A comparison of the efficiency, efficacy, comfort, and convenience of two hospital-grade electric breast pumps for mothers of very low birthweight infants

Early postpartum pumping behaviors, pumped milk volume, and achievement of secretory activation in breast pump-dependent mothers of preterm infants

OBJECTIVE

Pumping studies in mothers of preterm infants are limited by self-reported pumping behaviors and non-objective measures of pumped milk volume and secretory activation (SA).

METHODS

Non-randomized observational study of first 14 days postpartum in 29 mothers of preterm infants. Smart pumps measured and stored pumping behaviors and pumped milk volume. Selective ion electrodes measured sodium and sodium:potassium ratio to determine SA. Generalized estimating equations, cluster analyses and multivariate regression were used.

RESULTS

SA was delayed (median 5.8 days) and impermanent. Each additional daily pumping increased odds of SA within 2 days by 48% (p = 0.01). High-intensity pumping mothers (N = 17) had greater daily and cumulative pumped milk volume than low-intensity pumping mothers (N = 12). Pumping variables showed daily changes in the first week, then plateaued.

CONCLUSION

The first week postpartum is critical for optimizing pumping behaviors. Accurate, objective measures of pumping behaviors, pumped milk volume and SA are a research priority.

Multi-prong quality improvement approach for increasing mother's own milk use for very low birth weight infants

OBJECTIVE

Evaluate a single center quality improvement (QI) collaborative designed to increase the provision of mother's own milk (MOM) at discharge to premature infants through evidence-based practices while targeting perinatal health disparities.

DESIGN

This QI initiative was designed for preterm infants admitted to a single-center NICU within 24 h of life. Interventions were implemented between March 2022 and June 2022. MOM provision rates were compared between baseline (August 2021-February 2022), and after interventions (March 2022-December 2022).

RESULTS

The percentage of mothers who discontinued pumping during the infant hospitalization decreased from 49% to 35% (p < 0.01). Infant discharge diet with MOM improved from 36% to 58% (p < 0.001). Pump frequency at two weeks increased from 4.0 ± 2.6 to 5.1 ± 2.4 (p = 0.026).

CONCLUSION

Our collaborative increased the percentage of preterm infants receiving MOM at discharge and reduced the number of mothers who discontinue pumping during the NICU hospitalization.

An evaluation of patient comfort levels during expression with a modified pumping program: a prospective proof of concept study

Introduction

This study aimed to assess if the implementation of a gentle transition of vacuum mode into a breast pump suction pattern commonly used to initiate milk production would improve user comfort while expressing during the first four days postpartum.

Methods

This prospective study was conducted at OLVG hospital in the Netherlands in two sequential phases. Breastfeeding patients delivering >36 weeks gestation with an infant aged ≤96 h old and a clinical indication to express milk with a breast pump were recruited. Intervention group 1 (n = 40) used a hospital-grade electric breast pump with a standard breast pump suction pattern. Intervention group 2 used a hospital-grade electric breast pump with a modified breast pump suction pattern (n = 40). The primary outcome was an objective assessment of comfort as measured by participants' need to reduce vacuum level during the 20 min test session. Secondary outcomes included the total expression volume (ml) in 20 min pumping.

Results

The study found that the primary outcome of comfort was significantly improved with the modified breast pump suction pattern compared to the standard pattern (OR 1.29, 95% CI 1.08 to 1.6) with 86% vs. 67% of participants not needing to reduce applied vacuum levels. The amount of milk expressed did not differ significantly between phases (group 1: 7.6 ml (2.7-25.5 ml), group 2: 12.0 ml (1.2-31.5 ml), p = 0.43).

Discussion

This study is the first to demonstrate an improvement in user comfort driven by the implementation of gentle transitions in vacuum modes in a commonly used breast pump suction pattern. Research into this novel population combining both pumping and breastfeeding in the first days after birth offers new unique insights on the requirements of breast pump suction patterns.

Trial registration

Registered on clinical trials.gov NCT04619212. Date of registration November 6, 2020.

Lactation support in neonatal intensive care units in Germany from the mothers' perspective - a mixed-method study of the current status and needs

BACKGROUND

Establishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers' perspectives on lactation support in German neonatal intensive care units (NICUs).

METHODS

This paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers' perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs.

RESULTS

The results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information.

CONCLUSION

The overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs.

