Supporting breastfeeding and the provision of breast milk is an important task in the NICU. Dozens of studies now show improved outcomes specific to extremely premature infants. Babies who receive breast milk have fewer infections, sepsis, necrotizing enterocolitis, less chronic lung disease, retinopathy of prematurity, reduced time to full enteral feeds, and it has been linked with better cognitive outcomes.1-7 Over the long term, breast milk provides unique advantages into adulthood that influence such things as cardiovascular health, bone health and cognitive function.8, 9 Breastfeeding may also reduce risk of obesity and diabetes and has been linked with lower cholesterol levels in later life.9, 10 In addition to these medical health benefits, there are also psychological benefits to breastfeeding. The skin-to-skin contact during breastfeeding helps in physiologic stabilization of the infant and increased maternal infant bonding in a situation where this is more difficult – the NICU.
Most NICU nurses today agree that breast milk is at least important in the immediate period and particularly as related to prevention of necrotizing enterocolitis. It may sometimes be difficult to understand why the promotion of breastfeeding is such a challenge in the NICU. I have recently come across a study by Cricco-Lizza that puts this into perspective.11 This is an ethnographic study that reports the results of interviews with nurses in a Level IV or highest level NICU. This NICU had recently had some breastfeeding education but not all staff attended this education. The purpose of the study was to examine everyday practice values and explore how breastfeeding promotion fits into this.
I recently wrote a blog about the cultural influence of breastfeeding, focusing on the culture of the mother. However, there is a culture that exists in the NICU as well. Culture may be defined as “a learned social behavior of a particular group of people.” This unique culture in the NICU is described by Cricco-Lizza as focusing on tight control of actions, reliance on technology and maximal efficiency in use of time with the overall themes of uncertainty and teamwork or “sisterhood.”11 The reports of nurses who were interviewed for this study are very familiar to me! As a staff nurse, getting the routine, once-a-shift “chores” taken care of early in the shift was always important because you never knew when a sick baby might come through the doors, taking away any extra time you might have thought you would have or one of the babies on your assignment list would take a turn for the worse, become unstable and require far more care than at first anticipated. This theme of uncertainty is extremely common in the intensive care setting. The tight control of actions refers to things like the careful and precise measurement of medications, intravenous fluids, oxygen and recognizing small changes in infants early enough to respond quickly.
Reliance on technology becomes so important in the NICU to almost be distracting from attention to the patient! More and more technology provides the tight control desired but also creates more dependence on the technology and brings another level of challenge to the nurse at the bedside. The length of orientation, particularly to high level NICU care, is necessarily longer today because there are so many more machines that must be learned. Those already experienced in NICU care learn new technology as it comes along but still can feel overwhelmed in order to get skilled at the use and interpretation of an onslaught of information!!
The final theme Cricco-Lizza describes is maximal efficiency in use of time.11 Talk to any NICU nurse and she/he will tell you about how busy the day can be! Not usually every day but many days, particularly in high-acuity, high-census units with active birthing units where babies come into the world with different problems and in need of NICU care without notice can be very, very busy. While nurse-patient ratios may help, extra nurses are not always available and certainly for unexpected admissions or changes in patient condition.
So, how does this impact the promotion of breastfeeding? One can see that the importance of efficiency, tight control and reliance on technology fly in the face of the absolutely “tech-less” task of breastfeeding, where nurses have no control other than perhaps when it will be done. Infants who are learning to eat are less than efficient whether breastfeeding or bottle feeding but with bottle feeding, one can measure the progress at least by watching milk disappear.
The unit described by Cricco-Lizza was working on improving breastfeeding and many of the nurses interviewed could see the benefit and need for the change.11 There are many aspects of the NICU that are needed to create a culture change that fosters this move toward breastfeeding friendliness. Bonet et al describe some measures in units that had higher breastfeeding rates versus those with low rates.12 Units with higher rates encouraged parental presence at all times, provided space for pumping and direct breastfeeding, and talked to all mothers about breastfeeding and pumping early after delivery. One important point to make here is that the benefit of provision of breast milk is not just during the initial and critical period the infant spends in the NICU. The benefit extends beyond discharge. Many nurses feel that by encouraging the mother to pump early after birth and provide milk for the first few weeks or even during the NICU stay is success. While this is better than nothing, the benefits of breast milk extend far beyond the NICU stay and should be encouraged.
