This document discusses barriers to providing human milk feeding (HMF) in the NICU. It notes that while HMF provides numerous health benefits, many mothers struggle to establish and maintain an adequate milk supply. Barriers include lack of education for healthcare providers, lack of hospital policies supporting HMF, and demographic factors like low income that correlate with lower breastfeeding rates. Overcoming these barriers is important to maximize the benefits of HMF for vulnerable very low birth weight infants.

1. Complex Nursing Problem: Overcoming Barriers to Increased Human Milk Feeding in the NICU<br />Denise Breheny RNC-MNN, IBCLC<br />Queens University of Charlotte<br />Complex Nursing Problem: Overcoming Barriers to Increased Human Milk Feeding in the NICU: Overcoming Barriers to Increased Human Milk Feeding in the NICU<br />Introduction<br />There are few areas of health care, and specifically in neonatal intensive care unit (NICU), where multitudes of studies can link a specific therapy with optimized infant outcomes as is the case with human milk feedings (American Academy of Pediatrics, 2005; Flacking, Nyqvist, Ewald, & Wallin, 2003). Providing human milk feeding (HMF) as a therapy for very-low-birth-weight ([VLBW]; those weighing less than 1500g), especially when provided by the birth mother, has been found to be: efficacious, inexpensive, readily available, and virtually risk free.<br />The benefits of providing maternal breast milk to VLBW infants are numerous. One benefit regularly cited in the literature is the decrease in the occurrence of necrotizing enterocolitis (NEC) (Lucas & Cole, 1990). Other benefits include: decreased incidence in sepsis; decreased incidence of retinopathy of prematurity; more stable SaO2 during breastfeeding; and an improved feeding tolerance with breastfeeding (Hylander, Strobino, & Dhanireddy, 1998; Clark et al., 2004; Meier, Engstrom, Patel, Jegier, & Bruns, 2010). Many long term benefits have also been found for the VLBW infant who received HMF during the NICU stay. These include a decreased incidence of: asthma, allergies, otitis media, GI disorders, and diabetes mellitus (American Academy of Pediatrics, 2005). Even more importantly when the mother is intimately involved in the direct care and nurturing of her VLBW infant there is an increased sense of maternal bonding and empowerment (Strathearn, Mamun, Najman, & O’Callaghan, 2009).<br />Furthermore the science supports the nutritional benefits of MBM for the VLBW infant. The intricate composition of human milks assists with digestion; the protein is primarily whey, which forms a softer and a more easily digested gastric curd (Sisk, Lovelady, Dillard, Gruber, & O’Shea, 2008). The fat content of human milk is 50 percent of the total caloric content, and HMF include a natural complement of long chain polyunsaturated fatty acids which are essential in preterm neurological and retinal development (Meier et al., 2010). The primary carbohydrate is lactose, which is easily digestible and produces a soft stool consistency (Sisk et al., 2008). Human milk is an accelerant towards an earlier discharge due to the faster attainment of full feeds by the VLBW infant who receives early and frequent HMF (Meier et al., 2010).<br />Providing human milk as a therapy for VLBW infants and even more specifically their own mother’s breastmilk (MBM) is best medicine. Ethically, in light of all the evidence available supporting the use of human milk for this especially venerable population, providing exclusive and human milk is quickly becoming the standard of care in the majority of NICU settings for at least the first 4 weeks of hospitalization (American Academy of Pediatrics, 2005; California Perinatal Quality Care Collaborative, 2008; Schanler, Lau, Hurst, & Smith, 2005; http://www.cpqcc.org/quality_improvement/qi_toolkits,2008).<br />Although HMF is best practice there are major barriers to this success. For example Furman, Minich and Hack (1998) found only 48 percent of mothers with preterm infants were still expressing milk at NICU discharge. This paper will examine the barriers and look at the evidence which is available to find information which can assist nurses in being successful in providing assistance to the mothers and babies involved in their care, and maximizing the volume of HMFs for the VLBW infant in the NICU.<br />Complex Nursing Problem<br />There are many barriers and difficulties encountered when trying to provide MBM to VLBW infants. Financially MBM provides not only the greatest health benefits for the infant, it is also the most cost effective treatment. Demographically, the population of mothers who tend to be at greatest risk for preterm delivery, is also the population of mothers who typically have a preference for formula feeding over breastfeeding, and therefore are the least likely to proactively seek assistance towards establishing their breastmilk supply. Establishing a full milk supply for mothers who have delivered preterm infants is often more challenging when compared with mothers who deliver term infants and are not separated from their babies. There is a generalized misconception that the management of lactation can be postponed until the mother has recovered and the baby is deemed stable. There 