Human Milk and Breastfeeding for the Very Low Birthweight Infant
by Anne Eglash MD, IBCLC, FABM
The authors state that human milk feeding at discharge has increased from 44% in 2008 to 52% at 2017, but rates are significantly lower among non-Hispanic Blacks, American Indian/Alaska Native populations, and in the southern region of the USA.
VLBW infants who receive parents’ own milk have lower risks of necrotizing enterocolitis, late-onset sepsis, chronic lung disease, retinopathy of prematurity and neurodevelopmental impairment.
This policy statement covers a wide range of topics regarding VLBW feeding of human milk, including health outcomes, evidence on timing of milk expression, family support, transition to feeding at the breast/chest, fortification, use of donor milk, misadministration, contraindications, and the quandary of postnatal CMV infection via human milk.
Let’s proceed to the question, to see what you may or may not know about feeding human milk in the NICU.
- The birth parent of a VLBW infant is more likely to initiate lactation as compared to a birth parent of a term infant.
- NICU staff nurses play an important role in lactation support and education, but need dedicated lactation training.
- Studies on the timing of first milk expression consistently show that pumping and hand expression in the first hour after birth is key to successful lactation.
- The lactating parent expresses more milk if expression occurs at the infant’s bedside.
- Skin to skin care can be safely performed among infants who are ventilated or who are on continuous positive airway pressure.
- Direct feeding at the breast/chest should wait until the infant is 33 weeks gestation.
- Pasteurized donor human milk has less protein than parent’s own milk.
- Pasteurized donor human milk is recommended when there is insufficient parent’s own milk.
- Liquid fortifiers for human milk have been associated with Cronobacter sakazakii infection.
- Freezing of parent’s fresh milk kills all active cytomegalovirus (CMV) in the milk.
- Providing drops of colostrum in the cheeks (oral immune care) in the first few hours after birth reduces the risk of infant mortality.
See the Answer
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.
Like other organizational policy statements and protocols, this is an important resource and reference for anyone striving to improve support for human milk feeding and breastfeeding/chestfeeding in their NICU.
Studies on the timing of first expression are not clear. We cannot definitively say that milk expression in the first 1-2 hours is crucial for optimal milk production. It seems that the frequency of milk expression, at least every 3 hours with no more than a 4-5 hour break at night, is probably the most important factor. However, milk expression in the first hour will ensure the availability of colostrum for oral immune therapy.
Direct feeding at the breast/chest can begin when the infant shows feeding cues for suckling and has the respiratory reserve to manage oral feeding. This may be before 33 weeks gestation.
Liquid fortifiers are considered sterile. Use of powdered fortifiers increases the risk of Cronobacter Sakazakii infection.
The authors discuss the risk of CMV infection from parent’s own milk. Freezing inactivates CMV virus, but does not eliminate the risk of infant CMV infection from parent’s milk. The authors do not recommend screening parent’s milk for CMV infection, but they recommend including CMV testing if a NICU infant develops signs of sepsis.
Oral immune care, or the provision of colostrum orally in the first few hours after birth, is associated with fewer days to enteral feeding. So far studies have not shown a decrease in necrotizing enterocolitis or a decrease in mortality.
This policy emphasizes the need for NICU staff training. IABLE has a low-cost 5.5 hour accredited eCourse designed specifically for NICU healthcare teams entitled Basics of Breastfeeding Support for the NICU/PICU.