Infant factors that impact the ecology of human milk secretion and composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 3

Infants drive many lactation processes and contribute to the changing composition of human milk through multiple mechanisms. This review addresses the major topics of milk removal; chemosensory ecology for the parent-infant dyad; the infant's inputs into the composition of the human milk microbiome; and the impact of disruptions in gestation on the ecology of fetal and infant phenotypes, milk composition, and lactation. Milk removal, which is essential for adequate infant intake and continued milk synthesis through multiple hormonal and autocrine/paracrine mechanisms, should be effective, efficient, and comfortable for both the lactating parent and the infant. All 3 components should be included in the evaluation of milk removal. Breastmilk "bridges" flavor experiences in utero with postweaning foods, and the flavors become familiar and preferred. Infants can detect flavor changes in human milk resulting from parental lifestyle choices, including recreational drug use, and early experiences with the sensory properties of these recreational drugs impact subsequent behavioral responses. Interactions between the infant's own developing microbiome, that of the milk, and the multiple environmental factors that are drivers-both modifiable and nonmodifiable-in the microbial ecology of human milk are explored. Disruptions in gestation, especially preterm birth and fetal growth restriction or excess, impact the milk composition and lactation processes such as the timing of secretory activation, adequacy of milk volume and milk removal, and duration of lactation. Research gaps are identified in each of these areas. To assure a sustained and robust breastfeeding ecology, these myriad infant inputs must be systematically considered.

Prepregnancy Body Mass Index Is Associated with Time-Dependent Changes in Secretory Activation Measures During the First 7 Days Postpartum in Breast Pump-dependent Mothers of Premature Infants

Background: Little is known about the biology of secretory activation (SA) in overweight and obese (OW/OB) mothers who are breast pump dependent with a premature infant in the neonatal intensive care unit. Objective: To compare time-dependent changes in daily pumped milk volume, maternal milk sodium (Na) concentration, and Na-to-potassium (K) ratios (Na:K) in the first 14 days postpartum in breast pump-dependent mothers with prepregnancy body mass index (BMI) <27 and BMI ≥27 kg/m². Design/Methods: This secondary analysis for 39 subjects, 44% (n = 17) with prepregnancy BMI <27 and 56% (n = 22) with BMI ≥27, included transformed data of outcome measures, chi-square, t-tests, and growth curve models. Results: For days 1-7, daily pumped milk volume increased significantly more rapidly for mothers with BMI <27 (65.82 mL/d) versus BMI ≥27 (33.08 mL/d), but the daily rate of change in pumped milk volume during days 8-14 was not statistically different. Daily milk Na concentration decreased significantly faster in BMI <27 (-3.93 mM/d) versus BMI ≥27 (-2.00 mM/day) during days 1-7, but was not significantly different for days 8-14. No statistical differences were noted for Na:K ratio for either time period. Conclusion: These data add biologic evidence to previous research, suggesting delayed or impaired SA in OW/OB mothers, and suggest that the window of opportunity for research and clinical interventions is days 1-7 postpartum in this population.

Pay at the pump?: Problems with electric breast pumps

Breast pump marketing promises mothers that they will be able to follow cultural and scientific mandates to breastfeed their babies, but on their own schedules, including working outside of the home. Relatively little attention has been paid to the problems that women may experience with breast pumps. The Food and Drug Administration (FDA) regulates breast pumps as medical devices, and the agency collects data on adverse events experienced by consumers and recalls. Existing literature on breast pumps was reviewed in the contexts of medicalization and biomedicalization, and regulatory data were analyzed using mixed methods to examine the problems that women have experienced with breast pumps, which include electrical problems, suction problems, fluid leaks, injuries, and infections. While electric breast pumps promise women convenience and efficiency in pumping, women may incur personal costs, in the form of pain, injuries, and infections. These findings have implications regarding the risks of using these devices, the design of future pumps, and the future research into medical devices for reproductive and women's health.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Measuring Mothers' Viewpoints of Breast Pump Usage

Breastfeeding has short- and long-term positive influences on the health and wellbeing of the child. There are situations where breastfeeding does not occur and expressed or pumped mother's milk is used. Mothers and healthcare providers report problems or negative views on using pumps in studies across the globe. This systematic review and secondary analysis of 18 random control trials related to mothers' views of breast pumps examines the range of viewpoints gathered, the variety of measurement instruments used, how the outcomes are reported and the challenges that occur. It aims to inform critical reading of research as well as future research design. Devices which the mother views as comfortable and useful will facilitate more infants to receive human milk when direct breastfeeding does not occur, and they will have a positive influence on health and wellbeing.

Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units

Very low birth weight (VLBW; <1500 g birth weight) infants are substantially more likely to be born to black than to non-black mothers, predisposing them to potentially preventable morbidities that increase the risk for costly lifelong health problems. Mothers' own milk (MOM) may be considered the ultimate "personalized medicine" since milk composition and bioactive components vary among mothers and multiple milk constituents provide specific protection based on shared exposures between mother and infant. MOM feedings reduce the risks and associated costs of prematurity-associated morbidities, with the greatest reduction afforded by MOM through to NICU discharge. Although black and non-black mothers have similar lactation goals and initiation rates, black VLBW infants are half as likely to receive MOM at NICU discharge in the United States. Black mothers are significantly more likely to be low-income, single heads of household and have more children in the home, increasing the burden of MOM provision. Although rarely considered, the out-of-pocket and opportunity costs associated with providing MOM for VLBW infants are especially onerous for black mothers. When MOM is not available, the NICU assumes the costs of inferior substitutes for MOM, contributing further to disparate outcomes. Novel strategies to mitigate these disparities are urgently needed. IMPACT: Mother's own milk exemplifies personalized medicine through its unique biologic activity. Hospital factors and social determinants of health are associated with mother's own milk feedings for very low-birth-weight infants in the neonatal intensive care unit. Notably, out-of-pocket and opportunity costs associated with providing mother's own milk are borne by mothers. Conceptualizing mother's own milk feedings as an integral part of NICU care requires consideration of who bears the costs of MOM provision-the mother or the NICU?

