Introduction
For our 47th podcast episode, I review some of the general benefits of maternal breast milk and why it is so important for all infants, but especially those who are critically ill and in the NICU, to receive maternal milk. Human milk, often referred to as liquid gold, is considered the gold standard for feeding in all infants. Human milk provides many nutritional advantages for infants, but it is also advantageous in non nutritional aspects as well.
Unfortunately, NICU mothers face additional barriers that make it more difficult for them to effectively express their milk and ultimately breastfeed. Data has shown that for all NICU infants, preterm and/or critically ill, receive less than 20% of their own mother’s milk at 6 months of age, most commonly due to insufficient maternal milk production. Mothers whose infants are admitted to the NICU must depend on a breast pump to express their milk, often experience delayed milk letdown, and are often recovering from c-sections and/or have underlying medical conditions. Additionally, the stress NICU mothers endure coupled with the forced physical separation make it much more difficult for them to not only establish their supply, but also maintain it.
There are also significant racial disparities that exist and human milk provision is lowest among non-Hispanic Black and American Indian/Alaska Native populations. It is the standard of care for most NICUs to utilize Donor Human Milk (DHM) as an alternative or to help bridge the gap for infants, especially preterm infants when the mother’s breast milk is either not available or there is insufficient volume. But, it is suspected, at times, that the available option of DHM in NICUs and hospitals in general, is actually preventing the proper education and ultimately the decision for mothers to provide their breast milk for their infant. If mothers and their support partner are given another option, especially after the delivery of a preterm or critically ill infant, they may decide not to provide their own milk. Although donor breast milk is a great option that has shown a decreased incidence of NEC or necrotizing enterocolitis in preterm infants, it does not have the same overall protective mechanisms and bioactivity as the mother’s milk.
In the episode, we review what some of the common barriers are for NICU mothers in their physical ability and desire to provide breast milk for their infant. I share recommendations on what we as NICU clinicians can do to educate, support, and guide all mothers in a culturally sensitive and supportive manner. By sharing our knowledge empathetically, it allows mothers and their care partner to make an informed decision and one that has the potential to impact their infant while they are in the NICU and in the months and years that follow!
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Episode 47
Why is maternal human milk so beneficial for infants?
Human milk, often referred to as liquid gold, is considered the gold standard for feeding all infants, but especially preterm infants. Very low birthweight infants (VLBW) who receive their own mother’s milk throughout their NICU stay have a reduced incidence and severity of both short and long-term complications.
Infants fed human milk have shown an improvement in feeding tolerance as well as a decrease in the incidence of sepsis and necrotizing enterocolitis (NEC). The early administration of mother’s colostrum to extremely premature infants stimulates rapid positive growth in the intestinal mucosal lining and induces digestive enzymes. The colostrum helps to compensate for the shortened period of time premature infants are able to swallow amniotic fluid in the third trimester. Amniotic fluid has a variety of growth factors in it that help. toincrease the weight of the intestinal mucosa.
Human milk provides many nutritional advantages for preterm infants, but it is also advantageous for them in non nutritional aspects as well. Throughout the years, research has continued to show the presence of anti-infective properties of human milk that protect infants against infections of the gastrointestinal tract, upper and lower respiratory tracts, urinary tract, and protection against ear infections, and sepsis. Earlier discharge from the NICU is often facilitated by improved feeding tolerance and less overall illness. Meier et al (2010) stated that maternal milk contains beneficial immunologic, antimicrobial, anti-inflammatory, epigenetic, growth-promoting, and gut-colonizing properties. And it doesn’t end there, several additional studies have also shown that maternal breast milk is protective against several other conditions including, but not limited to diabetes, allergic diseases, asthma, heart disease plus many more!
What does the AAP recommend?
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for 6 months and continued breastfeeding for 2 years and beyond. Unfortunately, data has shown that for all NICU infants, preterm and/or critically ill, receive less than 20% of their own mother’s milk at 6 months of age. It is thought that this statistic is most often due to insufficient maternal milk production.
What are the common barriers for suboptimal milk expression in NICU mothers?
Mothers whose infants are admitted to the NICU are not only likely to experience more difficulty establishing breastfeeding, but it is also more difficult for them to pump and supply their milk as well. Mothers of preterm infants, especially very low birthweight (VLBW) infants must depend on a breast pump to express their milk. They do not have their term, vigorous infant at home with them demanding to feed every 1-3 hours. They may often experience incomplete mammary gland development and have delayed milk letdown due to the premature delivery as well. NICU mothers also have to deal with competing demands of their time due to additional obligations including but not limited to returning to work, caring for additional children at home, and transportation issues.