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 physicians. There is a general lack of knowledge and education for the various health care providers (HCP), particularly the nurses involved in the mother’s and or baby’s care, which leaves the nursing process nescient. Finally the dearth of hospital policies, protocols and standards of care for this specific situation tends to support failure for reaching goals, because no goals are in place. Together all these issues become a cacophony of events which result in severely reduced or totally absent MBM. <br />Financial Impact of Maternal Breast Milk in the NICU<br />The financial impact of using MBM when compared to the VLBW infant receiving donor human milk, or infant formulas are enormous. HMF are especially important in reducing the incidence of NEC which affects between 7-10 percent of VLBW infants (Hylander et al., 1998; Lucas & Cole, 1990; Sisk, Lovelady, Dillard, Grubbers, & O’Shea, 2007). There is evidence of a 33 percent mortality rate associated with NEC; there is also evidence that 33 percent of VLBW infants suffering long-term sequelae from having developed NEC during the NICU stay (Sisk et al., 2007). NEC is a very costly condition. NEC can increase the hospital stay by an average of 22 days for infants surviving a non-surgical incidence, and 2 months for those infants having a surgical intervention following contracting the condition (Bisquera, Cooper, & Berseth, 2002).<br /> Although MBM is clearly best, human milk banking has been around for over a century in many countries and has a accepted role in the care of the VLBW and ill infant (American Academy of Pediatrics, 2005; California Perinatal Quality Care Collaborative, 2008). Providing MBM to premature infants can be challenging. Many mothers of premature infants are sick in the postpartum period from the same complications that led to their premature infants' birth. Recovery from emergent surgeries, severe blood loss, and medical conditions such as pre-eclampsia and uterine infections can make it difficult for women to initiate and/or maintain an adequate milk supply for their infants. In addition, mothers with chronic medical conditions may require medications that make their milk unsafe for their infants. For all these reasons, pasteurized, banked donor human milk can provide an important alternative to premature formulas. The American Academy of Pediatrics (AAP) states that donor milk is considered a quot;
suitable feeding alternative for infants whose mothers are unable or unwilling to provide their own milkquot;
(American Academy of Pediatrics, 2005 p. 1). However, providing donor human milk is a very expensive option for the hospital. The cost (processing fee) of donor milk is around $4.00/ounce from non-profit sources and can run as high as $30.00/ounce from for-profit milk banks (M.R. Tully, personal communication, July, 2010). It is easy to see that the costs of providing donor milk for even the first four weeks of hospitalization can be exceedingly expensive. The alternative of having the mother provide her own expressed milk, which is the best for the baby, is clearly the most efficacious way to provide nutrition and therapy to these babies.<br />Demographic Factors which Decrease Human Milk Delivery in the NICU<br />There have always been a decreased number of mothers who initiate breastfeeding with their preterm infants, especially the VLBW infant when compared to those mothers who give birth to full term infants (Miracle, Meier, & Bennett, 2004). Numerous studies have shown that the same demographic factors where mothers show a preference for bottle-feeding over breastfeeding are also risk factors for mothers who deliver preterm. These risk factors include: low income, less education, and belonging to a racial or ethnic minority (primarily women of African American descent). States with high African American populations and large low-income populations are also the states with the highest rates of prematurity and the lowest breastfeeding rates (Centers for Disease Control and Prevention, 2008). What this means is the most vulnerable infants for increased morbidity are the least likely to benefit from MBM. In research by Miracle et al., (2004), women who chose initially to formula feed gave the following reasons for their decisions:<br />Lack of role models—no one in their families had ever breastfed so they assumed that they would formula-feed also.<br />A belief that breastfeeding would be painful—they had heard horror stories from relatives and friends who attempted to breastfeed and had difficulties.<br />Lack of knowledge about breastfeeding and a belief that formula and human milk were equivalent.