Milk Volume at 2 Weeks Predicts Mother's Own Milk Feeding at Neonatal Intensive Care Unit Discharge for Very Low Birthweight Infants

OBJECTIVE

This study sought to determine the maternal prepregnancy, pregnancy, and delivery risk factors that predicted coming to volume (CTV; achieving pumped mother's own milk [MOM] volume ≥500 mLs/day) and the continuation of MOM provision through to discharge from the neonatal intensive care unit (NICU) in mothers and their very low birthweight (VLBW; <1,500 g at birth) infants.

STUDY DESIGN

Secondary analysis of prospectively collected data from 402 mothers of VLBW infants admitted to an urban NICU, including detailed MOM pumping records for a subset (51%) of the cohort. Analyses included inverse probability weighting, multivariate regression, and chi-square statistics.

RESULTS

In this high-risk cohort (51.2% black, 27.1% Hispanic, 21.6% white/Asian; 72.6% low income; 61.4% overweight/obese prepregnancy), CTV by day 14 was the strongest predictor of MOM feeding at NICU discharge (odds ratio [OR] 9.70 confidence interval [95% CI] 3.86-24.38, p < 0.01.). Only 39.5% of mothers achieved CTV by postpartum day 14, an outcome that was predicted by gestational age at delivery (OR 1.41, 95% CI 1.15-1.73, p < 0.01), being married (OR 3.66, 95% CI 1.08-12.39, p = 0.04), black race (OR 7.70, 95% CI 2.05-28.97, p < 0.01), cesarean delivery (OR 0.22, 95% CI 0.08-0.63, p = 0.01), and chorioamionitis (OR 0.14, 95% CI 0.02-0.82, p = 0.03).

CONCLUSION

Continued provision of MOM at NICU discharge can be predicted in the first 14 postpartum days on the basis of achievement of CTV. We posit that CTV can serve as a quality indicator for improving MOM feedings in the NICU and that lactation support resources should target this early critical postbirth period.

A Password-Protected Web Site for Mothers Expressing Milk for Their Preterm Infants

BACKGROUND

Research has demonstrated that breast milk significantly decreases morbidities that impact length of stay for preterm infants, but there is a need to test interventions to improve breastfeeding outcomes. Since many Americans are using technologies such as the Intranet and smartphones to find health information and manage health, a Web site was developed for mothers who provide breast milk for their preterm hospitalized infants.

PURPOSE

This study examined the efficacy of a Web site for mothers to educate them about breast milk expression and assist them in monitoring their breast milk supply.

METHODS

Quantitative and qualitative data were collected from mothers whose preterm infants were hospitalized in a level IV neonatal intensive care unit (NICU) or transitional care unit (TCU) in an urban academic medical center in the Midwest.

RESULTS

Eighteen mothers participated in evaluation of the Web site. Thirteen mothers consistently logged on to the password-protected Web site (mean [standard deviation] = 13.3 [11.7]) times. Most participants, (69.2%), reported they used the breast milk educational information. Most mothers indicated that using the Web site log helped in tracking their pumping. These findings can be used to direct the design and development of web-based resources for mothers of preterm infants IMPLICATIONS FOR PRACTICE:: NICU and TCU staffs need to examine and establish approaches to actively involve mothers in monitoring the establishment and maintenance of an adequate supply of breast milk to improve neonatal health outcomes.

IMPLICATIONS FOR RESEARCH

An electronic health application that incorporates the features identified in this study should be developed and tested.

Using quality improvement to increase human milk use for preterm infants

This review will provide an overview of quality improvement methods that have been used to improve human milk use (mother's own milk and donor milk) for very low-birth-weight infants in the hospital setting in the last decade. We will review the following: (1) evidence-based practices known to increase mother's own milk for very low-birth-weight infants; (2) individual hospitals with exemplary lactation programs and past and current US-based statewide quality improvement collaboratives focused on increasing mother's own milk; and (3) existing quality metrics for human milk and gaps in metrics. Finally, we will provide practical examples of key driver diagrams and change concepts that may be used to inform quality improvement for mother's own milk for very low-birth-weight infants.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important, however not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and costs of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2016), handsearched relevant journals and conference proceedings, and contacted experts in the field to seek additional published or unpublished studies. We also examined reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