Many mothers that deliver critically ill and/or premature infants are also recovering from c-sections and/or have underlying medical conditions or comorbidities which may impact their ability to begin and maintain milk expression. The stress NICU mothers endure coupled with the forced physical separation make it much more difficult for them to not only establish their supply, but also maintain it. The separation and increased psychological distress negatively impacts appropriate mother-infant bonding which is the ultimate inhibiting circumstance for successful milk expression and ultimately breastfeeding. Additionally, research has shown that mothers who display decreased confidence in their maternal role, which is common for NICU mothers, will experience parental role alteration which negatively impacts their feelings of motherhood and does not empower them to express their milk.
Existing racial disparities for breastfeeding and maternal milk expression
Unfortunately, there are significant racial disparities that exist with preterm deliveries and the ability to supply maternal milk. Although African-American women have a 2.6 x greater risk of delivering a preterm infant when compared to white, non-hispanic women, they are 7.6 x less likely to provide their own milk. Human milk provision is lowest among non-Hispanic Black and American Indian/Alaska Native populations. According to Gyamfi et al, (2023), 25.8% of infants in the United States were exclusively breastfed at 6 months of age and African American infants were the least likely to be exclusively breastfed at 6 months with 19.8% in 2018.
Additionally, for infants in the NICU, fewer African American and Hispanic VLBW infants continue to receive their mother’s milk at discharge compared with non-Hispanic White infants. It has been hypothesized that this may contribute to the disparities in neonatal morbidity as well that are often present in these infants. African-American and Hispanic VLBW infants have a 2- to 4- fold increased risk for developing NEC, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and intraventricular hemorrhage (IVH) when compared with White VLBW infants.
How a mother’s social support system may impact their decision to provide breast milk for their infant
For many pregnant women, they make the decision to breastfeed or not after they consult with their family and peers based on varying factors including socioeconomic, health, political, cultural, and religion. In general, once fathers or care partners gain knowledge in lactation and the benefits for the infant, they begin to show more amped readiness to support their partner in their breastfeeding goals and efforts. Social support offered to African American women within the first 2 weeks from delivery, from their significant other as well as family, friends, peers, etc. is considered the most critical aspect in their decision-making.
How is donor human milk (DHM) different than maternal milk?
Although the use of donor human milk (DHM) has become the standard of care in most NICUs, maternal milk remains superior in its antimicrobial and protective mechanisms against prematurity-related complications. Additionally, the pasteurization process for DHM diminishes and/or eliminates many of the protective elements and protein content which can lead to suboptimal growth. Therefore, it is essential to focus on educating mothers and their support persons on all of the benefits of maternal breast milk and support them through their journey.
How can we support NICU mothers with their milk expression?
To start with, the benefits of breastfeeding and/or expressing maternal milk must be reviewed with mothers during pregnancy, after birth, and even more so if the infant was born prematurely. The first 3-5 postpartum days are a critical window of time as research has shown if there is a decrease in the expression frequency, it results in decreased long-term milk volume. Additionally, research has shown that it is also important for infants to receive their mother’s milk in the first 14 to 28 days of life to help decrease the incidence, severity, and risk of sepsis, NEC, and other common NICU morbidities.
The option to use DHM should be explained and proposed to parents as a bridge until the mother’s milk supply is established rather than as an alternative solution. Initiation of milk expression should begin as soon as possible after delivery with the goal of no later than 6-8 hours after delivery. After some education, appropriately trained support persons should provide expression assistance and all mothers should have access to hospital-grade pumps.
NICU care team members must encourage lactation in the NICU. By doing so, it will support all mothers, but also help to break down the inhibiting barriers with some of the known disparities. It is vital that NICU nurses are empathetic, share their knowledge, and try to build trusting partnerships with NICU mothers to promote their milk expression, establish breastfeeding, and nurture the feelings of motherhood. It has been reported that NICU mothers felt that the support and knowledge they received regarding lactation and breastfeeding varied widely between all of the healthcare professionals they interacted with. NICU care team members are in a position to have a large impact on maternal milk production, whether positive or negative. A supportive environment coupled with education, has the potential to positively impact the mother’s milk production in the NICU and beyond.
A study by Brodsgaard et al., (2022) found a mother’s preconception and attitude toward breastfeeding plays an integral role in their success. This along with early physical contact serve as strong predictors of lactation initiation, frequency of expression, and their interest in inviting their NICU to the breast while they are in the NICU. When possible, physical contact, but especially skin-to-skin care should be initiated as soon as possible after birth.