Mothers faced with caring for a medically complex/fragile infant may be willing to give up breast feeding unless the importance of continuing is stressed. Also, assisting the mother with direct breast feeding before discharge where she can be assured that the infant is receiving enough milk and tolerating it well will help her to be more confident in continuing to breast feed. One of the units described in the Bonet et al study did not place importance on direct breast feeding prior to discharge.12 An interviewee in this unit said that it would be better to have the mother put the infant to breast after discharge where she had more time and the baby could latch on gradually. Another unit was concerned about the bacterial content of the freshly expressed milk and tested all milk or pasteurized all milk, including mother’s own milk prior to feeding. This meant that the infant had little of the mother’s milk early on, leading to mothers thinking that their milk was unclean and not worth the effort to pump, also creating worry that it may not be good for the infant.
Bonet et al found that units with policies and procedures, particularly encouraging open and extensive visitation of mothers, advocating for early pumping, early use of mother’s own milk and starting direct breast feeding well before discharge were most helpful in sustained breastfeeding during and after discharge.12 Nurses who either had their own positive experience with breast feeding or had breast feeding education were more likely to be supportive and encourage mothers to provide breast milk and breastfeed. NICU nurses, in this study, were observed to focus more on the scientific evidence of breast feeding when talking to parents about it rather than the psychologic/psychosocial aspects. This appears to reflect the focus on technology and the science of infant care that was a high priority in this high level NICU. The findings in a NICU caring for less critical infants may be different and may show a different type of support for breast feeding mothers. In order to change breast feeding support, several aspects of unit culture must be considered. This may include taking into account the time needed for breast feeding support when calculating acuity and staffing levels. Placing value on the time required to support breastfeeding in this manner will provide the necessary time for it to be done. Often, the lower technologic measures like proper positioning, sound control and yes, encouraging breast feeding, make as much difference in outcome as the latest electronic equipment used in the NICU.
Learn more about Medela’s hospital human milk feeding solutions:
Breast pumps and breastfeeding accessories, enteral feeding,
warming and delivery
- Johnston M, Landers S, Noble L, Szucs K, Viehmann L. Breastfeeding and the use of human milk. Mar 2012;129(3):e827-841.
- Schanler RJ, Lau C, Hurst NM, Smith EO. Randomized trial of donor human milk versus preterm formula as substitutes for mothers’ own milk in the feeding of extremely premature infants. Pediatrics. Aug 2005;116(2):400-406.
- Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants’ risk of necrotizing enterocolitis or death. J Perinatol. Jan 2009;29(1):57-62.
- Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O’Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol. Jul 2007;27(7):428-433.
- Vohr BR, Poindexter BB, Dusick AM, et al. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics. Oct 2007;120(4):e953-959.
- Hylander MA, Strobino DM, Pezzullo JC, Dhanireddy R. Association of human milk feedings with a reduction in retinopathy of prematurity among very low birthweight infants. Journal of perinatology. Sep 2001;21(6):356-362.
- Patel AL, Johnson TJ, Engstrom JL, et al. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol. Jan 31 2013.
- Lucas A. Long-term programming effects of early nutrition – Implications for the preterm infant. J Perinatology. 2005;25(S2-S6).
- Ip S et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Tech Assess 2007.
- Owen CG, Whincup PH, Kaye SJ, Martin RM, Davey Smith G, Cook DG et al. Does initial breastfeeding lead to lower cholesteral in adult life? A quantitative review of the evidence. American Journal of Clinical Nutrition. 2008;88:305-314.
- Cricco-Lizza, Roberta. “Everyday nursing practice values in the NICU and their reflection on breastfeeding promotion.” Qualitative health research. 2010;21(3):399-409.
- Bonet, Mercedes, et al. “Approaches to supporting lactation and breastfeeding for very preterm infants in the NICU: a qualitative study in three European regions.” BMJ open6 (2015): e006973.