Mother’s own milk (MOM) provided to an infant is by far the best source of nutrition available. We know, though, that there is a marked disparity between mothers who are providing MOM initially, and those that continue to pump or breastfeed prior to or shortly after NICU discharge.
In addition, we know low income populations are at an even greater risk for discontinuing pumping and/or breastfeeding prior to the six month mark of exclusive breast milk feeding recommended by the American Academy of Pediatrics (AAP).
The importance of support and knowledge
I spoke with Twyla Hemmans, a clinical educator at Newark Beth Israel Hospital in Newark, New Jersey, about some of the challenges they face in a large inner city NICU. She confirmed, as stated in a marked amount of literature, that lack of support and lack of knowledge about the importance of MOM are significant barriers to mothers continuing to provide breast milk beyond their infant’s length of stay in the hospital.
Pumping and breastfeeding rates are significantly higher during a hospital stay than at discharge. This happens for a variety of reasons, including lack of knowledge regarding specific benefits of breastfeeding, a lack of role models, lack of support from fathers, and lack of support from employers when returning to work. Another challenge is the idea that breastfeeding is described as “natural,” but it is also a learned art for positioning, ensuring baby has a good latch, and ways to stimulate an infant, which may not come “naturally.”
Let’s first discuss the mothers’ lack of knowledge regarding specific benefits of breastfeeding.
A national survey found that only ¼ of the U.S. public agreed that feeding a baby with infant formula instead of breast milk increases the chances the baby will get sick.¹ This could be due to a variety of reasons, but one reason may be the heavy marketing and promotion of infant formula, and how mothers feel it has been enhanced over the years, and is therefore equivalent to breast milk. It is so important that this topic is discussed at prenatal visits, even as early as the first several visits.
It takes a lot of time and patience as a bedside nurse or lactation consultant when teaching mothers about the importance of MOM, as well as offering support and encouragement when it comes to mothers’ physical and emotional health in response to how they feel about their experience. This can be almost impossible with limited resources.
If you are a nurse with several patients, or work in a hospital that has limited lactation consultants, this can magnify the frustration a mom feels because she has limited professional support during her breastfeeding journey.
To help moms and hospital staff navigate this challenge, there are educational and support programs that have been incorporated into hospitals like “Feeding Your Baby” and “Parent Buddy Program” that provide additional resources to encourage mothers and help them successfully overcome breastfeeding barriers in the NICU.² At Newark Beth Israel, some PA’s have taken a Certified Lactation Counselor® (CLC) course. That has been encouraging to the staff in their own experience with patients. When all members of the team are willing participants, it fosters a supportive environment for everyone involved, including other clinicians and mothers.
Many mothers have heard that breastfeeding is natural. I know as a clinician in the NICU I always prefaced helping a mother breastfeed by saying, “I know you may have heard how natural it is for a baby to breastfeed. If it were that easy and natural, no hospital would go to the expense of hiring lactation consultants and sending staff nurses through breastfeeding education courses. If your baby latches the first time, just know you are one of the VERY RARE instances this happens. All I’m expecting at this point is to have your baby root some, maybe lick, and for you both of you to relax and enjoy this bonding time together.” That releases mom from the expectations and fears of “not doing it right,” thinking “my baby doesn’t like my milk,” or “I don’t have enough milk.”
Lack of role models is another significant barrier to breastfeeding. Let’s face it, breastfeeding is no easy task. Compound that stress with the stress of a baby in the NICU and limited emotional support. A mother needs the encouragement of trusted family and peers to support her breastfeeding journey in such an unnatural environment.
Level of support from fathers plays a large part in a mother’s willingness or ability to continue breastfeeding after discharge. A randomized controlled trial that included a two-hour prenatal intervention with fathers on how to be supportive of breastfeeding found a far higher rate of breastfeeding initiation among participants’ partners; 74% vs. 14% in the control group.
In another trial, mothers whose partners attended a program on how to prevent and address problems with lactation (fear, pain, low milk supply) were 25% more likely to be breastfeeding at 6 months compared to 15%, whose partners were only taught the benefits of breastfeeding.¹
Many mothers return to work early and, depending on their employer, may not have full support or an adequate place to pump. For example, they may receive pressure from co-workers about the time they spend pumping during their work day. Hourly wage earners are at greater risk for discontinuing pumping. That can be due, in part, to the fact they have less control over their schedules and because they are an hourly employee, they earn less money when they spend time away pumping.³’⁴
There are many challenges mothers face when it comes to breastfeeding or pumping. Milk supply, being one of those, decreases for a variety of reasons. The emotional impact of a baby in the NICU exacerbates the problem.
Discussing a mom’s situation and asking a few questions may help her identify ways to increase her supply. One question I always ask is how often they are pumping. Most moms will say they are pumping 8x/day. We know that isn’t always true. Remember, though, mom may simply be too embarrassed to admit she isn’t pumping.
Hemmans told a story about a mother who lived at a boarding house and did not have access to a freezer to store her milk. The NICU nurse, not realizing she didn’t have her own freezer, told the mom they couldn’t store any more milk because they had limited access in the NICU as well. Once they determined it was due to the fact she was in the boarding home and did not have a freezer, the social worker was able to intervene, provide a freezer for her to store her milk, and she continued pumping.
We can all help
It is imperative that all bedside nurses, not just lactation consultants, are trained to help mothers breastfeed. We refer to breast milk as “medicine” for our patients. That’s just one reason we, as healthcare professionals, need to feel confident about providing support to a mother.
It’s important for us to intervene when mom needs to pump or breastfeed her baby at the bedside. Hemmans said they do not have individual rooms and for that reason space and privacy can be an issue. Something as simple as offering a screen so that mom can pump can be instrumental in making mom feel supported and comfortable.
We want the best for mothers and babies in our care. Educating and supporting mothers through their breastfeeding journey is an incredible way we can provide just that.
- Barriers to breastfeeding in the United States – The Surgeon General’s Call to Action to Support Breastfeeding. (2011). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK52688/
- Bracht, M. (Fall 2008). Supporting Breastfeeding in a NICU. Newsletter of the Infant Mental Health Promotion Project (IMP). Retrieved from https://www.sickkids.ca/pdfs/IMP/21427-28IMPReprint-Bracht.pdf
- Centers for Disease Control and Prevention – Division of Community Health. A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease. Atlanta, GA: US Department of Health and Human Services (2013). Breastfeeding Practices and Policies.
- Heinig, M.J., Ishii, K.D., & Banuelos, J. (March 2006). Overcoming Barriers to Breastfeeding in Low-Income Women. A Policy Brief on Preventing Obesity in Early Childhood – Produced by the California WIC Association and the UC Davis Human Lactation Center.