Innovations in the provision of human milk and breastfeeding for infants requiring intensive care

The challenges of medically complex breastfed children and their families: A systematic review

Exclusive breastfeeding for the first 6 months and then alongside solid food for the first 2 years and beyond is the gold standard in young child nutrition. There is an abundance of literature relating to the preventative nature of breastmilk and breastfeeding against many infectious diseases and chronic conditions. However, despite medically complex infants and children being a group that could benefit most from continued breastfeeding, breastfeeding duration and exclusivity are lower among more complex paediatric populations. The reasons for this are not well known, and there is a paucity of data relating to supporting infants who have acute or chronic illness, disability or congenital anomaly to breastfeed. This systematic review aimed to understand the challenges of breast/chestfeeding the medically complex child and to establish the gaps in healthcare provision that act as barriers to optimal infant and young child feeding. The search was limited to studies published in English, focused on breastfed sick infants in hospital, with no date limits as there is no previous systematic review. Of 786 papers retrieved, 11 studies were included for review, and seven themes identified. Themes included practical and psychological challenges of continuing to breastfeed in a hospital setting, complications of the condition making breastfeeding difficult, lack of specialist breastfeeding support from hospital staff and a lack of availability of specialist equipment to support complex breastfeeding. The findings affirm the lack of consistent high-quality care for lactation support in paediatric settings and reinforce the need for further focused research in this area.

COVID-19 and the neonatal microbiome: will the pandemic cost infants their microbes?

Mortality and morbidity from SARS-CoV2 (COVID-19) infections in children remains low, including an exceedingly low rate of horizontal and vertical transmission. However, unforeseen complications to childhood health have emerged secondary to the pandemic. Few studies to date have examined unintended complications of the pandemic in newborns and infants. In this Commentary, we discuss the impact that COVID-19 may have on inheritance of the newborn microbiome and its assembly throughout the first years of life. In the early stages of the pandemic when vertical transmission of COVID-19 was poorly understood, several studies reported increased rates of C-sections in COVID-19 positive women. Initial recommendations discouraged COVID-19 positive mothers from breastfeeding and participating in skin-to-skin care, advising them to isolate during their window of infectivity. These shifts in perinatal care can adversely impact microbial colonization during the first 1000 days of life. While obstetrical and neonatal management have evolved to reflect our current knowledge of perinatal transmission, we are observing other changes in early life exposures of infants, including increased attention to hygiene, fewer social interactions, and decreased global travel, all of which are major drivers of early-life gut colonization. Composition of the gut microbiota in adults directly impacts severity of infection, suggesting a role of microbial communities in modulating immune responses to COVID-19. Conversely, the role of the intestinal microbiome in susceptibility and severity of COVID-19 in newborns and children remains unknown. The onset of adulthood diseases is related to the establishment of a healthy gut microbiome during childhood. As we continue to define COVID-19 biology, further research is necessary to understand how acquisition of the neonatal microbiome is affected by the pandemic. Furthermore, infection control measures must be balanced with strategies that promote microbial diversity to impart optimal health outcomes and potentially modulate susceptibility of children to COVID-19.

Feeding infants with complex congenital heart disease: a modified Delphi survey to examine potential research and practice gaps

OBJECTIVE

To determine clinical consensus and non-consensus in regard to evidence-based statements about feeding infants with complex CHD, with a focus on human milk. Areas of non-consensus may indicate discrepancies between research findings and practice, with consequent variation in feeding management.

MATERIALS AND METHODS

A modified Delphi survey validated key feeding topics (round 1), and determined consensus on evidence-based statements (rounds 2 and 3). Patients (n=25) were an interdisciplinary group of clinical experts from across the United States of America. Descriptive analysis used SPSS Statistics (Version 26.0). Thematic analysis of qualitative data provided context for quantitative data.