This updated review includes 41 trials involving 2293 participants, with 22 trials involving 1339 participants contributing data for analysis. Twenty-six of the trials referred to mothers of infants in neonatal units (n = 1547) and 14 to mothers of healthy infants at home (n = 730), with one trial containing mothers of both neonatal and healthy older infants (n = 16). Eleven trials compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and pump types. Twenty studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols, pumping frequency, provision of an education and support intervention, relaxation, breast massage, combining hand expression with pumping and a breast cleansing protocol.Due to heterogeneity in participants, interventions, and outcomes measured or reported, we were unable to pool findings for most of the specified outcomes. It was not possible therefore to produce a 'Summary of findings' table in this update. Most of the included results were derived from single studies. Trials took place in 14 countries under a variety of circumstances and were published from 1982 to 2015. Sixteen of the 30 trials that evaluated pumps or products had support from the manufacturers. The risk of bias of the included studies was variable. Primary outcomesOnly one of the 17 studies examining maternal satisfaction/acceptability with the method or adjunct behaviour provided data suitable for analysis. In this study, self-efficacy was assessed by asking mothers if they agreed or disagreed with the following statement: 'I don't want anyone to see me (hand expressing/pumping)'. The study found that mothers who were using the electric pump were more likely to agree with the statement compared to mothers hand expressing, (mean difference (MD) 0.70, 95% confidence interval (CI) 0.15 to 1.25; P = 0.01, participants = 68). Mothers who were hand expressing reported that the instructions for expression were clearer compared to the electric pump, (MD -0.40, 95% CI -0.75 to -0.05; P = 0.02, participants = 68). Descriptive reporting of satisfaction in the other studies varied in the measures used, did not indicate a clear preference for one pump type, although there was satisfaction with some relaxation and support interventions.We found no clinically significant differences between methods related to contamination of the milk that compared any type of pump to hand expression (risk ratio (RR) 1.13, 95% CI 0.79 to 1.61; P = 0.51, participants = 28), manual pump compared to hand expression, (MD 0.20, 95% CI -0.18 to 0.58; P = 0.30, participants = 142) a large electric pump compared to hand expression (MD 0.10, 95% CI -0.29 to 0.49; P = 0.61, participants = 123), or a large electric pump compared to a manual pump (MD -0.10, 95% CI -0.46 to 0.26; P = 0.59, participants = 141).The level of maternal breast or nipple pain or damage was similar in comparisons of a large electric pump to hand expression (MD 0.02, 95% CI -0.67 to 0.71; P = 0.96, participants = 68). A study comparing a manual and large electric pump, reported sore nipples in 7% for both groups and engorgement in 4% using a manual pump versus 6% using an electric pump; and in one study no nipple damage was reported in the hand-expression group, and one case of nipple damage in each of the manual pump and the large electric pump groups.One study examined adverse effects on infants, however as the infants did not all receive their mothers' expressed milk, we have not included the results. Secondary outcomesThe quantity of expressed milk obtained was increased, in some studies by a clinically significant amount, in interventions involving relaxation, music, warmth, massage, initiation of pumping, increased frequency of pumping and suitable breast shield size. Support programmes and simultaneous compared to sequential pumping did not show a difference in milk obtained. No pump consistently increased the milk volume obtained significantly.In relation to nutrient quality, hand expression or a large electric pump were found to provide higher protein than a manual pump, and hand expression provided higher sodium and lower potassium compared to a large electric pump or a manual pump. Fat content was higher with breast massage when pumping; no evidence of difference was found for energy content between methods.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Variation in nutrient content across methods may be relevant to some infants. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings. Independently funded research is needed for more trials on hand expression, relaxation and other techniques that do not have a commercial potential.

Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology

The majority of new mothers in the United States use breast pumps in the first 4 months postbirth in order to achieve their personal human milk feeding goals. Although these mothers seek guidance from health-care professionals with respect to the type and use of breast pumps, there are few evidence-based guidelines to guide this professional advice. This paper reviews the evidence to facilitate professional individualization of breast pump recommendations using three categories of literature: the infant as the gold standard to which the pump is compared; the degree of maternal breast pump dependency (for example, the extent to which the breast pump replaces the infant for milk removal and mammary gland stimulation); and the stage of lactation for which the pump replaces the infant. This review can also serve to inform public and private payers with respect to individualizing breast pump type to mother-infant dyad characteristics.

Milk production after preterm, late preterm and term delivery; effects of different breast pump suction patterns

OBJECTIVE

This study aimed to compare the effectiveness of two different breast pump suction patterns (BPSP) during the initiation of lactation in mothers of term, late preterm and preterm infants.

METHODS

Breast pump-dependent mothers (n=130) of term (n=19), late preterm (n=44) and preterm (n=67) infants were assigned to either a standard or irregular-BPSP after birth until the onset of secretory activation. Both groups used the same standard maintenance BPSP thereafter. Time to secretory activation, time to full milk production and daily milk output were compared between the standard and I-BPSP groups, and between the term, late preterm and preterm groups.

