The American Academy of Pediatrics recommends exclusive breastfeeding for infants for the first six months of life and continued breastfeeding for one year or longer (AAP, 2012). Breast milk has many health benefits for infants, including decreased rates of respiratory infections, asthma, ear infections, and gastrointestinal illnesses. For preterm infants in the neonatal intensive care unit (NICU), breast milk feeding has decreased the risk of necrotizing enterocolitis by 77% (AAP, 2012).
Although rates are going up, according to the latest Centers for Disease Control and Prevention (CDC) report (2016), 81.1% of women initiate breastfeeding their infants. Breastfeeding exclusivity and duration rates decline rapidly, and only 22.3% of infants are exclusively breastfeeding at six months after birth (CDC, 2016). The Surgeon General’s Call to Action to Support Breastfeeding addresses the necessity for health care providers to be educated about delivering evidence-based lactation care and support (U.S. Department of Health and Human Services, 2011).
Anatomy and Physiology
The anatomy and physiology of the lactating breast begins its development during pregnancy (Neville, M. & Morton, J, 2001). Progesterone levels elevate and the ductal lobules within the breast increase in number and size. During pregnancy, secretory differentiation occurs as fat globules increase in size in the cells of the mammary gland, referred to as stage I Lactogenesis. High levels of circulating progesterone during pregnancy inhibit the release of prolactin. At the time of birth, progesterone levels
drop upon delivery of the placenta, and the onset of copious milk secretion occurs, referred to as stage II Lactogenesis. As prolactin secretion takes place by either the newborn’s suckle at breast, or in the absence of direct breastfeeding, the effective use of a hospital-grade (multi-user) breast pump, milk removal occurs and milk secretion is maintained. Failure of efficient milk removal at this time can lead to breast involution and insufficient milk volume.
Preterm infants in the NICU demonstrate immature suckling capability for adequate milk removal (Geddes et al, 2017). Recent ultrasound studies indicate that oral vacuum is instrumental in milk removal. For the preterm infant, the degree of vacuum strength is compromised compared to the term infant, and this impacts feeding effectiveness. Until the preterm infant can overcome limitations caused by neurological or developmental immaturity, and respiratory conditions such as immature coordination of suck-swallow-breathing, effective pumping allows a mother to maintain milk expression.
Early Breast Milk Expression
Research demonstrates improved health benefits for all infants, especially infants weighing < 1500 g at birth, or very low birth weight (VLBW) infants (Parker, L.A. et al. 2012). Decreased morbidity associated with prematurity, feeding intolerances, sepsis and necrotizing enterocolitis are a few examples. Providing the nutrition of exclusive breast milk for premature infants in the NICU can be very challenging for mothers, despite its heightened necessity for this vulnerable population of newborns to receive their mother’s own milk (MOM).
Dr. LA Parker at the University of Florida in Gainesville, FL has performed extensive research on the subject of early initiation of breast milk expression on the impact of milk volume (Parker et al, 2012; Parker et al, 2015). Lactogenesis stage II occurs with the change from production of small quantities of colostrum to copious amounts of breast milk. For mothers delivering term infants, this stage takes place after delivery of the placenta with a decrease in progesterone, effective removal of milk from the breast, and ongoing prolactin levels. Preterm delivery and a delay in breastfeeding have been associated with a delay in Lactogenesis II. Mothers of preterm infants may be affected by decreased mammary gland development and decreased exposure to prolactin, cortisol and other hormones that occur during term pregnancy. Delayed lactogenesis can lead to inadequate milk volume and discontinuation of milk expression, or breastfeeding.
Secretory activation, initiation of copious milk secretion, occurs 30-40 hours after birth for the term infant who is capable of efficient milk removal. There are rapid increases in milk secretion at this time such that infant milk transfer increases from less than 100 mL/day on day one post-delivery to between 500-750 mL/day by day 5, and reaching 750-800 mL/day on average by one month (Saint, Smith, Hartmann 1984). Transition from Lactogenesis II to a sufficient milk output at two weeks for exclusive breastfeeding has been termed “coming to volume” (CTV) by Dr. Paula Meier and her research team at Rush University Medical Center in Chicago, IL (Meier et al, 2016). Once CTV is achieved at two weeks post-birth, some pumpdependent mothers are able to decrease pumping frequency and still maintain adequate milk output (Edwards & Spatz, 2010).