RESULTS

Round 1 generated 5 key topics (human milk, developing oral feeding skills, clinical feeding practice, growth failure, and parental concern about feeding) and 206 evidence-based statements. The final results included 110 (53.4%) statements of consensus and 96 (46.6%) statements of non-consensus. The 10 statements of greatest consensus strongly supported human milk as the preferred nutrition for infants with complex CHD. Areas of non-consensus included the adequacy of human milk to support growth, need for fortification, safety, and feasibility of direct breastfeeding, issues related to tube feeding, and prevention and treatment of growth failure.

CONCLUSIONS

The results demonstrate clinical consensus about the importance of human milk, but reveal a need for best practices in managing a human milk diet for infants with complex CHD. Areas of non-consensus may lead to clinical practice variation. A sensitive approach to these topics is needed to support family caregivers in navigating feeding concerns.

Lactation Outcomes Among Dyads Following Participation in a Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

Introduction: MamaCare is an adaptation of the CenteringPregnancy group prenatal care model designed to support women when the pregnancy has been complicated by the presence of known congenital anomalies. The lactation-related outcomes of participants were unknown. Materials and Methods: This is a retrospective descriptive cohort study describing the lactation-related outcomes of participants of MamaCare over 43 months. Data collection included abstraction of maternal demographic data, maternal group prenatal care session participation data, maternal pregnancy and delivery data, as well as documented lactation and breastfeeding data. Results: The total cohort consisted of 92 dyads. Of the 81 women who received an individualized prenatal nutrition consultation, 65 (80.2%) voiced a prenatal feeding goal of human milk and breastfeeding only, while the remaining 16 (19.8%) expressed goals of combination feeding (human milk and infant formula). For the surviving 85 infants, 91.8% of the mothers initiated lactation on the delivery day and the remaining 7 women initiated lactation on postpartum day 1. Also at the time of discharge from the initial intensive care unit stay, 87.1% of infants were receiving maternal human milk. Discussion: For families who participate in MamaCare, not only do they form a sense of community and learn about human milk and breastfeeding before delivery, the MamaCare facilitators and presenters normalize their experience to help MamaCare participants best meet their personal breastfeeding goals as well.

Influence of NICU Nurse Education on Intention to Support Lactation Using Tailored Techniques: A Pilot Study

BACKGROUND

Preterm infants' outcomes improve when fed their mothers' milk. Low percentages of neonatal intensive care unit (NICU) nurses support mothers facing barriers to establishing and sustaining adequate milk supplies. Nurses' motivations and attitudes are instrumental, but understudied, factors in their intention to promote maternal lactation.

PURPOSE

Using the Theory of Reasoned Action, this study explored (1) NICU nurses' attitudes, social pressures, feelings of preparedness, perceptions of comfort, and intention to support lactation; and (2) magnitude of relationships among these concepts before and after undertaking an educational module.

METHODS

A descriptive pre-/postintervention design included a sample of 24 NICU nurses who completed a module, including general lactation and hands-on expressing information. The Nursing Support for Breastfeeding Questionnaire was administered before and after completing the module.

RESULTS

Attitudes, social norms, perception of preparedness, and intention were moderate to high before and after completion of the module. Perception of comfort was moderate. When comparing pre- and postintervention, effect sizes for intention and perception of comfort were moderate. Magnitude of the relationship between attitudes and intention was strong before intervention and moderate after intervention. Subjective norms demonstrated stronger relationships with attitudes and intention after intervention. Preparedness and comfort had stronger relationships with attitudes than with intention both before and after intervention.

IMPLICATIONS FOR PRACTICE

Nurses' attitudes, perception of preparedness, and comfort are modifiable considerations in developing strategies to support evidence-based lactation techniques.

IMPLICATIONS FOR RESEARCH

Additional studies are needed with fully powered and stronger designs to validate findings to guide interventions for nurse support for NICU mothers to optimize lactation.

A Quality Improvement Project to Improve the Use of Mother's Own Milk (MOM) With Precision Oropharyngeal Therapy

BACKGROUND

Bioprotective properties of mother's own milk (MOM) support the use of targeted MOM administration methods, including oropharyngeal therapy (OPT) with MOM, which may mimic the protective effects of swallowed amniotic fluid, thereby improving infant health outcomes.

PURPOSE

To increase the use of MOM-OPT in premature infants in the first week of life.