RESULTS

Mothers using the irregular-BPSP demonstrated significantly greater daily milk output and established secretory activation significantly earlier. This effect was observed in mothers of term, late preterm and preterm infants.

CONCLUSION

The irregular-BPSP mimicking sucking of healthy newborns is more effective at achieving secretory activation and an earlier adequate milk supply than the standard-BPSP. The irregular-BPSP can be used successfully for mothers of preterm up to term infants who are breast pump dependent during the establishment of lactation.

The use of technologies to support human milk & breastfeeding

The application of lactation technologies is not limited to the NICU or the hospital setting. These technologies can be implemented within the home or hospital setting to promote the use of human milk and protect the breastfeeding relationship. Through the use of breast pumps, scales, and nipple shields, women can be supported to achieve their personal breastfeeding and lactation goals.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2014), CINAHL (1982 to March 2014), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias.

MAIN RESULTS

This updated review includes 34 studies involving 1998 participants, with 17 trials involving 961 participants providing data for analysis. Eight studies compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and multiple pump types. Fifteen studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols (five studies), pumping > 4 times per day versus < 3 times per day (one study), provision of a milk expression education and support intervention to mothers of preterm infants versus no provision (one study), provision of audio/visual relaxation to mothers of preterm infants versus no specific relaxation (two studies), commencing pumping within one hour of delivery versus between one to six hours (one study), breast massage before or during pumping versus no massage (two studies, of which one also tested a second behaviour), therapeutic touch versus none (one study), warming breasts before pumping versus not warming breasts (one study), combining hand expression with pumping versus pumping alone (one study) and a breast cleansing protocol versus no protocol (one study).There were insufficient comparable data on outcomes to undertake meta-analysis and data reported relates to evidence from single studies.Only one of the 17 studies examining maternal satisfaction/acceptability provided data in a way that could be analysed, reporting that mothers assigned to the pumping group had more agreement with the statement 'I don't want anyone to see me pumping' than mothers in the hand expression group and the statement 'I don't want anyone to see me hand expressing' (n = 68, mean difference (MD) -0.70, 95% confidence interval (CI) -1.25 to -0.15, P = 0.01), and that mothers found instructions for hand expression were clearer than for pumping (n = 68, MD 0.40, 95% CI 0.05 to 0.75, P = 0.02). No evidence of a difference was found between methods related to adverse effects of milk contamination (one study, n = 28, risk ratio (RR) 0.89, 95% CI 0.62 to 1.27, P = 0.51), (one study, n = 142 milk samples, MD 0.20, 95% CI -0.18 to 0.58, P = 0.30), (one study, n = 123 milk samples, MD 0.10, 95% CI -0.29 to 0.49, P = 0.61), (one study, n = 141 milk samples, MD -0.10, 95% CI -0.46 to 0.26, P = 0.59 ); or level of maternal breast or nipple pain or damage (one study, n = 68, MD 0.02, 95% CI -0.67 to 0.71, P = 0.96).For the secondary outcomes, greater volume was obtained when mothers with infants in a neonatal unit were provided with a relaxation tape or music-listening interventions to use while pumping, when the breasts was warmed before pumping or massaged while pumping.Initiation of milk pumping within 60 minutes of birth of a very low birthweight infant obtained higher mean milk quantity in the first week than the group who initiated pumping later. No evidence of difference in volume was found with simultaneous or sequential pumping or between pumps studied. Differences between methods was found for sodium, potassium, protein and fat constituents; no evidence of difference was found for energy content.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.Most studies were classified as unclear or low risk of bias. Most studies did not provide any information regarding blinding of outcome assessment. Fifteen of the 25 studies that evaluated pumps or products had support from the manufacturers.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including early initiation when not feeding at the breast, listening to relaxation music, massage and warming of the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

A multipronged approach is associated with improved breast milk feeding rates in very low birth weight infants of an inner-city hospital

Breast milk feeding has advantages over formula feeding in premature infants, but its use in them is low. We initiated measures in our inner-city hospital such as starting a dedicated lactation service, counseling the mothers prenatally and postnatally, educating hospital staff, and advocating with our state's Medicaid insurance to provide free home breast pumps. These measures were associated with improvement in our breast milk feeding rates in very low birth weight infants from 22% to 88% over 5 years. This article describes our multipronged approach and can help encourage and guide other units with similar demographics to improve their breast milk feeding rates.

Challenges to breastfeeding infants with phenylketonuria

Breastfeeding duration for infants with phenylketonuria (PKU) is less than other full-term infants. However, no study has examined the challenges encountered by mothers' breastfeeding infants with PKU. In 75 mothers of a child with PKU, three categories of breastfeeding challenges were identified: common breastfeeding issues, breastfeeding and PKU, and no challenges. The common breastfeeding issues can be identified in the literature but for these mothers, the issues are heightened due to frequent phenylalanine (Phe) monitoring. Even so, many mothers adapt breastfeeding to maintain desired Phe levels. A few mothers had no issues and were the exception, not the norm.