Initiate and Maintain Maternal Milk Volume
Establishment of breastfeeding for the very low birth weight (VLBW) preterm infant is fraught with many obstacles (Parker et al, 2012; Geddes et al, 2017). Often these infants are too ill to directly breastfeed immediately after birth. The method of initial oral feeding is often per feeding tube. A main priority at this time is the initiation and establishment of maternal milk volume. Recent evidence demonstrates expressing breast milk within an hour of delivery has a significant impact on how much milk volume mothers are able to produce at six weeks post-delivery. It has also been demonstrated that there is a strong correlation between the frequency of pumping and milk volume.
Research studies demonstrate mothers of infants in the NICU who are breast pump-dependent experience problems with delayed lactogenesis and inadequate milk volume. Only 29% of mothers of preterm infants were able to provide exclusive mother’s own milk throughout the NICU stay in one study (Schanler et al, 2005). Recent studies comparing different breast pump suction patterns and implementation of pumping within 1 hour of birth may reduce the number of mothers who cannot produce enough milk volume (Meier et al, 2010; Meier et al, 2012).
The first two weeks are a critical time for the initiation of an adequate milk supply (Meier et al, 2011). “Milk production is enhanced with pumps that mimic infant suckling patterns in the first few days of life” (Meier et al, 2012). Term infants exhibit an irregular, intermittent sucking pattern of rapid sucking bursts followed by long pauses (Santoro W., Jr. et al, 2010). Dr. Diane Spatz, a renown researcher and Director of the lactation program at Children’s Hospital of Philadelphia outfitted all breast pumps in the NICU with Medela© Symphony Plus® breast pumps featuring the Initiation Technology™ to facilitate the removal of colostrum and support the establishment of milk supply. (Fugate et al, 2015). While it is beyond the scope of this article to describe more fully the evidence-based breast pump technology, mothers using this technology had significantly higher milk volumes by day 14 post-delivery.
To facilitate early initiation of pumping, it is the primary responsibility of the nursing staff to educate the mother on pump use and the safe handling of human milk (Fugate et al., 2015). Expressed breast milk needs to be used in the order pumped for the first two weeks to maximize protein intake and immunological properties. NICU mothers are educated to label the bottles of their expressed milk in pumping session order from 1 to 60 (Meier et al., 2011). After these bottles are used, fresh nonfrozen human milk is preferable to frozen milk since immunomodulatory proteins are reduced by the freezing process (Akinbi et al., 2010).
Human Milk Oral Care
Human milk oral care is the process of applying fresh breast milk to an infant’s oral mucosa with a swab. Performing this care by mothers of infants hospitalized with congenital diaphragmatic hernia (CDH) was determined to have an impact on mothers to remain motivated to keep pumping and build their milk supplies (Froh, E. et al, 2015). Though research was performed for infants with CDH, it applies to all infants separated from mothers by hospitalization.
Evidence-Based Best NICU Practice
The ability of mothers to have adequate milk volume to exclusively feed their infants mother’s own milk (MOM) feedings from the NICU days through to discharge is based on best practice changes within NICU settings. All of the aforementioned implementation strategies are based on in-depth evidence for optimal lactation care. Between February 2008 and December 2012, 402 VLBW infants and their mothers were involved in a study at Rush University Medical Center to determine predictors
of MOM feeding at NICU discharge (Hoban et al, 2018). Findings demonstrated achievement of CTV by postpartum day 14 as the strongest predictor for infants receiving MOM feedings at NICU discharge in breast pump-dependent mothers. Clinical practice incorporating effective pumping technique and technology to prevent low MOM volume should be targeted during the first postpartum week.
Revised Baby Friendly Hospital Initiative
World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) published the Ten Steps to Successful Breastfeeding in 1989 for implementation of policies and procedures for facilities providing maternity and newborn services in support of breastfeeding. WHO and UNICEF launched the Baby-Friendly Hospital Initiative (BFHI) in 1991 to motivate facilities offering maternity and newborn services in the implementation of the Ten Steps. The latest revision of the Baby Friendly Hospital Initiative was released in April 2018. A key statement of this publication is: “The first few hours and days of a newborn’s life are a critical window for establishing lactation and providing mothers with the support they need to breastfeed successfully.” Breastfeeding is described as a biological norm for healthy moms and newborns. However, interruptions such as necessary medical procedures, and separation of mothers from their infants in the NICU population may pose an increased risk for breastfeeding challenges and the initiation and maintenance of milk supply.