<br />Miracle et al., (2004) also pointed out those women who according to their demographics were unlikely to choose breastfeeding included 71 percent African American, and that 62 percent of these women were low income. According to Miracle et al., (2004) in the United States, African American women are three times more likely than White women to deliver a premature low-birth-weight infant, and low-income women of all ethnicities are twice as likely to do so as women of higher socioeconomic status. Furthermore as seen in this study the simple intervention of talking to the mother about her important role in helping to feed her baby convinced a group that would be most unlikely to initiate breastfeeding to change their minds and begin to supply their milk to their NICU babies. This study pointed out that the personal connection made by the HCP with the individual mother during this discussion is very powerful. The mothers reported that they remembered the name and what he/she looked like, because the discussion is personalized (Miracle et al., 2004). This study revealed several things:<br />Even women who had chosen to formula feed their babies (even if born full term) want health care professionals (HCP) to discuss the benefits of human milk with them and give them enough information to make an informed choice.<br />Mothers receiving personalized information from HCPs are more likely to initiate lactation—even those least likely to do so because of their demographic features.<br />Professional encouragement for initiating lactation did not make mother feel coerced or guilty because the information given was factual and concentrated on the short term and getting the baby off to a good start (as opposed to discussing long-range goals such as breastfeeding for a year.)<br />These finding were extraordinary in providing data which showed that HCP played an important role in reversing mothers’ opinions and actions regarding providing MBM. <br />Difficulties with Establishing Milk Supply in Mothers of VLBW Infants<br />Establishing and maintaining a milk supply for the mother of a VLBW infant is much more difficult when compared to establishing a supply for a term infant. The breast itself may not be a fully developed internally when compared to the breast of a mother who delivered a term infant with a full 40 weeks of gestation (Hill, Aldag, Chatterton, & Zinaman, 2005a). It is speculated by some that the immaturity of the breast tissue may impede the lactation process of milk production which is known as lactogenesis II (LII). Other factors including stress, or having received a course of betamethasone to assist in maturing the baby’s lungs have also been found to delay LII (Grajeda & Perez-Escamilla, 2002; Henderson, Hartmann, Newnham, & Skimmer, 2008). The physical separation between mother and baby interferes with the release of hormones necessary for lactation, as well as the lack of stimulation necessary to initiate a milk supply. The bottom line is that the establishment and maintenance of a milk supply for hospitalized infants is dependent on the mother using an entirely mechanical regimen of either pumping or manual expression. For most women in this circumstance her success rests on not only her efforts but the efforts of HCPs; especially the nurses involved in her care are important, in fact crucial.<br />Evidence Based Practice Shown to Assist in the Development of Maternal Milk Supply<br />Evidence in Support of Early Intervention<br />The evidence base has been firmly established in research for what means are necessary for a mother to establish a full supply of MBM and there is no mystery to her being able to provide an adequate supply (defined as 500+mL/day) for her VLBW infant (Hill, Aldag, & Chatterton, 2001; Hill et al., (2005a); Hill, Aldag, Chatterton, & Zinaman, (2005b); Morton et al., (2009). Early and frequent stimulation of the breast to promote LII, followed by frequent milk removal are the keys to success in establishing a supply. <br />Research shows that milk volume is influenced by how soon the mother begins to stimulate her breasts following the birth of the baby (Hill et al., 2001). The optimal window is within the first 6 hours after delivery according to Furman, Minich, and Hack (2002). Of course the mother’s condition needs to be stable, and this can sometimes be a barrier in a complicated delivery; however, many times even the sickest mother is concerned over her vulnerable infant and willing to start the process. The Miracle et al. (2004) study showed that when a mother has received thoughtful, informed and evidence based information as to why postponing initiation could adversely impact her supply, she was willing to do whatever was necessary for her infant as her contribution to her baby’s health status.<br />Another study on milk initiation has validated the importance of early initiation of a milk supply by pumping and/or hand expression. In this study, there was no significant difference in milk weight (as a measure of volume) at 2-5 weeks postpartum between early initiators (< 48 hours after birth) and late initiators (> 48 hours after birth) when initiation alone was analyzed, but when mothers got an early start at pumping but pumped infrequently (< 6 times in a 24-hour period), milk volume was positively influenced (Hill et al., 2001).