Neonatal Intensive Care Unit-Specific Lactation Support and Mother's Own Breast Milk Availability for Very Low Birth-Weight Infants

Optimizing breastfeeding for hospitalized newborns: A narrative review of midwifery-led interventions

Breastmilk is the best source of nutrition for newborns. The World Health Organization recommends exclusive breastfeeding for the first six months of life as it has benefits to mother and child. However, breastfeeding can be challenging. Especially when the newborn is hospitalized, the physical separation of mother and child can make breastfeeding difficult. Hence pre- and post-natal midwife care supporting breastfeeding become more important. The aim of this narrative review is to identify measures taken by midwives in the labor ward, on the postpartum unit and at home that can influence breastfeeding success positively in hospitalized newborns. A literature review was conducted in PubMed and CINAHL and on the website of the European Institute for Breastfeeding and Lactation from April to September 2023. Studies from 2013 to 2023 written in German or English comparing two different measures/groups were considered. Twenty studies were included and five measures, taken by midwives, were identified. Skin-to-skin contact leads to higher (exclusive) breastmilk feeding rates, better sucking behavior and a shorter time to full enteral feeding. Regular breastmilk expression and supervised breastfeeding attempts result in higher breast milk feeding rates. Breastfeeding counselling enables the mothers to access lactation education. Uninterrupted visiting hours lead to higher exclusive breastmilk feeding rates. Midwives play a key role in promoting breastfeeding among hospitalized newborns involving initiating lactation, strengthening the mother-child bond and providing appropriate breastfeeding advice. There is a further need for research, as midwives are rarely involved in studies.

From the Field - The Case for a Paradigm Shift in Lactation Care for NICU Families: A Comprehensive Lactation Care Model

The importance of a child receiving their mother's own milk (MOM) in the care and treatment of preterm infants is undisputed in the literature. Despite this, lactation support in the Neonatal Intensive Care Unit is often fragmented. Gaps in adequate lactation care for infants receiving MOM, and barriers to that lactation care, can contribute to healthcare disparities and outcome inequalities. Here, I outline a comprehensive lactation care manager model based on the concepts of continuity of care and care management. This is a starting point for discussion that may be helpful in informing future research and adequate lactation care options.

An Examination of the Benefits of Lactation Consultant Services in NICUs for Mothers and Their Newborn: A Systematic Review

Background: It is well accepted that lactation consultant (LC) services can enhance the breastfeeding success in mother-infant dyads. However, despite such advantages, not all neonatal intensive care units (NICUs) offer LC services. The objective of this systematic review was to assess the available evidence on the effect of LC service on breastfeeding outcomes for mothers whose infants are in the NICU. Methods: The PRISMA Extension for Systematic Reviews were used to conduct this systematic review. The following databases: Embase, Medline, CINAHL, and Cochrane library were searched. An initial 464 studies were obtained. Duplicates and studies that did not fit the inclusion criteria were removed, leaving 30 full-text articles to review. Nineteen were further excluded after full-text review. A total of 11 studies were included. Due to the heterogeneity of the included studies, a meta-analysis could not be performed, instead a qualitative numerical summary was conducted. Results: Overall, 10/11 (90%) of studies observed a 6-31% increase in the number of infants who received mother's own milk, and 11-27% in the number of infants who received direct breastfeeds associated with the implementation of LC services in the NICU. The two most common types of LC services studied included: i) multidisciplinary lactation support-described as a team-based approach that includes at least one LC and ii) designation of LC formal role in the NICU. Conclusions: This review highlights that having LC services in the NICU is vital for meeting the unique needs and enhancing breastfeeding outcomes for mothers whose infants are in the NICU.

Direct breastfeeding frequency of late preterm and term infants in the neonatal intensive care unit and availability of mother's own milk at six months of age. a retrospective cohort study

BACKGROUND

Mother's Own Milk (MOM) reduces the risk of complications in premature infants. Breastfeeding rates for late preterm and term infants in the neonatal intensive care unit (NICU) are significantly lower than that of breastfed healthy term newborns at 6 months of age.

DESIGN

This was a retrospective cohort study of neonates born at 34 weeks 0 days or later. Infants who were directly breastfed in the NICU and were discharged on breast milk were included. Logistic regression modeling was used to determine the significance of association.

RESULTS

171 mother-infant dyads were included. After adjusting for confounders, the number of breastfeeding attempts during the NICU stay was significantly associated with the availability of MOM at six months of age (p = 0.003, 95% CI 1.02 to 1.14).

CONCLUSION

This study is the first to show an association between the number of direct breastfeeding attempts in the NICU and availability of MOM at six months of age.