One of the main key factors that inhibited successful milk expression was the separation of the mother and infant. A zero separation goal must be encouraged between the infant and mother when possible to minimize toxic stress and promote maternal confidence, bonding, and ultimately milk supply.
Zero separation also promotes skin-to-skin contact. Skin-to-skin care has many other known physiologic benefits for the infant, but it also promotes bonding and facilitates milk production and breastfeeding. Skin-to-skin care should be done early and as long as possible depending on the infant’s clinical condition. Non-nutritive sucking as well as direct nursing when physiologically appropriate are all beneficial and will not only enhance the mother’s supply, but promote continued breastfeeding post-discharge. Mother’s should be encouraged to begin oral feeding at the breast once the infant is clinically stable and shows physiologic readiness.
When able, NICU mother’s should be encouraged to pump at their infant’s bedside because greater milk volumes have been reported when mothers pump in close contact with their infants. When this is not possible, the use of virtual NICU webcams are also beneficial for mothers and their supply who are unable to be physically present.
To mitigate the racial disparities, African American women and their care partners should be provided with evidence-based and appropriate education on providing breast milk in a timely manner. Although their decision whether or not to provide expressed breastmilk may be influenced by their social support system, health professionals must discuss breastfeeding in a culturally sensitive and supportive manner. Additionally, it is key to provide African American mothers with available virtual and/or community-based peer support groups and resources.
NICU care team members must empower and encourage all NICU mothers to actively participate in caring for their infant so they become confident in their parental role. As previously mentioned, NICU mothers may have some difficulty transitioning into their role as a mother once their infant is admitted to the NICU due to their feelings of fear, worry, anxiety, and intimidation. Implementation of family-integrated care including daily skin-to-skin contact will encourage the parents to have an active role in caring for their infant, and it will also impact the mother’s desire to pump breast milk for her infant.
It is well-established that NICU mothers have additional barriers to overcome to successfully provide breast milk for their infant and to maintain exclusive use of their breast milk beyond the NICU. Yet, it is so crucial for all NICU mothers to provide breast milk for their critically ill infants. NICU care team members, but especially nurses, have the ability to make a substantial impact on the initiation and success of NICU mothers’ expression of breast milk. By providing a supportive environment along with evidence-based strategies, it will help to optimize the milk production of NICU mothers and ultimately improve NICU health-related outcomes.
Closing
I hope you found this episode informative. By discussing some of the inhibiting circumstances that NICU mothers face in their ability to establish adequate milk volumes, it not only lets NICU mothers know that they are not alone in the process, but it also helps to break down how we as clinicians can find adaptable ways to support them. I always feel that it is such a fine line in how healthcare workers approach mothers with education on the importance of providing breast milk for their baby, especially our NICU infants, without coming off as pushy or annoying. But, by giving parents and their support system the basic facts along with empathy, support, resources, and a hospital-grade pump, we can all make a huge impact and literally change the outcomes for our high-risk population!
Next time, we will look a little closer at the composition of breastmilk, all of its beneficial properties, and why it is so superior to formula and even DHM.
References
Boundy, E., Anstey, E., & Nelson, J. (2022). Donor human milk use in advanced neonatal care units – United States, 2020. Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report, 71(33), 1037 – 1040.
Brodsgaard, A., Andersen, B., & Skaaning, D. From expressing human milk to breastfeeding—An essential element in the journey to motherhood of mothers of prematurely born infants. Advances in Neonatal Care, 22(6), 560-570.
Eichenwald, E. Hansen, A., Martin, C., & Stark, A. (2017). Cloherty and Stark’s Manual of Neonatal Care, Eight Edition. Wolters Kluwer.
Gardner, S., Carter, B., Enzman-Hines, M., & Niermeyer, S. (2021). Merenstein & Garner’s Handbook of Neonatal Intensive Care Nursing: An Interprofessional Approach, Ninth Edition. Elsevier.
Gomella, T., Eyal, F., & Bany-Mohammed, F. (2020). Gomella’s Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 8th Edition. McGraw-Hill.
Gyamfi, A., Spatz, D., Jefferson, U., Lucas, R., O’Neill, B., & Henderson, W. (2023). Breastfeeding social support among African American women in the United States: A meta-ethnography. Advances in Neonatal Care, 23(1), 72-80.
Meier, P., Engstrom, J., Patel, A., Jegier, B., Bruns, N. (2010). Improving the use of human milk during and after the NICU stay. Clinics in Perinatology, 37(1), 217 – 245.
Parker, L. (2022). Donor human milk is not the solution. Advances in Neonatal Care, 22(6), 485-486.
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