Mother's own milk (MOM) improves infant health and is recommended by numerous international and national organizations.1,2 Research has repeatedly shown that infants born preterm and/or critically ill benefit immensely from consumption of MOM.3,4 Unfortunately, mothers delivering critically ill infants often produce insufficient quantities of MOM to provide these benefits.5,6 If adequate amounts of MOM are unavailable for infant consumption, feeds may either be withheld until MOM is available, the infant provided formula feedings or the infant fed pasteurized donor human milk. Gastrointestinal hormone secretion and motility are dependent on feedings, and therefore withholding feeds in the days after birth can decrease future feeding tolerance.7 Furthermore, provision of even small amounts of formula is associated with creating an abnormal intestinal microbiome potentially increasing the risk of complications, and donor human milk does not contain many of the protective elements found in MOM.8 Mothers of critically ill infants are also at significant risk for delayed secretory activation, which signals the change from production of small quantities of colostrum to copious amounts of MOM.5,9,10 Delayed secretory activation limits the amount of MOM available for infant consumption in the first few days of life, increasing the probability they will be provided alternative forms of nutrition or have feeds withheld, which are far inferior to colostrum feedings.

Strategies to promote lactation success in mothers of infants admitted to the neonatal intensive care unit (NICU) have primarily focused on mothers delivering preterm very low-birth-weight infants. However, all mothers of critically ill infants, whether born preterm or term, are at risk for insufficient MOM production and delayed secretory activation. The etiology of this insufficient MOM production is likely multifactorial including the need to use a mechanical breast pump for weeks to months and an increased risk of comorbidities including obesity, diabetes, and pregnancy-induced hypertension, which are known to negatively affect lactation.11-13 Long-term MOM production is strongly associated with production in the first few days after delivery, underscoring the need for strategies beginning soon after delivery to increase MOM production in this population.6,14 Therefore, it is essential that healthcare providers caring for infants admitted to the NICU and those caring for their mothers create an environment conducive to lactation and utilize evidence-based strategies to facilitate increased MOM production.

Strategies to facilitate establishment of successful lactation in the first few days after delivery include initiation of expression soon after delivery and frequent breast expression. Early initiation of expression has been found to increase MOM production, and hospital protocols generally recommend initiation of expression within the first 6 hours following delivery in mothers of infants admitted to the NICU.15 However, although the World Health Organization recommends breastfeeding initiation within 1 hour and several small studies suggest that initiation within the first hour following delivery may increase MOM production for the first 6 weeks following delivery and decrease time to secretory activation, no large randomized controlled trial has investigated the optimal time to initiate MOM expression in mothers of premature or critically ill infants.5,16

Unfortunately, due to the mother's need for assistance, expression initiation is often delayed. Mothers delivering critically ill infants frequently experience a complicated pregnancy and delivery requiring significant nursing care, which may take precedence over expression initiation. In fact, when surveyed, 43% of obstetrical nurses report lack of time and 31% report lack of available staff are significant barriers to expression initiation.17 It is possible that this burden could be reduced by educating the mother's family or significant other to provide assistance with expression initiation. Mothers delivering premature and/or critically ill infants are often admitted several days prior to delivery, creating an opportunity for the family or significant other to be educated regarding breast pump use. An easily accessible electric breast pump placed in the patient's room either prior to or immediately following delivery may also facilitate an earlier expression.

Frequent breast expression in the initial few days following delivery and before the onset of secretory activation is imperative for optimal MOM production.18 Frequent breast emptying is essential to establish and maintain MOM production and it is recommended that all mothers pump 8 to 12 times per day.19 Unfortunately, mothers of critically ill infants often express much less frequently than necessary to facilitate secretory activation and optimize MOM production. Expression opportunities may be missed due to perceived acuity level, nursing burden, and exhaustion following a difficult labor and delivery. However, if mothers understand the potential negative effect missed expression sessions may have on their MOM production and the important health benefits of MOM, they may be more likely to express more frequently. It is also possible that family members could provide expression assistance as needed during the mother's recovery.

Finally, it is imperative that mothers have access to hospital-grade breast pumps during the initial few days following delivery. Pumps should be consistently available in the mother's hospital room beginning either prior to or immediately following delivery to avoid delays in expression due to breast pump unavailability. Furthermore, mothers require access to a hospital-grade breast pump upon discharge from the hospital. Unfortunately, attainment of an appropriate pump for home use is often delayed and thus mothers may be dependent upon hand pumps or battery-operated breast pumps both of which are inadequate to provide the necessary breast stimulation and milk removal for establishment of lactation in the early days following delivery. Development of hospital-based systems is needed to ensure all mothers delivering critically ill infants have access to a hospital-grade breast pump upon discharge.

Programs of lactation support, which include both early initiation and frequent expression during the first few days following delivery, are necessary to facilitate increased MOM production in this vulnerable population.5,20 Because these first few days are critical for establishment of lactation, support from all healthcare providers including both obstetric and neonatal nurses is necessary to promote lactation success in mothers of critically ill infants, thus increasing the likelihood that sufficient quantities of MOM are available for infant consumption.

--Leslie A. Parker, PhD, APRN, FAAN

Clinical Associate Professor

University of Florida

Gainesville, Florida

References