The clinical experience of early skin-to-skin contact combined with non-nutritive comfort sucking in mothers of preterm infants: a qualitative study

BACKGROUND

In most areas of China, mothers typically do not participate in early care of preterm infants in NICU. This study aims to examine the early experience of mothers of preterm infants participating in skin-to-skin contact combined with non-nutritive comfort sucking in China.

METHODS

This qualitative research study used one-on-one, face-to-face, semi-structured in-depth interviews. Eighteen mothers who participated in early skin-to-skin contact combined with non-nutritive comfort sucking were interviewed in the NICU of a tertiary children's hospital in Shanghai between July and December 2020. Their experiences were analyzed using the inductive topic analysis method.

RESULTS

Five themes about skin-to-skin contact combined with non-nutritive comfort sucking were identified, including alleviation of maternal anxiety and fear during mother infant separation, reshaping the maternal role, promotion of active breast pumping, enhances the mother's willingness to actively breast feed and building the maternal confidence in baby care.

CONCLUSION

Skin-to-skin contact combined with non-nutritive comfort sucking in the NICU can not only enhance the identity and responsibility of the mother's role, but also provide non-nutritive sucking experience for promoting the establishment of oral feeding in preterm infants.

Neonatal Intensive Care Unit Interventions to Improve Breastfeeding Rates at Discharge Among Preterm and Low Birth Weight Infants: A Systematic Review and Meta-Analysis

Background: While breast milk is widely accepted as the best source of nutrients for almost all newborns, breastfeeding can be especially challenging for preterm and low birth weight (LBW) infants. With increased risk of admission to neonatal intensive care units (NICUs) and separation from parents, this population experiences significant barriers to successful breastfeeding. Thus, it is crucial to identify interventions that can optimize breastfeeding for preterm and LBW infants that is continued from birth and admission, through to hospital discharge and beyond. Objectives: To identify and analyze evidence-based interventions that promote any and exclusive breastfeeding among preterm and LBW neonates at discharge and/or postdischarge from hospital. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Searches were performed in the following databases: MEDLINE Ovid, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health (CINAHL). Results: From the 42 studies included, 6 groups of intervention types were identified: educational and breastfeeding support programs, early discharge, oral stimulation, artificial teats and cups, kangaroo mother care (KMC), and supportive policies within NICUs. All groupings of interventions were associated with significantly increased rates of any breastfeeding at discharge. All types of interventions except artificial teats/cups and oral stimulation showed statistically significant increases in exclusive breastfeeding at discharge. KMC demonstrated the highest increased odds of breastfeeding at discharge among preterm and LBW infants. Conclusions: A variety of effective interventions exist to promote breastfeeding among hospitalized preterm and LBW infants. Hospital settings hold unique opportunities for successful breastfeeding promotion. PROSPERO registration: CRD42021252610.

The time to initiate trophic feeding and its predictors among preterm neonate admitted to neonatal intensive care unit, Multicenter study, Northwest Ethiopia

Background

Trophic feeding is a small volume, hypo-caloric feeding, gut priming or minimal enteral feeding acclimate the immature gut of enteral fasting preterm neonates. Delayed starting of trophic feeding had resulted in short and long-term physical and neurological sequels. The current study aimed to estimate the time to initiate trophic feeding and its predictors among preterm neonates admitted in the neonatal intensive care unit of Debre Markos, Felege Hiwot, and Tibebe Ghion comprehensive specialized hospitals.

Methods

An institutional-based prospective follow-up study was conducted among 210 neonates. The data were collected with interview and chart review, entered into Epi data 3.1 and exported to Stata 14.1 for analysis. Multivariable Cox regression models were fitted to identify predictors of time to initiate trophic feeding.

Result

A total of 210 neonates were followed for 10136 person-hours of risk time and 191 (90.95%) of neonates were started trophic feeding. The overall incidence of starting trophic feeding was 2 per 100 (95% CI: 2, 2.2) person-hours observations. The median survival time was 42 hours (95% CI: 36, 48). APGAR- score at first minute <7 (AHR: 0.6, 95% CI: 0.44, 0.82), gestational age of <34 weeks (AHR: 0.69, 95% CI: 0.5, 0.94), presence of respiratory distress syndrome (AHR: 0.5, 95% CI: 0.36, 0.68), presence of hemodynamic instability (AHR: 0.37, 95% CI: 0.24, 0.57), presence of perinatal asphyxia (AHR: 0.63, 95% CI: 0.44, 0.89), cesarean section delivery (AHR: 0.63, 95% CI: 0.44, 89) and being delivered within the study hospitals (AHR: 0.54, 95% CI: 0.39, 0.74) were found to be statistically significant predictors of time to initiate trophic feeding.

Conclusion

There was a significant delay to initiate trophic feeding in the studied hospitals. Gestational age of below 34 weeks, APGAR-score of less than seven, out-born delivery, cesarean delivery, presence of respiratory distress syndrome; perinatal asphyxia, and hemodynamic instability were predictors of delay in starting of trophic feeding. Standardized feeding guideline has to be implemented to overcome delays in enteral feeding initiation.