METHODS

Quality improvement methods were used to implement precision dosing of OPT.

RESULTS

After changing processes and replacing the colostrum immune therapy practice with longer-term precision OPT, the percentage of ordered doses administered to infants in the first week of life increased from 24% to 64%. There was also a 15% increase in very low birth-weight infants who received MOM (from 50% to 65%) at discharge. There were no reported adverse events related to OPT administration.

IMPLICATIONS FOR PRACTICE

Replacing the unit's short-term colostrum immune therapy protocol with the longer-term precision OPT increased the number of doses given in the first week of life and increased the number of very low birth-weight infants discharged receiving MOM.

IMPLICATIONS FOR RESEARCH

Researchers should consider studying the reported positive effects of OPT related to infant response (positive oral stimulation, reduction in oral aversion, and improved oral feeding skills), parent participation in care, and maternal milk expression behaviors (longer milk expression duration).

Human Milk and Breastfeeding Outcomes in Infants With Myelomeningocele

BACKGROUND

In 2015, the study setting instituted an enteral feeding pathway, "PO Ad Lib Feeding to Support Breastfeeding." Many infants admitted to the study setting's newborn/infant intensive care unit with a primary diagnosis of myelomeningocele fall within the setting's enteral feeding pathway's inclusion criteria.

PURPOSE

The primary objective of this study is to describe the enteral feeding exposure and trends, by type and method, among infants with myelomeningocele.

METHODS

Retrospective descriptive cohort design. Participants were infants with a primary diagnosis of myelomeningocele between 2013 and 2016. The electronic health record was used to collect descriptive data (demographics and daily enteral feeding exposure). Data were analyzed using descriptive statistics.

FINDINGS/RESULTS

More than 80% (n = 148, 81.3%) of the participants' mothers had a personalized prenatal nutrition consultation and the majority of those mothers (n = 102/118, 86.4%) had a goal to breastfeed for more than 6 months. The majority (n = 144/182, 79.1%) of the study cohort was exposed to mothers' own human milk as their first feed. It is also notable that 80.8% (n = 147) fed at least once directly at the breast; however, infants were also fed by bottle or by feeding tube.

IMPLICATIONS FOR PRACTICE

It demonstrates that with appropriate evidence-based breastfeeding interventions, mothers having infants with myelomeningocele can expect to feed their infants human milk as well as direct breastfeed.

IMPLICATIONS FOR RESEARCH

Future research should focus on human milk/breastfeeding outcomes of infants with myelomeningocele post-hospital discharge. Long-term breastfeeding may have an important role in the development of infants with myelomeningocele.

Oropharyngeal Mother's Milk: State of the Science and Influence on Necrotizing Enterocolitis

Oropharyngeal administration of mother's own milk-placing drops of milk directly onto the neonate's oral mucosa-may serve to (ex utero) mimic the protective effects of amniotic fluid for the extremely low birth weight infant; providing protection against necrotizing enterocolitis. This article presents current evidence to support biological plausibility for the use of OroPharyngeal Therapy with Mother's Own Milk (OPT-MOM) as an immunomodulatory therapy; an adjunct to enteral feeds of mother's milk administered via a nasogastric or orogastric tube. Current methods and techniques are reviewed, published evidence to guide clinical practice will be presented, and controversies in practice will be addressed.

Beyond BFHI: The Spatz 10-Step and Breastfeeding Resource Nurse Model to Improve Human Milk and Breastfeeding Outcomes

A report released by the World Health Organization states that worldwide less than 10% of birth occur in hospitals certified through the Baby-Friendly Hospital Initiative. Furthermore, the Baby-Friendly Hospital Initiative's primary focus is on breastfeeding for healthy, mother-infant dyads. This article provides alternative models for implementing evidence-based care during maternal-infant separation so that mothers can achieve their personal breastfeeding goals. These include the Spatz 10-step model for human milk and breastfeeding in vulnerable infants and the Breastfeeding Resource Nurse model. Clinical outcome data are provided to demonstrate the effectiveness of the models as well as a road map of strategies to implement the models and measure outcomes.