Providing mother's own milk in the context of the NICU: a paradoxical experience

BACKGROUND

Mothers of very preterm infants continue to face challenges related to providing their expressed breast milk in the neonatal intensive care unit (NICU).

OBJECTIVE

This qualitative study sought to understand the experience of mothers of hospitalized very preterm infants related to their daily pumping routine during the NICU stay.

METHODS

Fourteen women who were pumping breast milk for their hospitalized infants were interviewed. Sequential, semistructured, audiotaped individual interviews were conducted at 2 different time points: within 2 weeks following delivery when the mothers were pumping only, and 4 to 6 weeks once breastfeeding had been initiated.

RESULTS

The central themes found were: becoming a "mother-interrupted" and negotiating a paradoxical experience of separation and connection. Unique to these findings were the paradoxical view of the pump as both a wedge and a link to their infants, the intense dislike the mothers had for the tasks required to provide their expressed breast milk, and diversionary tactics used during pumping sessions.

CONCLUSION

The complexity of thoughts, actions, and behaviors revealed in the mothers' narrative accounts provides a guide to direct future breastfeeding interventions and management.

Randomized trial comparing the effectiveness of 2 electric breast pumps in the NICU

BACKGROUND

Mothers with preterm infants may need to express milk for considerable periods. Research to improve breast pump design has focused on compression stimuli, frequencies, and vacuums.

OBJECTIVE

This study aimed to compare the effectiveness of 2 electric pumps: Medela Symphony (pump S) and a novel pump (Philips AVENT Twin electronic pump; pump A). Both offer flexibility of rate and suction; pump A also incorporates petal compression cushions. Primary outcomes were (1) milk weight expressed during 10-day study period and (2) weight of milk expressed in a 15-minute test.

METHODS

Seventy-one mothers with preterm infants < 34 weeks were randomized. Mothers completed 10-day diaries including weight of milk expressed. Milk weight expressed during a single 15-minute test period and data on pumping mode, skin-to-skin contact, breastfeeding at infant discharge, and mothers' opinions of the pump were recorded.

RESULTS

There was no significant difference in milk expressed during the first 10 days between groups. Pump S mothers expressed significantly more milk during a fixed 15-minute period. Mothers using pump A awarded higher scores for certain characteristics of the pump, notably location of control button and ease of use. Similar proportions of infants received breast milk at discharge, but pump A mothers were more likely to be directly breastfeeding (odds ratio, 4.27 [95% confidence interval, 1.29, 14.1]).

CONCLUSION

The breast pumps showed similar effectiveness in terms of milk expression and maternal opinions. The finding that breast pump design may influence breastfeeding at infant discharge merits further investigation.

The institutional cost of acquiring 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit

BACKGROUND

Human milk from the biologic mother (HM) reduces disease burden and associated costs of care during and after neonatal intensive care unit (NICU) hospitalization for very low birth weight (VLBW; birth weight < 1500 g) infants, when compared to feedings of donor human milk (DHM) or commercial formula (CF). However, compared to DHM and CF, little is known about the institutional cost to acquire HM from the biologic mother.

OBJECTIVE

This study aimed to determine the institutional cost of acquiring HM for VLBW infant feedings during the NICU hospitalization.

METHODS

This analysis examined 157 maternal pumping records from a prospective cohort study evaluating health outcomes and cost of HM feedings for VLBW infants. The costs for the breast pump rental fee, 1-time pump kit purchase, and disposable food-grade containers for storing expressed HM were evaluated using standard cost analysis techniques.

RESULTS

The median cost of acquiring 100 mL of HM varied from $0.51 when mothers pumped ≥ 700 mL daily to $7.93 for those who pumped < 100 mL daily. Mothers who pumped ≥ 100 mL daily had lower acquisition cost compared to both DHM ($14.84/100 mL) and CF ($3.18/100 mL). For mothers who pumped > 100 mL daily, the exact day of pumping where the cost of HM was less expensive than DHM or CF was 4 to 7 days and 6 to 19 days, respectively.

CONCLUSION

Human milk from the biologic mother has lower acquisition cost than DHM and CF when mothers provided ≥ 100 mL daily and pumped for a sufficient number of days (range, 4-19). Neonatal intensive care units should prioritize resources to ensure that mothers achieve this daily milk volume.

Supporting breastfeeding in the neonatal intensive care unit: Rush Mother's Milk Club as a case study of evidence-based care

The translation of the evidence for the use of human milk (HM) in the neonatal intensive care unit (NICU) into best practices, toolkits, policies and procedures, talking points, and parent information packets is limited, and requires use of evidence-based quality indicators to benchmark the use of HM, consistent messaging by the entire NICU team about the importance of HM for infants in the NICU, establishing procedures that protect maternal milk supply, and incorporating lactation technologies that take the guesswork out of HM feedings and facilitate milk transfer during breastfeeding.