Proactive Lactation Care is Associated With Improved Outcomes in a Referral NICU

BACKGROUND

Mother's milk improves outcomes. Referral neonatal intensive care units face unique lactation challenges with maternal-infant separation and maternal pump dependency. Little is known about lactation resource allocation in this high-risk population.

RESEARCH AIMS

To determine differences in human milk outcomes, (1) the proportion of infants fed exclusive or any mother's milk and (2) recorded number and volume of pumped mothers' milk bottles, between two models of lactation care in a referral neonatal intensive care unit.

METHODS

This retrospective, longitudinal, two-group comparison study utilized medical record individual feeding data for infants admitted at ≤ Day 7 of age and milk room storage records from reactive and proactive care model time periods (April, 2017-March, 2018; May, 2018-April, 2019). The reactive care model (n = 509 infants, 58% male, median birth weight and gestational age of 37 weeks,) involved International Board Certified Lactation Consultant referral for identified lactation problems; whereas, the proactive model (n = 472 infants, 56% male, median birth weight and gestational age 37 weeks) increased International Board Certified Lactation Consultant staffing, who then saw all admissions. Comparisons were performed using chi square, Mann Whitney, and t-tests.

RESULTS

A proactive lactation approach was associated with an increase in the receipt of any mother's milk from 74.3% to 80.2% (p = .03) among participants in the proactive model group. Additionally, their milk room mean monthly bottle storage increased from 5153 (SD 788) to 6620 (SD 1314) bottles (p < .01).

CONCLUSIONS

In this retrospective study at a tertiary referral neonatal intensive care unit, significant improvement inhuman milk outcomes suggests that increased resources for proactive lactation care may improve mother's milk provision for a high-risk population.

Study of perinatal transmission of SARS-CoV-2 in a Mexican public hospital

OBJECTIVES

COVID-19 is a viral transmissible disease and there is limited evidence on vertical transmission and prevalence of SARS-CoV-2 during pregnancy, birth, and the postnatal period. This descriptive cross-sectional study aimed to evaluate the possible perinatal transmission of SARS-CoV-2 in mothers and neonates in a Mexican population.

METHODS

A total of 133 nasopharyngeal swab samples from mothers, 131 swab samples from neonates, and 140 colostrum samples were obtained, and the presence of SARS-CoV-2 was determined by qPCR.

RESULTS

One in eight asymptomatic 38-39 weeks' pregnant women were positive for the presence of SARS-CoV-2 in nasopharyngeal swabs taken just before delivery; and one in 12 nasopharyngeal swabs collected from neonates immediately after delivery without breast feeding were also positive. It was also determined that one in 47 colostrum/milk samples were positive for the test. In addition, there was no association between positive results and any collected metadata of mothers or newborns.

CONCLUSIONS

Asymptomatic women carried the SARS-CoV-2 virus during delivery, with perinatal transmission of SARS-CoV-2 to newborns. Since neonates were sampled immediately after birth, the detection of positive cases might be due to infection by the virus in utero.

Human Milk Expression, Storage, and Transport by Women Whose Infants Are Inpatients at a Tertiary Neonatal Unit in Melbourne, Australia: An Exploratory Study

BACKGROUND

Expression and storage of mothers' own milk at home and its transportation to hospital neonatal units are a common practice worldwide when newborns are inpatients. Studies assessing adherence to hospital protocols and guidelines for this are not widely published.

PURPOSE

To explore the advice received and practices followed by mothers when expressing, storing, and transporting their milk from home to the hospital, with a substudy exploring the factors related to temperature maintenance of refrigerated milk at recommended values.

METHODS

Cross-sectional descriptive study at the neonatal intensive care unit of Mercy Hospital for Women, Melbourne, Australia. Mothers who were discharged home after birth of the infant, but whose infant(s) remained in the neonatal unit for 7 days or more participated. All participants completed a self-administered questionnaire. In the substudy, home refrigerator temperature and surface temperature of milk on arrival to the hospital were recorded.

RESULTS

The questionnaire was completed by 100 mothers; 38 participated in the substudy. Median travel time from home to the hospital was 32 minutes (range, 2-135 minutes). Lactation consultants were the largest group providing information, with 44 participants (45%) identifying them as the primary information source. Knowledge about recommended refrigerator storage times for expressed milk was correct in 53 mothers (54%). Coolness of milk was better maintained when transported in an insulated food container than nonuse (surface temperature: mean 9.1°C vs 12.2°C; P = .007). Distance and travel duration were not correlated with temperature.

