Table 1: Study Findings related to Maternal Perceptions of and Health Providers Support
Strategies for Providing Breast Milk to Preterm Infants in the NICU
Author
Objective
Methods
D: Design
S: Sample
T: Target
Bernaix, et
al., 200629
Describe parents’
experience of
providing BM and
BF for a
premature infant.
D: Descriptive
S: n=9
T: Couples of NICU
infants.
Describe
maternal
experiences
providing BM and
transitioning to
direct BF.
Explore NICU
nurses formative
experiences with
infant FF and/or
BF.
Examine NICU
organization and
systematic
promotion
support of BF.
D: Descriptive
S: n=10
T: Mothers of infants
born between 33-36
weeks GA.
USA
Boucher, et
al., 201114
Canada
Cricco-Lizza,
2009a36
USA
Cricco-Lizza,
2009b34
USA
Cricco-Lizza,
201025
USA
Dowling, et
al., 201233
USA
Examine how
NICU nurses’
everyday practice
values impacts
BF transition.
Examine short
and long term
provision of BM
before and after
implementation of
single-family
rooms.
Findings related to
Maternal Perceptions in
Conjunction with
Breast Milk
Findings related to
Health Providers Support
Strategies
Providing BM was
rewarding, difficult and
sometimes discouraging.
Mothers ‘emotional
support emerged from her
partners’ vested interest
“we” or “I” or obstructive in
providing BM.
Mothers describe
providing and maintaining
their BM supply is
significant in forming
attachments with their
infants before BF initiation.
Many nurses have limited
personnel experience with
pumping BM or BF.
Health professionals’
support requires sensitivity
as parents adjust their
expectations from BF to
providing BM.
D: Observation,
semi-structured
interviews, chart and
teaching documents
review
S: n=144
T: NICU Nurses.
D: Observation,
semi-structured
interviews
S: n=114
T: NICU nurses
Mothers consistently
receive BF promotion and
pumping support from key
BF personnel from
admission and throughout
hospitalization.
Policies for BF and BM,
removal of formula
company marketing,
interdisciplinary BF teams
are indicators of
organizational support.
Mothers report feeling
resistance from nurses to
support mothers providing
BM and transitioning to
direct BF because both
are time intensive.
D: Mixed methods,
Survey, Pumping
diary
S: n=40
T: Mothers of infants
at a NICU before
and after opening
single family rooms.
Mothers prefer privacy at
home, but pump at the
bedside to avoid missing
their infants' health
providers and receive
updates on their infants’
progress.
Nurses’ timely actions and
values used to maximize
health outcomes for
premature infants can be
counterintuitive to the
mother–infant transition to
direct BF.
Health professionals need
sensitivity to provide
privacy while mothers are
pumping in their infants'
room and adjustment of
rounding so mothers may
participate in their infants'
plan of care.
D: Ethnographic
S: n=144
T: NICU Nurses.
Mothers describe how
scheduled feeding in the
NICU are a barrier to
learning and responding to
their infants' feeding cues.
Many nurses formative
background is FF and have
limited professional BF
experience.
Dweck, et al.,
200835
USA
Ericson &
Flacking,
201338
Sweden
Flacking, et
al., 200615
Sweden
Graffy &
Taylor, 20055
UK
Hill & Aldag,
200511
USA
Hurst, et al.,
201326
USA
Examine impact
of a dedicated LC
had on neonates
receiving BM at
three time points.
Compare the
effectiveness of
two methods,
before and after
infant TW and
maternal
estimation of BM
transference
during BF, for
supporting
transition from
tube feeding to
BF.
Explore the
stories of
"becoming a
mother" and BF
their preterm
infants.
Examine
mothers’
perspectives on
the information,
advice, and
support they
receive with BF.
Describe
variables that
impact milk
supply of mothers
of non-nursing
preterm infants at
day 4 postpartum
and at 6 weeks
after discharge.
Describe
mothers’ daily
experience of
pumping BM for
their VLBW
infants.
D: Retrospective
chart review
S: n=486
T: Infants born
inside (IB) hospital
and transferred in at
a regional (OB)
NICU before and
after LC support.
D: Mixed method,
retrospective chart
review, survey
S: n=196 infants,
n=45 nursing staff
T: Mothers and
infants transitioning
to BF and NICU
nurses.
Mothers’, whose infants
are transferred to a
regional NICU, benefit
from LC support to provide
BM reflecting an increase
in amount of BM provided.
