A mother’s culture and family beliefs have a significant effect on her decision to breastfeed, length of breastfeeding, breastfeeding exclusivity, and other infant feeding practices. However, women whose infants are admitted to the NICU have other influences on this decision and continued practice. I remember a period of time when mothers were encouraged to provide milk for their infant “for at least the first 2 weeks.” Of course, any human milk is better than none, but this is a very short period of time that certainly does not provide many of the benefits we know to be associated with breastfeeding.
The culture of the NICU in general can have an influence on the continued supply of maternal milk. Nurses go into NICU, in many cases, for the high acuity, high tech experience. Most nowadays recognize the value of human milk, but may not support the act of breastfeeding over concern for a fragile infant. While Dr. Meier’s studies,1,2 now many years old, showed that sucking from a breast resulted in less distress than sucking from a bottle, direct breastfeeding is a concern because you “can’t see the baby closely enough,” and “don’t know how much the baby is getting,” and it may be a foreign concept to some, particularly for a first feeding. Nurses often want to give the first feeding themselves to “see how the baby does.” Therefore, it is from a bottle, and the baby may, in fact, not do well – thus discouraging the process of putting the baby to breast.
Even for nurses who support direct breastfeeding and have sufficient experience and education to support mothers in this process, it takes a lot of nursing time and attention that might be in short supply in a busy, high acuity environment.
In a fairly recent study by Hallowell, Spatz, Hanlon, and others, 6,060 NICU nurses were questioned about their work environment and breastfeeding support.3 Those nurses worked in 104 different NICUs. Nurses reported giving breastfeeding support to 14% of the infants they cared for on the last shift they worked. That doesn’t take into account the actual needs of the infants they were caring for, i.e. whether the infant was receiving feedings or not. There was no attempt to define “breastfeeding support” through the survey. They did find, however, that with inadequate staffing, parental support and teaching was the most frequently rationed nursing activity. Staffing was highly correlated with breastfeeding support, or lack of it!
Other studies have shown that having a lactation consultant dedicated to the NICU results in improved initiation and duration rates of breastfeeding. In that study, half of the sample NICUs had no lactation consultant available. So, if the mother was not getting breastfeeding support and education from the nurse, it was unlikely that she was getting it. We know that, given most staffing acuity matrixes, infants who are “growing and feeding” are the lowest acuity and staffed with more patients to nurses, leaving less time for the parent teaching that is often needed most at this point in the infant’s hospitalization.
Day-to-day feeding practices
In an ethnographic study by Cricco-Lizza,4 in which NICU nurses were asked about infant feeding beliefs and day to day feeding practices in the NICU, NICU values revealed that nurses confronted uncertainty through firm control of care, reliance on technology, and strict time efficiency, but that these values also posed challenges to nursing efforts to promote breastfeeding. The results of the interviews could be categorized into three main themes. These were:
- Nurses identified health benefits of breastfeeding, but spoke in greater detail and with more emotion about day-to-day challenges of breastfeeding in the NICU.
- Formula feeding evoked less emotion and most nurses viewed it as safe and convenient.
- Despite infant feeding challenges in the NICU, nurses who had breastfeeding continuing education and/or some positive experiences with breastfeeding identified evidence-based breastfeeding benefits for mothers and babies, emphasized the health-based differences between human milk and formula, and were more committed to working through difficulties with breastfeeding.
Challenges nurses identified included the stress mothers faced by having an infant in the NICU, which may affect their milk supply, not having gotten a good milk supply started from the beginning, and the challenges of pumping to be followed by direct breastfeeding. In addition, nurses identified environmental constraints and lack of privacy for breastfeeding in the NICU.
Nurses talked about the extra work involved in feeding human milk from a bottle, like defrosting and warming the milk, doing a 2 RN check, and making sure it had not gotten past the expiration date. When directly breastfeeding, nurses talked about the challenges and disturbance to the infant having to do pre- and post-weight checks to determine how much the baby ate. One shared that sometimes she would just hand the mother a bottle to avoid the extra time to help her breastfeed.
Others felt formula feeding was safe and faster (maybe forgot to defrost frozen milk). One shared that with formula, you didn’t have to do the 2 RN check and so it was easier to get a bottle of formula. “It’s not someone’s secretions so we don’t really check as much. I think the bottle is easier.” In some cases, there was distrust about what was in the mother’s milk and if it would be safe for the baby.
Education and awareness
Finally, in keeping with the last theme, those who had breastfeeding education (about 30%) were committed to providing human milk to the baby, although the time issue was still present. Some of those nurses also shared that, “it’s definitely a lot more work,” and some still shared that they would just give the mother the bottle due to time constraints. Many nurses’ beliefs were based on their own experiences rather than the science of lactation.
That paper shared what some of us have found in our own experience in the process of obtaining Baby Friendly status. The 20-hour breastfeeding course (15 hours of didactic instruction and 5 hours of clinical supervision) that is part of the program was not specifically written for the NICU. Many nurses who were required to attend the course found it not applicable to the NICU babies they cared for, and therefore resented the time they spent getting the information. Certainly, education has shown an improvement in NICU nurses’ acceptance of and ability to support mothers in breastfeeding efforts, so other programs and lactation consultants may be necessary to accomplish this.
At the end of the day, there may be many obstacles to providing the best breastfeeding support. But with an awareness of staffing constraints, day-to-day feeding practices, and the right education, we can make a difference that benefits babies, their mothers, and the nurses that care for them.
- Meier P, Anderson GC. Responses of small preterm infants to bottle-and breast-feeding. MCN: The American Journal of Maternal/Child Nursing. 1987 Mar 1;12(2):97-105.
- Meier P. Bottle-and breast-feeding: effects on transcutaneous oxygen pressure and temperature in preterm infants. Nursing research. 1988;37(1):36-41.
- Hallowell SG, Spatz DL, Hanlon AL, Rogowski JA, Lake ET. Characteristics of the NICU work environment associated with breastfeeding support. Advances in neonatal care: official journal of the National Association of Neonatal Nurses. 2014 Aug;14(4):290.
- Cricco-Lizza R. Infant feeding beliefs and day-to-day feeding practices of NICU nurses. Journal of pediatric nursing. 2016 Mar 1;31(2):e91-8.