Overcoming barriers to increased human milk feeding in the NICU

1. Complex Nursing Problem Overcoming Barriers to Increased Human Milk Feeding in the NICU Denise Breheny, RNC-MNN, IBCLC Queens University of Charlotte

2. Complex Nursing Situation Introduction Providing human milk feedings (HMF) as a therapy for very-low-birth-weight ([VLBW]; those weighting less than 1500g) infants, especially their own mother’s milk has been found to be: Efficacious Inexpensive Readily available Virtually risk free Providing human milk feedings to VLBW infants is becoming the standard of care in the majority of NICU settings for at least the first 4 weeks of life The AAP and U.S. DHHS recommend exclusive breastfeeding for all infants, healthy or ill for the first 6 months “Breastfeeding” does not necessarily mean suckling from the breast, but rather giving breastmilk by any means necessary (gavage, bottle or breast)

3. Complex Nursing Situation Providing HMF especially the mother’s own milk (MBM) is a complex nursing situation There are many barriers Financial ̶ Demographic Physiologic ̶ Hospital culture Lack of knowledge by health professionals Absence of hospital policies, protocols, and standards of care promoting evidence based practices for MBM initiation and maintenance Deciding to breastfeed involves social and cultural norms and depends on social support mechanisms Milk supply may diminish 4 to 6 weeks after delivery without constant support Furman et al. (1998) found only 48% of mothers withpreterm infants were still expressing milk at NICU discharge

4. Science of Human Milk for Preterm Infants Benefits from the literature 6-10 times less necrotizing enterocolitis (NEC) in VLBW infants receiving HMF Decreased incidence of sepsis Decreased incidence of retinopathy of prematurity More stable SaO2 during breastfeeding Improved feeding tolerance with breastfeeding Long-term benefits Maternal bonding and empowerment—maternal bonding in the NICU Decreased incidence of asthma Decreased incidence of allergies Decreased otitis media and GI disorders Decreased risk of diabetes melitus Increased IQ

5. Science of HMF for Preterm Infants Nutritional Benefits Composition facilitates digestion Protein is primarily whey, which forms a softer, more easily digested gastric curd Contains 20 amino acids, nine that are essential Fat provides 50% of total caloric content , and long chain polyunsaturated fatty acids (AA, DHA) Primary carbohydrate is lactose, which is easily digestible and produces soft stool consistency Faster attainment of full feeds

6. Why Do Neonatologists hate NEC? The incidence of NEC is 7-10% in VLBW Infants There is a 33% mortality rate with NEC There is a 33% morbidity rate of long-term sequelae including: Short Gut Syndrome Neurodevelopmental delay and possibly long term neurological problems NEC is very costly NEC can increase hospital stay by 22 days for non-surgical survival NEC can increase hospital stay by 2 months for surgical survival NEC can increase the hospital cost by $73K – 186K There is substantial evidence available which links HMF to a reduction in the incidence of NEC and it is dose dependent, meaning that the more HMF received the less likely the incidence of NEC

7. Demographic Barriers The most vulnerable infants for increased morbidity are those least likely to benefit from MBM Demographically mothers who prefer to formula feed are also the most at risk for delivering a preterm infant Lower Education Typically women choosing to breastfeed are more educated Low income Low-income women of all ethnicities are twice as likely to deliver prematurely when compared to higher socioeconomic status Belonging to a racial minority African American women are three times more likely than White women to deliver a premature low-birth weight infant In one study, of all women not choosing to breastfeed, 71% were African American and 62% of those women were low income

8. Financial Barrier-Donor Milk Because of the importance of making HMF, the first feedings for the VLBW infant, many NICU’s have looked into pasteurized donor milk for first feedings when the mother’s milk is not available Pasteurized banked donor milk can provide an important alternative to infants Pasteurized donor milk is considered a suitable alternative by the American Academy of Pediatrics Human milk banking has been around for over a century and has an accepted role in the care of the VLBW infant There is a processing fee for donor milk of $4-30/oz. The cost of donor milk is very prohibitive to many institutions The alternative of having the mother provide her own expressed milk, which is best for the baby, is clearly the most efficacious way to provide both nutrition and therapy to these babies

9. Physiologic Barriers Establishing MBM is more difficult for the mother of a VLBW infant Many mothers of the VLBW infant are sick in the postpartum period Recovery from emergent surgery -- Severe blood loss Uterine infections -- Pre-eclampsia These and other chronic conditions can delay a mother from initiating her milk supply Mother baby separation The breast isn’t fully developed for lactation due to a decreased period of gestation The ability to establish a milk supply is dependent on the assistance of the health care providers and especially the involvement of nurses

10. Barriers of Hospital Culture There is much evidence available to support milk initiation, however many hospital’s cultures do not support these practices Studies have shown that mothers will readily agree to provide MBM for their infant after receiving personalized information from health care providers Mothers need to start pumping within 6 hours of the baby’s birth For mothers who are unable to start by pumping due to medical condition, manual expression should be initiated Mothers who combine hand expression with pumping during the first few days postpartum have been shown to routinely establish appropriate milk supplies

11. Barrier: Knowledge Deficit of Health Care Providers There are two major barriers that undermine successful lactation management in the NICU and both are due to a generalized knowledge deficit of health care providers for this population The misconception that management of lactation can be postponed until the mother has recovered and the baby is deemed stable The prevalent attitude that the responsibility for lactation support rests with a small number of specialized care providers and/or the mother versus a collaborative team that includes physicians It is the responsibility of everyone that is in contact with the mother or baby are competent with adequate knowledge, training, and skills that are supportive of the mother’s lactation management. However, education is only as effective as the policy that backs up the practice of the skill set and therefore written policies and protocols need to be in place as well as insuring that the staff is sufficiently educated in these matters.