<br />Breast massage and manual expression has been shown to improve milk production, both in mothers who either double pump (pump both breasts at the same time) as well as when mother pump sequentially (Morton et al., 2009). Morton et al. (2009), found that by adding manual expression techniques to augment machine pumping, mothers were able to significantly increase their daily milk volumes; and, their volumes were still increasing at the end of the study period. The results of this study were compared to previous studies completed by Hill et al. (2005a), using mothers from similar demographic profiles who had only pumped for a similar eight week study. This study validated the importance of the use of manual expression to subsequent milk production levels for the mother of a preterm or hospitalized infant (Morton et al., 2009). <br />Evidence in Support of Effective Milk Removal<br />Effective emptying is another critical element towards maximizing a mother’s MBM as well as preventative to engorgement and mastitis (Daly, Kent, Owens, & Hartmann, 1996). In a more recent study, the benefits of increased milk production were shown with mothers of preterm infants who used two practices: hand expression of colostrum and “hands-on pumping” (HOP) once the milk came in (Morton et al., 2009). Mothers who used manual expression of colostrum more than five times per day in the first three postpartum days demonstrated sustained high output over the eight-week study. In Morton’s study, once the milk came in, mothers were taught HOP. Instead of passively relying only on pump suction during the expression session, mothers were taught to use breast compression, massage, and if needed, manual expression. The overall increase in milk volume for 42 mothers was 63%. By week eight, mothers who used frequent, early manual expression, as well as HOP, had a mean daily volume of over 950mL/day (Morton et al., 2009).<br />Successful effective empting of the breast as shown in Morton et al. (2009) is highly correlated with superior milk removal; however, many HCPs may limit the actual volume yield by making suggestions on the amount of time needed for a mother to completely remove milk from her breasts. Mitoulas, Lai, Gurrin, Larsson and Hartmann (2002), found that infants averaged 16.6 minutes to drain the breast. Other protocols that appear as part of research suggest either pumping for 10-15 minutes on a side or pumping until the milk flow stops. Recent research by Prime et al. (2009) showed that several milk ejections (MER) occur during breastfeeding, but that the interval, length and duration of the MER varied from mother to mother. This information appeared to be confirmed in the 2009 study completed by Morton et al., where mothers were allowed to pump for as long as they felt they were still ejecting milk using their HOP to guide them on the fullness of their breasts. Graphs were presented which clearly showed that at 15 minutes into pumping the mothers were still experiencing milk ejections and continued pumping an additional 50mL before stopping at 25 minutes (Morton et al., 2009). In the establishment of a pumping protocol, specifics as to the amount of time a mother should pump to produce a maximized volume should be individualized to each mother while being observed throughout the pumping process so appropriate teaching can occur.<br />Evidence in Support of Frequency of Breast Stimulation<br />The evidence has also addressed the frequency of breast stimulation and milk expression that a mother needs to maintain in order to achieve and keep her milk at optimal volume levels. In a comparison of mothers of preterm infants who were pumping and term mothers who were both breastfeeding and pumping, Hill et al. instructed the mothers to pump at least eight times a day (2005b). Examination of the mothers’ daily journals for milk volume data showed the researchers that actual pumping averaged only six times a day, compared to the mothers of term infants who were feeding about nine times a day (Hill et al., 2005b). When the authors measured milk volume at the 6 or 7th day postpartum, they found that they could predict milk adequacy at 2 and 6 weeks postpartum. In Morton’s study it was found that high frequency pumping significantly influenced the mean daily volumes at 2 weeks but not at 8 weeks (2009). In most of the evidence available at this time, study volumes have been consistent with an average daily frequency of 6-7 times by study participants. Researchers have found it difficult to increase the frequency although it has always been requested by most researchers for the mother to pump a minimum of 8 times or more daily. From the evidence that is available it would appear that mothers are able to maintain, or even increase their milk volumes by pumping a minimum of 6 times daily.<br />Solutions for Maximizing Human Milk Feedings in the NICU<br />Baby-Friendly Hospital Initiative<br />The Baby-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization (WHO) and United Nations International Children’s Fund (UNICEF) in 1991, following the Innocenti Declaration of 1990 (World Health Organization: Baby-friendly Hospital Initiative, 2010). The initiative is a global effort to implement practices that protect, promote and support breastfeeding. Studies which have evaluated hospital’s compliance with BFHI have found that breastfeeding rates increased in countries where BFHI guidelines were routinely implemented, (Merten, Dratva, & Ackermann-Liebrich, 2006). The BFHI includes the Ten Steps to Successful Breastfeeding (Table 1). Step 5 mandates that hospital staff involved with the assisting of mother and babies are responsible for the assistance in mothers establishing an ample milk supply. Even if separated from her baby by prematurity or illness, the mother still should receive assistance in establishing her milk supply according to the BFHI model. All maternity staff and mothers are expected to know the importance of feeding and or pumping frequency necessary for the success of establishing an ample milk supply. Nurses and all HCPs who are in contact with mothers and neonates are responsible for knowing the basic physiology of lactation and practicing skill sets that work with the mother’s physiology instead of against it. 