IMPLICATIONS FOR PRACTICE

More diligent monitoring of conditions under which mothers' own milk is transported to hospital is required, and the use of an insulated food container for refrigerated/frozen milk, even for a short duration, should be strongly recommended. Staff to be trained and better equipped to provide uniform, concise information on expressed human milk management to mothers.

IMPLICATIONS FOR RESEARCH

Further research to correlate factors associated with transporting human milk expressed at home and infant health outcome is needed.

Use of Telemedicine for subspecialty support in the NICU setting

The regionalization of neonatal care was implemented with an overarching goal to improve neonatal outcomes.¹ This led to centralized neonatal care in urban settings that jeopardized the sustainability of the community level 2 and level 3 Neonatal Intensive Care Units (NICU) in medically underserved areas.² Coupled with pediatric subspecialist and allied health professional workforce shortages, regionalization resulted in disparate and limited access to subspecialty care.^3-6 Innovative telemedicine technologies may offer an alternative and powerful care model for infants in geographically isolated and underserved areas. This chapter describes how telemedicine offerings of remote pediatric subspecialty and specialized programs may bridge gaps of access to specialized care and maintain the clinical services in community NICUs.

"Liquid Gold" Lactation Bundle and Breastfeeding Rates in Racially Diverse Mothers of Extremely Low-Birth-Weight Infants

Background: In 2015, we implemented a comprehensive lactation bundle named Liquid Gold. Lactation bundles in the neonatal intensive care unit have not been well studied. Materials and Methods: This is an ongoing quality improvement breastfeeding project of racially diverse mothers and infants of extremely low birth weight (≤1,000 g). Four epochs were assessed; baseline (B; January 2012-July 2013), transition (T; human milk [HM]-derived fortifier; August 2013-December 2014), Liquid Gold (LG; full bundle, including staff education, colostrum oral care, kangaroo care, antenatal and postpartum counseling, provision of pasteurized donor HM, and breast pumps; January 2015-February 2016), and current (C; ongoing impact, Spanish-speaking lactation consultant, and HM cream; March 2016-April 2019). Results: Four hundred twenty-three mother-infant dyads were assessed. The rate of exclusive mother's own milk at discharge increased significantly in LG compared with previous epochs and was sustained over time. During LG, African American (AA) mothers had a significant surge of breastfeeding initiation (30% in B and 41% in T versus 78% in LG), but this was not sustained in C. AA mothers also experienced a significant decline in the use of exclusive formula feeding in the C epoch (68% in LG versus 46% in C). Hispanic and White mothers sustained their breastfeeding rates over time. Conclusions: Our Liquid Gold lactation bundle led to a significant increase in the provision of HM in the NICU and at discharge in the most vulnerable infants. AA mothers experienced the highest surge in breastfeeding initiation and greatest reduction in formula use. Breastfeeding goals and support need to be tailored to each mother with specific consideration for racial/ethnic background for optimal success.

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.

Prevalence of prelacteal feeding and associated risk factors in Indonesia: Evidence from the 2017 Indonesia Demographic Health Survey

Background

Prelacteal feeding (PLF) is a recognised challenge to optimal breastfeeding but remains common in Indonesia. Meanwhile, PLF-related epidemiological research is limited, particularly in this setting. This study examines the prevalence and determinants of overall PLF as well as common PLF types (formula, other milk, and honey) in Indonesia.

Methods

Data from 6127 mothers whose last child was ≤23-month-old were drawn from the 2017 Indonesia Demographic and Health Survey. Multivariable modified Poisson regression was used to measure the prevalence ratio (PR) for selected PLF risk factors. PLF was defined as anything to drink other than breast milk within three days after birth, before breastmilk flows. Additional analyses were performed on mothers who gave formula, other milk, and honey.

Results

About 45% babies in Indonesia received PLF with formula being the most frequent (25%), followed by other milk (14%), plain water (5%), and honey (3%). Factors associated with higher prevalence of any PLF were higher wealth quintiles in rural area (PR 1.07; 95% CI 1.03–1.11 per increase in quintile), baby perceived to be small at birth (PR 1.23; 95% CI 1.12–1.35), caesarean deliveries at either public (PR 1.27; 95% CI 1.13–1.44) or private facilities (PR 1.15; 95% CI 1.01–1.31), and not having immediate skin-to-skin contact after birth (PR 1.32; 95% CI 1.23–1.42). PLF was less prevalent among mothers who gave birth to second/subsequent child (PR 0.82; 95% CI 0.76–0.88) and who had an antenatal card (PR 0.89; 95% CI 0.80–0.99). These patterns did not apply uniformly across all PLF types. For example, honey was more common among home births than deliveries at health facilities, but formula and other milk were more common among caesarean deliveries.

Conclusions

Mapping risk factors for PLF, especially by types, could help to design more targeted interventions to reduce PLF and improve breastfeeding practices in Indonesia.