12. Solution: Change hosptial Culture The Baby-Friendly Hospital Initiative(BFHI) was launched by the WHO & UNICEFF in 1991 as a global effort to implement practices that protect, promote and support breastfeeding BFHI guidelines routinely implemented substantially increase breastfeeding rates Having a hospital that follows the BFHI would be a big step towards insuring that provisions are in place to assist in this nursing problem

13. Maximal HMF for the vulnerable preterm infants during hospitalization is essential A definitive protocol which utilizes the evidence which is currently available needs to be in place to appropriately support the management of lactation for the mother of VLBW infants (Step 1 of BFHI) A concerted effort of a multidisciplinary team is an excellent strategy to improve HMF along with the development of a strong unit culture in support of human milk Obstetric, perinatal, neonatal and pediatric professionals should have the knowledge, skills and attitudes necessary to effectively support the provision of MBM to the VLBW infant (Step 2 of BFHI) Talking to the mother about her important role in helping to feed her baby has been shown to change the mind of a mother who had planned to bottle feed (Step 5 of BFHI) Early milk production is correlated with milk volume and lactation success Mothers who apply more “hands-on” (hand expression, using massage during pumping) pumping techniques can substantially increase their milk supply

14. The Role of the Nurse is very important Determine the mother’s intention to breastfeed Ensure that the mother knows the benefits of breastmilk for preterm infant Successful initiation of lactation Milk expression should begin as soon as possible less than 6 hours following delivery Teach the use of both the pump and hand expression Provide a means of prompt delivery of the mother’s milk to her infant Maintaining an adequate milk supply Directly related to frequency of milk expression, complete emptying. and duration of pumping Encourage the mother to communicate frequently with you and/or lactation consultant to discover milk supply problems early Encourage the use of support systems to help her express milk frequently Encourage the use of relaxation techniques and adequate sleep Review her medical history and medications for issues which may lower her milk production

15. The Role of the Nurse is very important (continued) If you are unsure about adequately being able to provide any of the above information, you should seek education to be prepared to work with females of child bearing age. They may be lactating, and it is our responsibility as their caretaker to protect their baby’s milk supply. Become active or continue participation in unit PI keeping track of the number of mothers expressing within the first 6 hours—set goals—achieve them and reset higher goals Make sure that your hospital has breastfeeding policies in place which specifically address the mothers of preterm infants Be aware that with small exception, mothers of VLBW infants usually agree to provide their milk, even the sickest mothers. They deserve to receive adequate evidence based information which will fully explain the benefits to their baby for them to provide their milk. This needs to be done early, because expression needs to start early in order to obtain the highest volume of milk possible

16. Conclusion This paper has attempted to address some of the evidence based techniques which have been found to assist the mother of the VLBW infant, in establishing and maintaining her milk supply. This is a complex nursing problem because failure to involve the mother in the direct care of her infant by providing her milk, can result in costly medical difficulties. There are many barriers to this process including the misconception that the management of lactation can be postponed until the mother has recovered and the baby is deem stable. Another major barrier is the prevalent attitude that the responsibility for lactation support rests with a small number of specialized care providers and/or the mother versus a collaborative team that includes all health care providers coming in contact with either the mother or the baby.

17. Conclusion (continued) All mothers deserve the opportunity to change their minds about whether they want to supply their milk, and then they need to be provided with the support that will enable them to achieve their goals. Mothers of VLBW infants may remain pump dependent for weeks to months before they can rely on the breastfeeding infant to maintain their supply. Besides providing equipment and supplies that are needed, hospital staff, and especially nurses involved in either the care of the baby or mother need to become an educated and a supportive body capable of providing the correct information which will help these mothers achieve their goals.

18. Conclusion (continued) Mothers need on-going, consistent, and frequent contact with the staff to see how she is doing and offering help and suggestions when they are needed, such as in the case of a faltering milk supply. Policies and protocols need to be in place so that every mother gets consistent information from all mother-baby staff including physicians, motivating them to continue expressing MBM. This can only be accomplished through evidence-based practice that is implemented uniformly and respected across every department that mothers interact with in the daily care of their hospitalized infant.

19. Nursing Question Nursing Question: In your practice as an RN you will probably come in contact with a patient who may be lactating. Any female of child bearing age may possibly be a lactating mother: Have you asked your female patients if they were currently lactating or breastfeeding? Have you given thought to how you will help her to maintain her milk production while in your care? Do you feel that in your circumstance, that you have an adequate education in lactation to handle the situation? Do you know how to find information which can help you to provide adequate lactation care?

20. The End Thank You