LCs support is pivotal to
mothers’ whose infants are
transferred as BM
education may not be
shared or comprehended
before the infant is
transferred.
BM feeding is a
nonintrusive and feasible
method for assessing and
supporting the transition of
an infant from tube feeding
to BF. Provision of BM
was less stressful for
mothers and supportive of
BF.
BM fed infants were at
higher risk (OR=2.76, CI
[1.5, 5.1]) to be
supplemented compared to
TW infants as staff was
unsure if BM fed infants
had received adequate milk
volume.
D: Grounded theory
design, in-depth
interviews
S: n= 25
T: Mothers of infants
in 7 NICUs.
D: Descriptive, open
ended questions
S: n=720
T: Mothers of
premature infants
who are BF in NICU
after 6 weeks
postpartum.
D: Longitudinal,
survey, milk diary
S: n=81
T: Mothers of nonnursing preterm
infants who provide
BM by pumping.
Mothers feel remote from
their preterm infants.
Mothers provide BM thus
bonding and building
attachment with their
infants.
Staff support and
encourage BM, but support
is sporadic when infant
transitions to BF in the time
driven atmosphere of the
NICU.
Mothers desire to know
what to expect during
pumping, BF initiation,
transitioning to direct BF,
and being cared for
emotionally.
Professional support for
families’ needs to be
consistent using protocols
for BF support and training
for peer and health care
providers.
Mothers with low income
experiencing significant
stress after discharge
produce inadequate milk
for their infants.
Maternal milk supply at day
4 (and income) may
identify 85% of mothers
with low milk production at
6 weeks.
D: Descriptive semistructure interviews
S: n=14
T: Mothers of infants
admitted to a NICU
with lactation
support at 14 days
and 4 to 6 weeks
after delivery.
Mothers report the themes
of being a “mother
interrupted”, a paradoxical
relationship with the breast
pump which is a “wedge
and a link” to their infant,
and negotiating time and
distraction strategies to
consistently pump.
Health professionals may
support mothers by
discussing how she
manages pumping,
providing privacy at the
infants’ bedside or
distraction strategies at
home.
Lee, et al.,
201240
USA
Lessen et al.,
200718
USA
Maastrup, et
al., 201228
Denmark
Meier, et al.,
20136
USA
Merewood,
200632
USA
Miracle, et
al., 200421
USA
Evaluate the
effect of a
bundled
intervention to
increase BM
feedings in
premature
infants.
Describe
maternal,
neonatal, and
outside variables
associated with
the intention,
initiation, and
duration of BF.
Describe BF in
Denmark NICUs
with 98%
initiation of
lactation.
D: Longitudinal
intervention study
S: n=22 NICUs in
the CA Perinatal
Quality of Care
Collaborative.
T: NICUs with
bundled BM support
compared to
standard of care.
D: Longitudinal,
descriptive
S: n=100
T: Mothers of
preterm infants
admitted to a NICU.
Mothers benefit from
consistent structured
support to produce BM.
Bundled interventions
significantly increased
from baseline (54.6%) to
intervention period (61.7%;
P = .005) with sustained
improvement over 6
months post-intervention
(64.0%; P = .003).
Mothers who provide BM
or BF are significantly
impacted by family
support, timely BF
information, and a
supportive NICU
environment.
D: National survey
S: n=19
T: Danish NICUs in
2009.
Families benefit from
consistent support from
staff (policies) for BM
pumping, skin-to-skin
contact, allowing parents’
presence in the NICU, and
restricting the use of bottle
feeding.
Mothers value PCs to
mentor and facilitate
expressing BM and
transitioning to BF.
50% of mother who provide
BM are able to direct BF
their infant before and/or
after discharge. Health
professional support for
early initiation significantly
impacts infants’ BM intake
duration.
Standardized polices for
BM pumping, skin-to-skin
contact, parents’ presence,
and restricted use of bottlefeeding optimizes BF.
Examine the
Rush Mother's
Milk Club support
for mothers of
preterm infants
expressing BM
and BF.
D: Case study
S: n=1
T: Rush Mother's
Milk Club program.
Explore impact of
peer counselors
on BF duration
among mothers
of premature
infants in an
urban population.
Examine mothers
previously
intending to
formula feed who
provided BM after
delivering their
VLBW infant.
D: Randomized
clinical trial
S: n=108
T: NICU Motherpreterm infant BF
dyads.