Examining the use and outcomes of a new hospital-grade breast pump in exclusively pumping NICU mothers

PURPOSE

To determine whether exclusively pumping mothers of preterm infants could achieve full milk production while using the Ameda Platinum breast pump the first 14 days postpartum.

SUBJECTS

Twenty-six mothers who delivered infants between 26 and 32 weeks' gestation at 2 Intermountain Healthcare hospitals completed the study. Mothers could not take milk-enhancing or milk-reducing substances, feed directly at the breast, have had breast surgery, or use any other breast pump during the study.

DESIGN

Nonexperimental, descriptive study.

METHODS

Mothers were instructed to use the Ameda Platinum breast pump exclusively 8 times daily, for 14 days. They recorded milk volumes, suction pressures, cycle speeds, and time spent pumping. A "Performance Questionnaire" was completed at the end of the study with questions about the ease of use, preferred speed and suction settings, and overall performance of the pump.

MAIN OUTCOME MEASURE

Full milk production was defined as 700 mL/d. Speed and suction settings, as well as average pumping session length, were analyzed in relation to categories of maximum milk volumes expressed.

RESULTS

The average maximum daily milk volume for all mothers was 817 mL/d. Sixteen mothers produced milk volumes more than 700 mL/d and 9 of these mothers were able to express more than 1000 mL/d. Those with daily milk production more than 700 mL/d used lower suction pressure settings to stimulate the milk ejection reflex and to empty the breast. These higher-producing mothers also chose ending speeds of 50 to 60 cycles per minute, similar to the nutritive sucking pattern of a healthy newborn. Mothers producing less than 500 mL/d used higher suction pressures, faster ending cycle speeds, and longer pumping times. Suction pressures varied widely among all of the mothers and were influenced by the mothers' nipple or breast sensitivity, which varied from mother to mother and day to day. Mothers reported liking separate controls for speed and suction and used them to achieve maximum comfort and milk volume.

CONCLUSIONS

The Ameda Platinum breast pump is an effective hospital-grade pump for exclusively pumping mothers to establish full milk production by 14 days postpartum. Separate control of speed and suction allows mothers a wide range of options to achieve greater comfort and multiple milk ejections, both of which contribute to optimal milk expression.

"Breastfeeding" by feeding expressed mother's milk

This article provides the pediatric community with a practical overview of milk expression and an update on the recent literature. Approaches for working mothers, preterm infants, critically ill infants, and mothers before lactogenesis II are presented separately, as these groups may benefit from practices tailored to individual needs.

Effectiveness of four manual breast pumps for mothers after preterm delivery in a developing country

BACKGROUND

Hospital-grade electric pumps may be useful to initiate and sustain adequate milk production for mothers who are unable to breast-feed their babies hospitalized at special care nurseries (SCN), but their cost is generally not affordable for SCN and for most mothers in developing countries. Therefore, manual breast pumps (MBPs) can be an alternative, but the best option is unknown considering clinical parameters and mothers' preference from among currently available MBPs.

OBJECTIVE

To compare the effectiveness of four MBPs in terms of milk volume, nutritional composition, and breast emptying in order to assist in making a choice for health care personnel and mothers in SCN settings. Duration of expression and maternal preference were also evaluated as secondary outcomes.

METHODS

Mothers of preterm infants used 4 MBPs in a random order, 2 with a squeeze-handle mechanism (Isis and Harmony) and 2 with a cylindrical mechanism (Little Heart and Evenflo), both at the hospital and in home settings using each pump over one 24-hour period.

RESULTS

Milk volume, nutritional composition, breast emptying, and duration of expression were not different among MBPs. Scale of maternal preference rated higher those with the squeeze-handle mechanism than the cylindrical mechanism (p < 0.05).

CONCLUSIONS

There was no difference found in the effectiveness across the four pumps tested. The mothers' rating for comfort and ease of use showed a marked difference between pumps. These factors, plus cost, need to be considered when evaluating manual pumps for use in SCN settings in developing countries.

Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants

OBJECTIVE

The objective of this study was to compare the effectiveness, efficiency, comfort and convenience of newly designed breast pump suction patterns (BPSPs) that mimic sucking patterns of the breastfeeding human infant during the initiation and maintenance of lactation.

STUDY DESIGN

In total, 105 mothers of premature infants ≤34 weeks of gestation were randomly assigned to 1 of 3 groups within 24 h post-birth. Each group tested two BPSPs; an initiation BPSP was used until the onset of lactogenesis II (OOL-II) and a maintenance BPSP was used thereafter.

RESULT

Mothers who used the experimental initiation and the standard 2.0 maintenance BPSPs (EXP-STD group) demonstrated significantly greater daily and cumulative milk output, and greater milk output per minute spent pumping.

