THE NEONATAL UNIT
Preterm babies are at high risk of poor human milk feeding outcomes, despite high initiation rates. For example, the National Neonatal Audit Programme showed that 40% of babies born at less than 33 weeks were exclusively formula fed at discharge in 2017. Multiple factors are involved - the need to establish and maintain milk supply for long periods by mechanical expression, anxiety and stress associated with the baby's illness, underdeveloped breast tissue and hormonal environment, and the necessary use of antenatal steroids, which also delay lactogenesis II. As the neonatal unit admission progresses, there is an increasing failure to meet mothers' own goals for human milk provision to their preterm babies. Lack of human milk feeding is associated with worse health outcomes for the babies and higher costs to the healthcare system. To give preterm babies and their families the best chance of exclusive maternal milk provision and conversion to direct breastfeeding/chestfeeding, professionals can:
1. Motivate families. Antenatal and postnatal counselling on the specific impact of maternal milk provision is effective to increase initiation and length of breastfeeding. Parents who had intended to formula feed are very open to providing human milk if their baby were born sick or premature, and report being pleased they received counselling and satisfied with providing their milk. Information that is likely to be important to families includes the association of formula with higher rates of morbidity and mortality in very low birth weight babies, particularly with increased rates of necrotising enterocolitis. Human milk is associated with dramatically lower rates of retinopathy of prematurity (ROP), and there is a dose response relationship with brain growth, long term neurodevelopmental outcomes and hospital readmissions.
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2. Focus on urgent and frequent expression of milk from birth. A pilot RCT showed that in the context of prematurity, expressing within an hour of birth more than doubled yield up to the end of study at 3 weeks of age. A larger trial did not confirm these findings and recommended that expressing within 3-6 hours of birth is a useful goal. The UNICEF Baby Friendly Initiative recommendation is to express within 2 hours of birth, while the WHO recommendation is 1-3 hours and other international experts recommend within the first six hours.
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3. Advise mothers/parents to express frequently from birth. The UNICEF Baby Friendly Initiative recommendation is to express 8-10 times per 24 hour period, at least once at night. Similarly, the WHO recommends at least seven times per day. There is no clear-cut evidence for this specific frequency but at least 7 times a day in the first 2 weeks has been associated with significantly increased yield and at least 5 times per day in the first 3 weeks with higher rate of breastfeeding long term.
3. Encourage families to target higher volumes than their baby needs in the first few weeks. In very preterm babies each 10ml/kg/day of mother's own milk that the baby receives at day 7 gives an odds ratio of 1.2 for exclusive human milk feeding at 36 weeks gestation. The UNICEF Baby Friendly Initiative recommends aiming for at least 750ml in 24 hours by day 14, as this mimics the average intake of a term baby. Other authors recommend a target of 500ml as this is associated with increased breastfeeding at discharge. One study identified a volume of 407ml at day 7 and 518ml at 14 days as having the optimal sensitivity and specificity in predicting good milk yield at 42 days.
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4. Maximise skin to skin contact. Apart from multiple short-term physiological benefits, including temperature stabilisation, reduced response to pain, increased sleep time and maturity of sleep organisation, skin to skin contact doubles the the likelihood of any breastfeeding at one to two months' follow up. Mothers report increased confidence in their role, being needed and getting to know their baby, and parents’ responsiveness and sensitivity to their baby at discharge and at home is increased.
Skin to skin contact during, or immediately before, expressing milk is associated with a third increase in yield, and overall expressed milk yield is associated with the amount of time spent in skin-to-skin contact.
Image with thanks to the Neonatology Unit, 12 de Octubre University Hospital, Madrid. Patient consented to educational use
5. Maximise family integrated care. Apart from other benefits like reduced length of stay, increased weight gain and decreased parental stress, family integrated care has been shown to improve breastfeeding rates at discharge, including increased amounts of breastmilk exposure at discharge. Family integrated care is when parents provide almost all aspects of their infants' care during admission, and are viewed as part of the multi-disciplinary team.
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Other factors with weaker evidence of improved breastfeeding rates include the use of guided visualisation/relaxation soundtracks and avoiding bottles through use of nasogastric tube or cup feeds. Controversial issues, which have conflicting evidence, include the use of pacifiers and test-weighing babies, and whether electric pumping is better than hand expressing directly after birth.
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'Double pumping' - expressing milk from both breasts at the same time - is more time-efficient and may give a greater yield overall, although evidence is conflicting. Here are some ways to create a 'hands free pumping' bra in the postnatal ward and NICU with minimal cost (see photos of using tubigrip or CTG belts, and this slideshow for more detail on using tubigrip).
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Psychological Impact
Expressing in this way is demanding and emotionally draining. When asked in an unpublished survey during the planning of a research project (involving 675 parents of preterm babies), 90% reported problems with expressing and/or breastfeeding. One third reported concerns over low milk supply. Many qualitative research studies confirm this anxiety about milk volumes among parents of premature babies on the neonatal unit.
Stress and mental health problems related to expressing and breastfeeding/chestfeeding could operate in both directions as the demands of expressing and the anxiety over pumped volumes exacerbated the parent's distress, and they also felt that their distress and anxiety negatively affected their milk supply. The practical demands of expressing took away time from self-care, sleep, caring for their baby and other children. Expressing away from the baby was particularly distressing, focusing attention on the separation.
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To give holistic care to the whole family, health professionals should be aware of these impacts on mental health. High quality support and advice in the early period to establish a full milk supply will benefit the parent's mental health. It is particularly important to ensure people are aware of the expected small volumes of colostrum and that it is normal to express colostrum for 2-3 days before mature milk comes in - this will prevent common unnecessary anxiety.
Counselling on the impact of human milk for the infant needs to be done sensitively to avoid a feeling of excessive pressure, leading to guilt, judgement and inadequacy - in the questionnaire respondents recommended gentle support, encouragement, reassurance and empowerment. Mothers/parents may have extremely complex and conflicting feelings around expressing milk - for example the pump may be seen as representing both a connection to and a barrier from their baby. A thorough analysis of the potential harm of approaching lactation purely from a perspective of maximising the provision of human milk to the baby is discussed here.
Helping people to express during skin to skin (as pictured above) or at the cot side (which may need attention to privacy) may reduce the burden of expressing, as well as improving volumes expressed. Explaining that there may be unavoidable antenatal factors making expressing more difficult for some may help them to avoid comparing themselves with others and feeling inadequate (for example gestation at birth, antenatal and intrapartum complications and use of steroids). As with all care, it is of course important to place each family at the centre and support their own choices around feeding and expressing decisions.
With thanks to Oxford and Sheffield neonatal units for these images (patients consented for educational use)