Creation of a Regional Human Milk Assembly: A Model to Influence Practice and Policy Change in the NICU

BACKGROUND

The 2011 Surgeon General's Call to Action to Support Breastfeeding highlights a need for optimizing lactation-based education for all health professionals; however, few schools of nursing and medicine offer lactation-based curriculum. In an effort to address these gaps in education and care, the director of the lactation program at a large urban children's hospital developed and instituted the annual regional Human Milk Assembly (HMA), a half-day collaborative meeting of the hospital's regional and referral hospitals' neonatal intensive care unit (NICU) nursing staff, to address lactation-based educational and training needs of all participating institutions.

PURPOSE

The purpose of this study was to determine whether and how participating HMA hospitals implemented the best practices surrounding human milk and breastfeeding shared by the host institution during a 10-year span of the HMA.

METHODS

A prospective descriptive study was designed using an electronic web-based survey (SurveyMonkey.com) to elicit participant data. Quantitative data were analyzed using descriptive statistics whereas qualitative data were analyzed for themes via content analysis.

RESULTS

Thirty-one of the 50 hospitals surveyed responded to the electronic survey for a total of 34 individual participants. Seventeen of the 22 (77%) of best practices were implemented at rates of over 50%.

IMPLICATIONS FOR PRACTICE

By enabling a culture of transparency and sharing, hospital staff can be encouraged to implement best practices across a network of regional care centers.

IMPLICATIONS FOR RESEARCH

This annual regional HMA could be a model for other areas and research should be conducted to evaluate such programs nationwide.

Mothers of Infants With Congenital Diaphragmatic Hernia Describe "Breastfeeding" in the Neonatal Intensive Care Unit: "As Long as It's My Milk, I'm Happy"

BACKGROUND

Very little is known about the breastfeeding experience of mothers of infants born with congenital anomalies and cared for in the neonatal intensive care unit (NICU). Often, studies related to breastfeeding and lactation in the NICU setting are focused on the mothers of late preterm, preterm, low-birth-weight, and very-low-birth-weight infants. Congenital diaphragmatic hernia (CDH) is an anatomic malformation of the diaphragm and affects 1 in every 2,000 to 4,000 live births. Currently, there are no studies examining the health outcomes of infants with CDH and the effect of human milk. Research aim: This study aimed to describe the breastfeeding experience of mothers of infants with CDH cared for in the NICU.

METHODS

A prospective, longitudinal qualitative descriptive design was used. Phased interviews were conducted with a purposive sample of 11 CDH infant-mother dyads from a level 3 NICU in a children's hospital.

RESULTS

Six themes emerged from the data: (a) hopeful for breastfeeding, (b) latching on . . . to the pump, (c) we've already worked so hard, (d) getting the hang of it-it's getting easier, (e) a good safety net, and (f) finding a way that works for us.

CONCLUSION

For this population of CDH infant-mother dyads, the term breastfeeding is not exclusive to direct feeding at the breast and the mothers emphasized the significance of providing their own mother's milk through a combination of feeding mechanisms to their infants with CDH.

NICU Nurses and Lactation-Based Support and Care

BACKGROUND

The provision of human milk and breastfeeding is essential in the neonatal intensive care unit (NICU) population. However, recent national research has demonstrated very low percentages of NICU nurses providing lactation-based support and care to patients and families, and less than half of all NICUs have an International Board Certified Lactation Consultant (IBCLC) on staff.

PURPOSE

The purpose of this study was to describe how NICU bedside nurses are providing lactation-based support and care during their shifts and the frequency of that support. The secondary aim was to gain an understanding of the NICU nurses' attitudes toward human milk and breastfeeding.

METHODS

Through a prospective descriptive cohort design, the authors of this study created and disseminated a web-based survey (SurveyMonkey) of 21 questions including the Iowa Infant Feeding Attitude Scale (IIFAS) to a Northeastern urban hospital staff of bedside nurses.