D: Semi-structured
interviews
S: n=23
T: Mothers intending
to formula feed (FF)
who provided BM at
an urban NICU.
At 12 weeks post
discharge, mothers
interacting with PCs
compared to mothers
receiving standard care
had 181% greater odds of
providing BM.
Mothers chose FF
because they had no BF
role models, were fearful
of pain and lifestyle
modifications.
Parents desire consistent
scientific information about
BM, incorporating PCs as
part of the BF team,
strategies to protect milk
supply in pump dependent
mothers and support
transitioning to direct BF.
Inclusion of PCs as part of
the providers’ team
supports mothers providing
BM to their infants after
discharge.
Health professionals
providing evidence-based
information about BM and
BF is a pivotal for mothers
who do not have a BF
model and does not
increase feelings of
pressure or coerced.
Montgomery,
et al., 200823
USA
Myers &
Rubart,
201324
USA
Niela-Vilén,
et al., 201442
Finland
Oza-Frank, et
al., 201339
USA
Pineda, et al.,
200937
USA
Pineda,
2011a10
USA
Compare BM
rates before and
after the BM
Early Saves
Trouble (BEST)
program
(provision of milk
for the first 7
feeding days for
infants <2 kg
birth weight).
Examine BF
support and
barriers for
mothers and
NICU nurses.
Describe the
perceptions of
mothers on BF
their premature
infant.
Describe the
effect of lactation
and peer support
on the amount of
BM intake at
discharge.
Describe the
effect of an
education
intervention for
staff and parents
to change NICU
BF practices.
Investigate the
relationship
between motherpremature infant
initiation,
success, and
duration of direct
BF with the
number of infant
BM feedings at
NICU discharge.
D: Design: Chart
review
S: n=130 infants
T: NICU Infants <2
kg birth weight
before and after the
BEST program.
Mothers approached
within 3 hours of delivery
to provide BM
demonstrated significantly
increased BM production
and/or BF throughout their
infants’ hospitalization and
at discharge.
BEST program
intervention, significantly
increases in BM: Exclusive
BM (p=.009), some BM
(p=.046) for the first 7
feeding days, and banked
human BM (P>.001).
D: Design: Survey
with two open
response questions
S: n=15 mothers, 45
nurses
T: Mothers who
provided BM to their
preterm infant and
NICU nursing staff.
D: Longitudinal,
online peer support
group, thematic
analysis
S: n=22 mothers
T: Mothers of BF
premature infants.
Mothers’ identified BM as
good for the infants’ health
and “Something only I can
do.” However, pumping
was reported as time
consuming, difficult if there
were no breast pumps and
limited time with the LC.
Nurses’ identified barriers
as inconsistent information,
RN discomfort with BF
maternal stress, set
feeding amounts, FF, and
not enough lactation
equipment and personnel.
Mothers perceived that
staff valued mothers
providing BM more
mothers transitioning to
BF. Mothers believed early
discharge was at the
expense of transitioning to
BF and mothers struggled
to BF after discharge.
Provision of BM was
highest (44%) for motherinfant pairs seen by both
peer counselors and LCs.
Compared to mothers
seen by only LCs (12%) or
peer counselors (15%).
Significant increases in
number of direct BF during
NICU stay.
A standardized pathway
was created for health
professionals to support
mothers from skin-to-skin,
pumping to direct BF.
Mothers who direct BF
their infant at the first oral
feed, had higher GA
infants, and had lengthy
BF session, significantly
impact their maternal milk
supply and ability to
provide BM after
discharge.
Health providers supported
mothers with varying levels
of BF knowledge.
Education regarding BM
expression and BF after
discharge was limited.
D: Design:
Retrospective chart
review
S: n=401 NICU
infants
T: Mothers who
provided BM.
D: Retrospective
infant chart review
and staff survey
S: n=135 motherinfant dyads, n=88
staff nurses.
T: Staff intervention
practices.
D: Retrospective
chart review
S: n=66 mothers
T: Mothers of VLBW
infants who initiate
NICU BM feedings.
Health professionals
providing combined
support of peer counselors
and professional support
positively affects maternal
milk supply.
Staff documenting key
steps in a standardized
pathway on a BF care plan
on the infants’ chart
significantly increase the
number of direct BF
sessions and maintained a
78% BM initiation rate.
Health professional in
NICU are pivotal to
facilitate an infants' early
initiation and ongoing direct
BF sessions.