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.<br />Health Care Professionals Play an Important Role in the Mother’s Feeding Decision<br />A concerted effort of a multidisciplinary team along with the development of a strong unit culture in support of human milk is an excellent strategy to improve HMF. 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. In support of the evidence presented by Miracle et al. (2004) and the AAP’s best medical practices for VLBW infants, neonatologists have taken on the task of presenting this information to the mothers in hope that they will agree to provide their expressed milk for their babies. This is a big step towards changing the attitudes and increasing the amount of HMFs delivered to VLBW infant; especially when presented in the antepartum period when preterm delivery is eminent.<br />Even with the involvement of Neonatologists as mentioned above, many facilities are still lacking specific protocols, policies, or scripting as to how this information is presented to each mother, or even more critically, when this information is presented to the mother. In my working situation a neonatologist may not present this information until the baby is several days old, and this is often too late for the mother to rescue her milk supply. These are some of the reasons to support the use of specific protocols with scripting placed into service which would help to guide the health professional in the most appropriate time frame to help with the mother’s ability to supply milk for her infant.<br />Nurses are the omnipresent health care provider, and therefore have a central role in providing information and support to new mothers of VLBW infants. Most nurses have been supportive of a mother’s choice; but they had been ambivalent about their roles in influencing breastfeeding initiation and have felt in the past that approaching mothers regarding feeding choices could be determined to be invasive, coercive and guilt provoking. In light of the information that the Miracle et al. (2004) study provided, there are many missed opportunities to firmly set the tone at first contact with the mother by all health professionals including the staff nurse, on how important it is to initiate early and frequent milk removal in order to provide enough milk for the baby during the NICU stay.<br />Practice Protocols Show the Facilities Support of Best Practice<br />According to Cadwell and Turner-Maffei (2009), the foundation of continuity of care is evidence-based policies that are routinely practiced consistently so that mothers get consistent information across the multidisciplinary continuum of healthcare providers that the mother and her baby may encounter. Detailed policies, protocols and procedures should be easily available to the staff and to mothers. Written policies and procedures to guide the organization, the HCP and specifically the nurse, would enable consistent, and evidence based practice. Practices, and protocols designed to support the mother in initiation and protection of her milk supply would be a way to assist the staff nurse in utilizing the nursing process with her patient. Nurses for these patients, both the mother and the baby, would have specific guidelines they could follow, for example: The mother’s nurse would know that her assessment would include an assessment of how much milk the mother was making, and if this amount was consistent with her day of hospital stay. Does she have a breastpump? If she is still unable to manage breast stimulation with a breastpump, does she know how to use hand expression? The baby’s nurse would also assess her baby’s situation; does this VLBW infant have orders for colostrum mouth care? Has the mother collected any colostrum? Both nurses should be concerned and working in collaboration as they complete their particular patient’s individualized nursing process. What if the NICU nurse calls the mother for some expressed colostrum, and the mother has not even started pumping, or has expressed MBM but she is bed bound and unable to deliver this to her infant? Through the use of specific protocols which will state, when it is expected that a mother will begin pumping, and what plans are in place for MBM to be delivered to the NICU etc., everyone will be better able to recognize when specific goals are being met or not being met and how to improve on completing the nursing process. <br />When hospital personnel are competent with adequate knowledge, training and skills, staff skills would better support the mother and her goals and the baby’s needs and care plan. 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.