RESULTS

A total of 140 of the 389 eligible NICU bedside nurses responded to the survey. Between 50.7% and 72.9% of nurses reported to providing lactation-based support and care during the previous shift worked and during the previous week worked, respectively. The participants' responses to the IIFAS resulted in an overall score of 69.1, indicating an attitude of "positive to breastfeeding."

IMPLICATIONS FOR PRACTICE

The study demonstrates that the majority provide lactation-based support and care on every shift and hold very positive attitudes toward the provision of human milk and breastfeeding. Hospitals should be encouraged to promote educational and training programs in their respective institutions.

IMPLICATIONS FOR RESEARCH

Researchers should examine NICU nurses' attitudes and beliefs about human milk and breastfeeding on a national scale.

Pump Early, Pump Often: A Continuous Quality Improvement Project

Research demonstrates that although many mothers initiate pumping for their critically ill children, few women are successful at maintaining milk supply throughout their infants' entire hospital stay. At the Garbose Family Special Delivery Unit (SDU) at the Children's Hospital of Philadelphia, we care for mothers who have critically ill infants born with complex cardiac and congenital anomalies. Human milk is viewed as a medical intervention at our institution. Therefore, nurses on the SDU wanted to ensure best practice in terms of pumping initiation. This article describes a continuous quality improvement project that ensured mothers pumped early and often. Childbirth educators can play a key role in preparing mothers who are anticipating an infant who will require hospitalization immediately post-birth.

Minimizing Patient Safety Events Through a Multidisciplinary Approach to Human Milk Management

Optimization of nutrition is key in infant development and it is well documented that human milk is the ideal form of nutrition for infants during the first year of life. However, unaltered maternal human milk may not be sufficient to meet the nutritional demands of premature infants. Under these circumstances, addition of a fortifier to the maternal human milk has become standard practice. In one newborn/infant intensive care unit (N/IICU) located in Philadelphia, fortification and modification of human milk is handled within the Human Milk Management Center (HMMC). A multidisciplinary team rounds weekly on all infants receiving fortified or modified human milk. Feeding orders and maternal milk supply are discussed to ensure the feeding is ordered correctly, the final caloric concentration is correct and a backup feeding order is in place for low maternal milk supply. Through this multidisciplinary discussion, the team has been able to identify and resolve potential errors from reaching the patient. Improvement in patient safety while providing human milk remains of utmost importance and the central goal of the HMMC collaborative.

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.

Making meaning of pumping for mothers of infants with congenital diaphragmatic hernia

OBJECTIVE

To describe the process of initiation and maintenance of milk supply and potential transition to direct breastfeeding among mother/infant dyads with infants with congenital diaphragmatic hernia (CDH).

SETTING

A Level-III neonatal intensive care unit.

PARTICIPANTS

Eleven mother/infant dyads with infants with CDH.

METHODS

Prospective, longitudinal qualitative descriptive design. Semistructured interviews were conducted over the course of the NICU stay. Conventional content analysis was used.

RESULTS

Human milk oral care emerged from the interview data as a strong facilitating factor to encouraging mothers to continue pumping during hospitalization. Four main themes emerged regarding the importance and value of human milk oral care for the mothers in relation to pumping and maintenance of milk supply: (a) It motivates me; (b) I'm a part of my baby getting better; (c) We do it together, and (d) We're getting somewhere.

CONCLUSIONS

The findings of this study reflect the importance and value of human milk oral care as a driving factor to motivate mothers to maintain milk supply during the critical time when the infant with CDH is not able to take in enteral nutrition and throughout the hospital stay.

The birth of the GEMs group: implementation of breastfeeding peer support in a children's hospital

The need to support and promote breastfeeding is unquestionable. The World Breastfeeding Week 2013 theme, "Breastfeeding Support: Close to Mothers," focuses on "breastfeeding peer counseling." Mother support groups are traditionally community-based and little is published about peer-to-peer support for mothers who have critically ill newborns. This study describes the development of a support group established in a children's hospital. The Group of Empowered Mothers focuses on a unique population of mothers (those with critically ill hospitalized infants) and involves 3 basic tenets: healthcare provider support; mother-to-mother support; and Certified Breastfeeding Consultant Support.