The updated guidance of the Ten Steps continues to cover the protection, promotion and support of breastfeeding healthy term newborns rather than the needs of the sick or preterm infants. However, it does mention that small, sick and/or preterm newborns have their own set of needs and that more specific guidance is available elsewhere. In 2004, Dr. Diane Spatz adapted the Ten Steps for Vulnerable Infants, and as a result, there was an increase in the percentage of infants receiving mother’s own milk (MOM) at initiation of feeds and at discharge (Fugate et al., 2015).
The revised Baby Friendly Initiative has several key points inclusive of support for the initiation and maintenance of breast milk in times of common difficulties:
- Practical support for preterm or late preterm infants is critical to establish and maintain milk production
- Mothers of preterm infants often have health problems and need extra motivation and support for milk expression
- Late preterm infants are generally able to exclusively feed at the breast, but are more at-risk for jaundice, hypoglycemia and feeding difficulties, requiring increased vigilance
- Mothers of multiples need extra support
- Mothers need to be taught how to express their breast milk as a means to maintain lactation if separated from their infants
- Mothers must be supported and encouraged to express their own milk as a priority
- Mothers should have adequate space to express milk adjacent to their infants
- For preterm infants unable to breastfeed directly, non-nutritive sucking (pacifier use) may be beneficial until breastfeeding is established
A primiparous 27 year old had preterm labor at 32 weeks gestation and delivered a baby boy who was admitted to the NICU. During this mom’s pregnancy, contact with a lactation consultant in private practice was established. Mom signed consent to give permission for information and/or photos of breastfeeding-related nursing care to be anonymously used for professional articles or studies for professional education. Another aspect of the consent covered the use of emailing or texting for non-urgent care and treatment. The following is a partial exchange of texting between mom and the author.
December 5, 2018
Mother: New doctor on rotation today and she came in and was like WOW look at all that milk!
Author: Great! Because you have enough breast milk, your baby will tolerate his feedings well. He most likely will gain weight and be discharged earlier than if he was being fed formula.
If the amount of milk you are expressing is filling the small containers close to the level of the yellow valves, you should start using the larger containers. Soon you will have enough breast milk to start storing it in the freezer because you will have more milk than your baby will need in the NICU.
December 5, 2018 — On day seven post-delivery, mom was able to express 10 ounces from 11pm-12N and texted the author to ask if this was a good milk volume.
December 9, 2018
December 9, 2018 — On day 11 post-delivery, Mom was expressing a little over 600 mL’s.
Author: You are doing great! The goal by day 14 is to be expressing 750-850 mL in 24 hrs. You are increasing your milk supply by continuing to pump seven times in 24 hours and are right on track! Do you have any questions about putting your baby to breast next week? You had said yesterday that you were told you would have the opportunity to put your baby to breast.
Mother: Not yet. I’m sure I’ll have questions once we try it.
December 13, 2018
Mother: We latched and licked today but mostly just spooned my breast milk to Andy. I’m expressing 650-700 mL/24 hours.
December 16, 2018
Milk output is 675-820 mL/24 hours
Baby Andy was discharged from the NICU at age six weeks. There were some feeding issues related to anemia which postponed his discharge by a few weeks. Mom had initiated and maintained adequate milk volume by effective pumping. Andy is a robust, healthy five month old and has only been fed MOM. This mom continues to express her breast milk for her now five month old.
Initiation and maintenance of adequate milk volume is based on ongoing effective infant suckle at breast, or effective pumping technique for infants in the NICU. Early milk expression using effective breast pump technology within one hour of birth in the absence of an infant at breast significantly alters a mother’s ability to achieve a full milk supply by 14 days; known as “coming to volume”. Evidence-based NICU practice adheres to the goal of achieving mother’s own milk feedings in the NICU
and at discharge from the NICU. Many NICU settings do not have unit protocols that support the latest breast pump technology for support of optimal mother’s milk volume. There is opportunity for continuous process improvement projects in the area of breast milk feeding and pumping in the NICU population because every preterm infant in the NICU deserves to receive mother’s own milk (MOM).