<br />Nursing Interventions and Nursing Process<br />Nurses need to use the nursing process to evaluate the situation and see that every opportunity to assist a mother to establish her milk supply is utilized. Nurses with adequate education in the physiology of lactation will have the information to fully assess their patients’ needs and provide the appropriate care. Early interventions can take place during the most critical first hours following delivery when colostrum production is minimal, often less than 30mL over the entire 24 hour period following birth. Being able to express a few drops manually is often more encouraging to a mother than using a machine for several occasions and not visualizing any production. Nurses who have the appropriate knowledge base understand this and can be more encouraging to a mother rather than allow these critical hours to pass without an attempt towards an intervention, or even worse tell the mother she isn’t producing any milk. While using the nursing process, the nurse can use the teaching moments provided by showing the mother how to manually remove milk, and as a time to remove any anxiety or fear of pain while expressing milk, as well as other indicators cited by Miracle et al. (2004). The nurse can assist the woman to become comfortable with touching and handling their breast and can accustom her to the feel of her breast. This has the advantage of the woman being able to distinguish normal from unusual and may be a life-saving technique for the mother when she completes breast self-exams.<br />Sometimes initiation of milk production by pumping isn’t feasible—there may not be a pump available, or the mother may feel unable because she already has too many body attachments for her care such as IV lines, catheter, and heart monitors etc.—doesn’t mean that the nurse should forego the opportunity to provide assistance during this critical time period. Both the NICU nurses as well as the postpartum nurses, and everyone who has a role in caring for the mother and/or her infant is responsible for knowing and being able to demonstrate the basic skills that assist mothers with the establishment of a milk supply. With the proper education, the nurses and other HCP have a clear understanding of why these mothers need consistent and appropriate encouragement and assistance during the most critical periods following the birth of the infant. Having current policies, protocols and standards of practice in place are needed in order to translate evidence into practice. Following established and agreed-upon policies protects employees against liability as well.<br />Conclusion<br />This paper has attempted to address some of the evidence based techniques which have been found to assist the mother of a hospitalized, and particularly the VLBW infant, in establishing, maximizing, 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 for the VLBW infant. 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. Many hospitals do not have policies or procedures in place which address these issues, subsequently MBM feedings are not maximized in availability to the VLBW infant.<br />The mothers of VLBW infants 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. 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. <br />0694690Table 1.The Ten Steps to Successful BreastfeedingThe BFHI promotes, protects, and supports breastfeeding through The Ten Steps to Successful Breastfeeding for Hospitals, as outlined by UNICEF/WHO. The steps for the United States are:1 - Have a written breastfeeding policy that is routinely communicated to all health care staff.2 - Train all health care staff in skills necessary to implement this policy.3 - Inform all pregnant women about the benefits and management of breastfeeding.4 - Help mothers initiate breastfeeding within one hour of birth.5 - Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.6 - Give newborn infants no food or drink other than breastmilk, unless medically indicated.7 - Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.8 - Encourage breastfeeding on demand.9 - Give no pacifiers or artificial nipples to breastfeeding infants.10 - Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic00Table 1.The Ten Steps to Successful BreastfeedingThe BFHI promotes, protects, and supports breastfeeding through The Ten Steps to Successful Breastfeeding for Hospitals, as outlined by UNICEF/WHO. The steps for the United States are:1 - Have a written breastfeeding policy that is routinely communicated to all health care staff.2 - Train all health care staff in skills necessary to implement this policy.3 - Inform all pregnant women about the benefits and management of breastfeeding.4 - Help mothers initiate breastfeeding within one hour of birth.5 - Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.6 - Give newborn infants no food or drink other than breastmilk, unless medically indicated.7 - Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.8 - Encourage breastfeeding on demand.9 - Give no pacifiers or artificial nipples to breastfeeding infants.10 - Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic<br />Note. 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http://www.cpqcc.org/quality_improvement/qi_toolkits/nutritional_support_of_the_vlbw_infant_rev_december_2008:quot;
http://www.cpqcc.org/quality_improvement/qi_toolkits/nutritional_support_of_the_vlbw_infant_rev_december_2008:<br />