Promoting Breastfeeding in the
NICU
Improving Success in Providing Breast Milk for
NICU Babies
Dana Arrieta RN IBCLC
Part 1
How to improve success in providing breast milk for
NICU babies
• Mothers of NICU babies need a way to connect to their babies when the
situation has disconnected them.
• Mothers feel powerless. They feel their bodies have failed them. Mothers
aren't providing the care to their babies, many feel like visitors.
• How can we help?
• Replace fear with provision. BREAST MILK!
• Help mothers to invest and the rewards will outweigh the efforts.
• This will strengthen bonding with their NICU baby.
• Mother’s must know the REAL benefit and critical need for their own milk
for their own baby.
What are the benefits?
• Premature breast milk differs from term milk in that it will meet the needs
of the low-birth-weight-neonate.
• Preterm breast milk has higher levels of energy, lipids, protein, nitrogen,
fatty acids and some vitamins and minerals.
• Preterm breast milk has higher levels of immune factors, including cells,
immunoglobulins and anti-inflammatory elements.
• Specific antibodies in breast milk provided by the environment mother is
exposed to and baby is surrounded by. (NICU and home)
How does mom get the best start?
• Pump early. Latest research states if a mom begins pumping within one
hour of birth, she will have more milk for months to come. Latest within 6
hours of birth.
• Pump often. Mom must pump Q2-3 hours during the day with one longer
stretch at night for rest.
• Hospital Grade pump. Most NICU hospitals will provide Symphony pump.
Encourage mom to rent the same pump if she has a micro preemie. Have
mom call her insurance to find out what pump is provided. (ACA)
• Preemie setting. Teach mom how to use the preemie setting, if available,
on your hospital grade pump until volume of milk has increased.
• Keep a pumping log to see progress. Encouragement! RN’s check daily.
• Hand express after pumping. Can increase milk volume up to 80% during
the first couple weeks of establishing mom’s milk supply.
• Skin to skin and kangaroo care often and early!
Hand Expression
research by Dr. Jane Morton
• The first 3 days after birth can have a HUGE impact
on future milk production potential.
• Pump-dependent mothers of NICU babies who used
hand expression more then 5 times/day for the first
3 days, pumped 955ml/day by week 8! (31 ounces!)
• This technique combines breast massage,
compression, hand expression and electric pumping.
You must ask the Mother:
• What kind of a pump does she have?
• When did she start pumping? (A mother who did not get a
good start pumping may start to see decrease in volume
around month two)
• How often does she pump?
• Did she hand express in the first 2 weeks post birth?
• Has she successfully breastfeed another child?
• Is she on any medication? Birth control?
• Any breast surgeries? Problems with thyroid? RED FLAGS!
Fun pumping facts:
• Mother’s who pumps 8-10 times a day during the first week to
10 days post birth, may result in 750-1000ml per day! (that’s is
22-33 ounces!)
• Fat rises to the top of expressed breast milk , have mom
gently mix milk before pouring into storage containers. (fat
may be sticking to edges and you will lose calories)
• Teach mother’s that the lipid (fat) content increases in her
milk at the end of the pumping session and she should pump
until milk has stopped flowing.
• Lipids provide at least 50% of the calories in human milk.
(empty breast completely)
Kangaroo Care and Skin-To-Skin
So many benefits
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Regulate heart rate, breathing, temperature
Improves head circumference, growth and weight gain
Accelerates autonomic and neurobehavioral maturation
Improves sleep patterns
Analgesia during painful procedures (heel sticks) Less Pain! Less Crying!
Strengthens maternal/infant bonding
Increases length of breastfeeding
Increases breast milk supply
Recommendations: STS at least 2 hours or more. Pump and hand
expression after STS.
• Possible shorter hospital stay and health care cost savings!
• It’s a WIN WIN!
Part 2
Medication Madness
• Things to remember:
• All medications cross the placenta and enter human breast
milk to some degree.
• Every baby and mother couplet will be unique.
• How medications transfer into human milk is largely a
function of their physiochemical characteristics.
– Molecular weight
– Lipid solubility
– Protein binding
Influencing Factors
• Maternal:
• Most influential:
• Relative oral absorption of
medication
• Plasma level of medication
• Maternal plasma level of
drug
• Molecular weight of
medication
• Oral bioavailability
• Protein binding of
medication
Drug may Transfer into Human Milk if they:
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Attain a high concentration in maternal plasma
Are low in molecular weight
Are low in protein binding
Pass into brain easily
THEN, we must consider oral bioavailability
Note from Dr. Hale: Numerous medications are either destroyed in the
infant gut, fail to be absorbed through the gut wall, or are rapidly picked
up by the liver. Once in the liver, they are either metabolized or stored but
often never reach the mother’s plasma.
Things to consider:
• Has the mother been on this medications throughout her entire
pregnancy?
• What are the risk vs. benefits for mother and baby? (antidepressants)
• Is the mother on multiple medications? (not a lot of research on this)
• Watch for drug interactions.
• Be cautious of drugs that have a long pediatric half-life, as they can build
up in the infants plasma overtime. (barbiturates, benzodiazepines and
meperidine/demerol)
• Generally centrally active drugs penetrate the milk in high levels.
(anticonvulsants, antidepressants, antipsychotics)
• Some medications may require monitoring of labs, infant feedings, liver
function, etc. ( these are NICU babies, this may be routine)
• MONITOR THE BABY
Fork in the Road
• Trouble Lurking:
• Avoiding the Pitfalls:
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Missed or infrequent pumping.
Decreasing milk supply
Mother and baby are not doing
skin-to-skin
Mother is disconnected, depressed,
frustrated and exhausted.
Referral to lactation asap. Early
intervention is the key.
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Avoid bottles if baby can go directly
to breast
An ample milk supply means a
smoother transition to breast
Possible SNS
Tube feeding while at breast
Non-nutritive suckling at breast
during tube feeding
Shield use for premature infants
Encourage mother to stay with
infant as much as possible
Encourage Mother’s support group
Wrap it Up with Love
• Encourage these
mother’s to stay
connected to their
babies.
• Let them know what
they do matters.
• You are making a HUGE
impact on their life. Be
a blessing.
• Celebrate when
mother’s bring in
expressed breast milk.
• Be kind and soft
hearted.
References:
• Wambach, Karen and Riordan, Jan. Breastfeeding and Human Lactation.
Fifth Edition. Pages: 132, 137, 472, 477, 479, 481 and 483.
• Hale, Thomas PH.D. Medications in Mother’s Milk 2012.
• Pages: 7-12.
• Dr. Morton, Jane . Hand expression. Lactation Matters. ICLA. “Is Pumping
out of Hand?” Sept 6th, 2011
• Clip art: Windows, office.com