CONCLUSION

BPSPs that mimic the unique sucking patterns used by healthy-term breastfeeding infants during the initiation and maintenance of lactation are more effective, efficient, comfortable and convenient than other BPSPs.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2011), CINAHL (1982 to January 2011), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth, and crossover trials commencing at least 28 days after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias. Data were checked for accuracy.

MAIN RESULTS

We included 23 studies with 10 studies (632 mothers) providing data for analysis.Mothers provided with a relaxation tape produced more milk than mothers who were not (mean difference (MD) 34.70 ml/single expression, 95% confidence interval (CI) 9.51 to 59.89, P = 0.007). A lower milk volume over six days was reported when comparing hand expression to the electric pump (standardised mean difference (SMD) -1.00 ml, 95% CI -1.64 to -0.36, P = 0.002); other studies of the same pump using different measures did not find a significant difference (12 to 36 hours postpartum SMD -0.38 cc, 95% CI -0.86 to 0.10, P = 0.12); day five postpartum SMD -0.62 ml/day, 95% CI -1.43 to 0.19, P = 0.13). No evidence of difference in volume was found with simultaneous or sequential pumping, or between manual and electric pumps studied. One study reported a higher sodium concentration in hand expressed milk compared to a manual pump (SMD 0.59 mmol/L, 95% CI 0.22 to 0.96, P = 0.002) and to an electric pump (SMD 0.70 mmol/L, 95% CI 0.32 to 1.09, P = 0.0003), and lower potassium concentration compared to a manual pump (MD -0.37 mmol/L, 95% CI 0.00 to 0.73, P = 0.05) or to an electric pump (SMD -0.32 mmol/L, 95% CI -0.69 to 0.06, P = 0.10). No evidence of difference was found for energy content, milk contamination or adverse effects. Reports of maternal views were not comparable. Economic aspects were not reported.  

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low cost interventions including early initiation when not feeding at the breast, relaxation, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, small number of studies reviewed, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

The initial maternal cost of providing 100 mL of human milk for very low birth weight infants in the neonatal intensive care unit

OBJECTIVES

Human milk (HM) feeding is associated with lower incidence and severity of costly prematurity-specific morbidities compared to formula feeding in very low birth weight (VLBW; <1,500 g) infants. However, the costs of providing HM are not routinely reimbursed by payers and can be a significant barrier for mothers. This study determined the initial maternal cost of providing 100 mL of HM for VLBW infants during the early neonatal intensive care unit (NICU) stay.

METHODS

This secondary analysis examined data from 111 mothers who provided HM for their VLBW infants during the early NICU stay. These data were collected during a multisite, randomized clinical trial where milk output and time spent pumping were recorded for every pumping session (n = 13,273). The cost analysis examined the cost of the breast pump rental, pump kit, and maternal opportunity cost (an estimate of the cost of maternal time).

RESULTS

Mean daily milk output and time spent pumping were 558.2 mL (SD = 320.7; range = 0-2,024) and 98.7 minutes (SD = 38.6; range = 0-295), respectively. The mean cost of providing 100 mL of HM varied from $2.60 to $6.18 when maternal opportunity cost was included and from $0.95 to $1.55 when it was excluded. The cost per 100 mL of HM declined with every additional day of pumping and was most sensitive to the costs of the breast pump rental and pump kit.

CONCLUSIONS

These findings indicate that HM is reasonably inexpensive to provide and that the maternal cost of providing milk is mitigated by increasing milk output over the early NICU stay.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Manual expression and electric breast pumping in the first 48 h after delivery

BACKGROUND

Early feeding for preterm infants via the mother's own milk is crucial for lowering morbidity and mortality. Obtaining the mother's milk in the first few days is sometimes difficult; an effective way of mediating this problem has not yet been established. The aim of the present study was therefore to investigate whether breast pumping using a hospital-grade electric pump was more effective in maximizing the available milk volume and more comfortable than manual expression in the first 48 h after birth.

METHODS

A sequential cross-over study was performed in a maternity ward, in a tertiary perinatal center, Japan. Eleven women whose infants were admitted to the neonatal intensive care unit were sequentially allocated to either manual or electric breast expression (Symphony) for their first expression after 6 h following birth. The women then used the other method for the next expression, and continued to alternate between methods until seven sessions had been completed for each method. The time interval between expressions was 3 h. Main outcome measures were volume of milk expressed per session and pain assessment at each expression using the Wong and Baker face-scale.

RESULTS

Net milk yield per woman was 2 mL manually (median; range: 0-12.6 mL) and 0.6 mL (0-7.2 mL) by electric expression (P < 0.05). The frequency of women stating no pain was higher for electric pumping than manual expression (90% vs 36%, respectively; P < 0.05).

CONCLUSIONS

In the early postpartum period, the best way to obtain colostrum is by gentle manual expression. For mothers who feel pain during manual expression, use of the stimulation phase of the Symphony pump may be preferable.