to the NICU in premature infants.

Conclusion
Utilizing telenursing programs can be a valuable solution for enhancing breastfeeding self-efficacy and lowering NICU readmission rates in mothers of premature infants after discharge from the hospital. By providing education, counseling, and addressing breastfeeding challenges through online messaging platforms, telenursing interventions can significantly boost maternal confidence in breastfeeding and decrease the need for NICU readmission. Hence, integrating telenursing programs into post-discharge care protocols is highly recommended to optimize the health of premature infants after discharge.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (Code: IR.MUI.NUREMA.REC.1400.055). Written informed consent was obtained from all participants.

Funding
This study was extracted from the doctoral thesis of the first author, funded by Isfahan University of Medical Sciences (Grant No.: 55258).

Authors' contributions
Conceptualization, design, data collection, and data analysis: Atefeh Shamsi; design, methodology, and supervision: Mahboobeh Namnabati; contribution to the study: Asghar Ehteshami and Hamed Zandi Esfahani

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank Shahid Beheshti, Al-Zahra, and Imam Hossein hospitals in Isfahan, as well as all the mothers who participated in the study, for their cooperation.



 

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