Pineda,
2011b30
USA
Rossman, et
al., 201120
USA
Rossman, et
al., 201241
USA
Rossman, et
al., 201316
USA
Sisk, et al.,
2006 22
USA
Sisk, et al.,
200931
USA
Swanson, et
al., 201217
Scotland
Investigate the
relationship
between
maternal factors
and BM factors at
discharge.
D: Retrospective
infant chart review
S: n=135 motherinfant dyads
T: 81 mother-infant
dyads.
Describe the
relationship
between new
mothers of VLBW
infants and BF
PCs.
D: Descriptive,
semi-structured
interviews
S: n=21
T: Mothers of VLBW
infants in an urban
NICU.
D: Descriptive
S: n=17
T: Health providers,
nurses,
neonatologist, LCs,
and dietitians.
D: Descriptive,
semi-structured
interviews
S: n=23
T: Mothers of VLBW
infants.
Describe health
providers’
perceptions of
PCs providing
primary lactation
care for mothers.
Mothers’
description of the
meaning of
providing BM for
their VLBW
infants.
Compare stress
and anxiety
levels of mothers
who intended to
FF and mothers
who intended to
BF after BM
counseling.
Explored
characteristics of
mothers who
provided BM from
their infants’ birth
to discharge.
Explores
maternal
confidence and
self-efficacy in
socially
disadvantaged
mothers; focused
on maternal
understanding of
preterm infants'
feeding
behaviors.
D: Longitudinal,
survey,
questionnaire
S: n=115
T: Mothers intending
to BF and mothers
intending to FF after
counseling.
D: Longitudinal,
questionnaires
S: n=196
T: Mothers intending
to BF and mothers
intending to FF who
provided BM after
LC counseling.
D: Cross-sectional,
semi-structured
interview
S: n=19
T: Low income
mothers in an innercity NICU.
During hospitalization 78%
of mothers provided BM
ranging from 1 to 109
days, M=48 days, 48% at
discharge, and 34%
provided exclusive BM at
discharge.
PCs are able to mentor
mothers of VLBW infants
because they have their
own story; encouraging
mothers to pump BM and
BF while coping with their
emotional stress.
Mothers benefit from PCs
supporting and following
up on their expression of
BM throughout their
infants’ hospital stay.
Mothers at-risk to provide
BM at discharge are nonCaucasians and Medicaid
who require tailored
support.
Mothers describe their BM
as providing life and
healing to their infants.
Mothers provide BM to
help address feelings of
failure and guilt associated
with VLBW infants' birth.
Mothers in both groups
report that pumping was
worth the effort. 100%
were glad staff helped
them with expression, and
they were motivated to
provide BM to benefit
infants' health.
Of the 184 (95%) mothers
providing BM, 159 (86%)
provided > 50% milk
intake for first 2 weeks for
their infant and 114 (62%)
at discharge.
Professional emotional
support of mothers of
VLBW needs to
acknowledge mothers' faith
in the healing properties of
their BM.
Mothers report providing
BM symbolizes "embodied
contact" with their infant
which increases their
maternal self-efficacy with
increased confidence in
interaction with their
infants.
Professional support is
unable to provide the
personal connection of a
PC.
Health providers’ report
that PCs augmented care
and are a champion for the
peer counseling program,
and support mothers within
NICU culture.
Health professionals may
counsel mothers of VLBW
to provide BM without
increasing maternal stress
and anxiety.
Mothers’ antenatal
intention to provide BM
was the greatest predictor
of ongoing BM provision.
High risk mothers, i.e., low
income, education, need
prenatal counseling to
provide BM.
Health professionals'
positive feedback and
encouragement motivates
mothers to continue to
provide BM.
Swift &
Scholten,
201027
South
Australia
Describes the
experiences of
parents of 36
weeks GA infants
who are
prohibited from
being discharge
due to a feeding
difficulty.
D: Retrospective,
phenomenological,
in-depth interviews
S: n=9
T: Parents whose
infants had feeding
difficulties.
As discharge is delayed
maternal perception of
providing BM negatively
changes. Mothers desire
to direct BF but their
infants' feeding behaviors
delays discharge.
Health professionals
support parents by
focusing on their
relationship with their
infants instead of the
issues surrounding the task
of feeding and delayed
discharge.
Table Legend
BM = Breast Milk
FF = Formula Feeding from Bottle
TW = Test Weights
BF = Breastfeeding
LC = Lactation Consultation
PC = Peer Counselor
GA = Gestational Age