This article was previously published in Neonatal Intensive Care, Vol. 31, No. 4 / Fall 2018
Akinbi, H., Meinzen-Derr, J., Auer, C., Ma, Y., Pullum, D., Kusano, R., Zimmerly, K. (2010). Alterations in the host defense properties of human milk following prolonged storage or pasteurization. Journal of Pediatric Gastroenterology and Nutrition, 51(3), 347-352.
American Academy of Pediatrics Section on Breastfeeding (2012). Breastfeeding and the use of human milk. Pediatrics 129(3), e827-e841. doi: 10.1542/peds.2011-3552
Centers for Disease Control and Prevention (2016). Breastfeeding report card United States/2014. Atlanta, GA: Author. Retrieved from http://www.cdc.gov/breastfeeding/ pdf/2016breastfeedingreportcard.pdf
Edwards T., and Spatz, D. (2010). An innovative model for achieving breast-feeding success in infants with complex surgical anomalies. J Perinat Neonat Nurs, 24(3), 246-253.
Froh, E., Deatrick, J., Curley, M., & Spatz, D. (2015). Making meaning of pumping for mothers of infants with congenital diaphragmatic hernia. JOGNN: 44(3), 439-449.
Fugate, K., Hernandez, I., Ashmeade, T., Miladinovic, B., & Spatz, D. (2015). Improving human milk and breastfeeding practices in the NICU. JOGNN: 44(3), 426-438.
Geddes, D., Chooi, K., Nancarrow, K., Hepworth, A., Gardner, H. and Simmer, K. (2017). Characterisation of sucking dynamics of breastfeeding preterm infants: a cross sectional study. BMC Pregnancy and Childbirth, 17:386. DOI 10.1186/s12884-017-1574-3
Hoban, R., Bigger, H., Schoeny, M., Engstrom, J., Meier, P., and Patel, A. (2018). Milk volume at 2 weeks predicts mother’s own milk feeding at neonatal intensive care unit discharge for very low birthweight infants. Breastfeeding Medicine, 13(2): 135-141.
Meier, P., Engstrom, J., Patel, A., Jegier, B., and Bruns, N. (2010). Improving the use of human milk during and after the NICU stay. Clin Perinatol. 37(1), 217-245.
Meier, P., Engstrom, J., Janes, J., Jegier, B., & Loera, F. (2012). Breast pump suction patterns that mimic the human infant during breastfeeding: Greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. Journal of Perinatology, 32(2), 103-110.
Meier, P., Patel, A., Hoban, R., and Engstrom, J. (2016). Which breast pump for which mother: an evidence-based approach to inidividualizing breast pump technology. J Perinatol. 36(7):493-499).
Neville, M. & Morton, J. (2001). Physiology and endocrine changes underlying human lactogenesis II. Journal of Nutrition, Nov. 13(11): 3005s-3008s.
Parker, LA., Sullivan, S., Krueger, C., Kelechi, T., and Mueller, M. (2012). Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. Journal of Perinatology, 32, 205-209.
Parker, L., Sullivan, S., Krueger, C., and Mueller, M. (2015). Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeeding Medicine 10 (2): 1-8.
Saint, L., Smith, M., and Hartmann, PE. (1984). The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum. Br J Nutr. 52: 87-95.
Santoro W. Jr., Martinez F.E., Ricco, R.G., Jorge, S.M. (2010). Colostrum ingested during the first day of life by exclusively breastfed healthy newborn infants. J Pediatr, 156(1): 29-32.
Schanler, RJ, Lau, C., Hurst, NM, and Smith, E. (2005). Randomized trial of donor human milk versus preterm formula as substitutes for mothers’ own milk in the feeding of extremely premature infants. Pediatrics, 116(2): 400-406.
Spatz D. (2004). Ten steps for promoting and protecting breastfeeding for vulnerable infants. Journal of Perinatal & Neonatal Nursing, 4, 385-396.
U.S. Department of Health and Human Services. (2011). The Surgeon General’s call to action to support breastfeeding, 2011. Washington, DC: Author. Retrieved from http://www.surgeongneral.gov/library/calls/breastfeeding/calltoactiontosupport breastfeeding.pdf
World Health Organization, UNICEF, (2018). Protecting, promoting, and supporting breastfeeding in facilities providing maternity and newborn services: the revised Babyfriendly Hospital Initiative 2018