Best Practice Guidelines To
Support Breastfeeding in the NICU
10 Ps for Practice
Developed by the Michigan Breastfeeding NetworkBreastfeeding of premature or sick babies offers unique challenges. This document identifies ten practices to support breastfeeding in neonatal intensive care units (NICUs). It includes practices that promote human milk as the primary source of nourishment and practices that help transition the baby to effective breastfeeding. These guidelines are applicable to preterm babies as well as sick term babies.
A written policy is developed by a multi-disciplinary team and communicated to all NICU personnel and families.(1-3)
1. Include in this policy:
All personnel involved in the care of NICU babies receive comprehensive on-going training and evaluation of basic competencies and skills necessary to implement the policy. (1,10-14)
1. This training includes:
Health care professionals encourage and inform mothers of NICU babies and their support networks about the benefits and management of breastfeeding.(1,5,13-15, 21)
Breastfeeding or human milk expression is initiated early and is done frequently and consistently with easy access to efficient breast pumps. (6,9-10,15-16,22-23)
An individualized written feeding plan is developed that begins at admission and continues until baby transitions to effective feeding at the breast. (1,6,10-11,22,26-27)
The expectation for feedings should include the use of human milk for the first feedings and extend to meeting the mother’s goal for breastfeeding post-discharge.(1,4,11,21)
This plan includes the following steps:
a. Inform mother of the medical importance of human milk for her baby.(1,4,6-7,10)
b. Establish an ample milk supply sufficient to meet or surpass the needs of a term baby. (4,7,15)
c. Encourage early and frequent skin-to-skin/Kangaroo Care, accompanied by naso-gastric feeds when appropriate. (1,4,7,10,15,17,24-25,28)
d. Provide frequent opportunities for non-nutritive sucking at breast. (7,10,13,15)
e. Ensure that first oral feedings are at the breast. (15,22)
f. Encourage frequent practice sessions at breast. (15,22)
g. Assess and document progress of baby’s feeding at breast. (11,22,24)
h. Assess intake with the use of pre and post-feeding test weights. (10,22,24-26)
i. Use a nipple shield, supplemental nursing system or other strategies to enhance milk intake at the breast, if necessary. (15,24-26)
j. Delay use of bottles as long as possible so baby has many opportunities to practice feeding at breast. (4,17)
k. Develop a “Transition to Home Breastfeeding Plan” in collaboration with a lactation consultant. (11,29)
l. Refer to community lactation services and support groups for on-going help and assessment post-discharge.
Human milk is the primary source of nutrition for all NICU babies. (1,5,6,9-10,12,17,21-22,25)
Mother and family are empowered to be involved in baby’s care and feeding through close and frequent contact throughout the hospital stay. (6,10,15,27)
Mother and baby are given the opportunity and encouragement for frequent practice at breast prior to discharge home. (4,6,10,15)
Outpatient support is provided post-discharge for assisting mother in reaching her breastfeeding goals. (1,4,10,13,26-27,32)
PROGRESSION TOWARD BEST PRACTICE
Breastfeeding practice and outcome goals are established, regularly monitored and reevaluated. A plan to meet these goals is developed and implemented by a multidisciplinary team. (7,14)
3. Recognize staff members who provide optimal breastfeeding support.
Michigan Breastfeeding Network
Co-Chairs: Mary Dubensky, RNC, BSN, IBCLC email@example.com
Rosemary Shy, MD firstname.lastname@example.org
1. Landers, S. (2003) Maximizing the Benefits of Human Milk Feeding for the Preterm Infant. Pediatric Annals, 32(5), May, 298-306.
2. Cadwell, K. (1999) Reaching the Goals of "Healthy People 2000" Regarding Breastfeeding, Clinics in Perinatology, Vol 26(2), June, 527-537.
3. Bell, E., Geyer, J., & Jones, L. (1995) A Structured Intervention Improves Breastfeeding Success for Ill or Preterm Infants. MCN, 30, 309-14.
4. Morton, J. (2002) Strategies to Support Extended Breastfeeding of the Premature Infant. Advances in Neonatal Care, 2(5), 267-282.
5. Schanler, R., Shulman, R., & Lau, C. Feeding strategies for premature infants: Beneficial outcomes of feeding fortified human milk versus preterm formula. Pediatrics: Vol 103(6), Jun 1999; Health Module pp 1150-1157.
6. Schanler, R. & Hurst, N. (1999) The use of human milk and breastfeeding in premature infants. Clinics in Perinatology. 26(2).
7. California Perinatal Quality Care Collaborative. Nutritional Support of the Very Low Birth Weight Infant: Part I Available at: www.cpqcc.oeg/NutritionToolkit.html.
8. American Academy of Pediatrics (2005) Policy Statement: Breastfeeding and the Use of Human Milk Work Group on Breastfeeding, Pediatrics 115 (2) 496-506.
9. The Human Milk Banking Association of North America, Inc. (2005) Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings.
10. Meier, P. (2003) Supporting Lactation in mothers with very low birth weight infants. Pediatric Annals
11. Furman, L., Minich, M., & Hack, M. (1998) Breastfeeding of very low birth weight infants. J Human Lact 14(1).
12. Schanler, R., Shulman, R., Lau, C., O'Brian Smith, E. & Heitkemper, M. (1999) Feeding strategies for premature infants: Randomized trial of gastrointestinal priming and tube-feeding method. Pediatrics: 103, 2; 434-9.
13. Kavanaugh, K., Meier, P., Zimmermann, B. & Mead, L. (1997) The rewards outweigh the efforts: Breastfeeding outcomes for mothers of preterm infants. J. Human Lact. 13(1).
14. Harrold, J. & Schmidt, B. (2002) Evidence-based neonatology: making a difference beyond discharge from
the neonatal nursery. Current Opinion in Pediatrics, 14:165-169.
15. Meier, P. (2001) Breastfeeding in the Special Care Nursery, Prematures and Infants with Medical Problems. Pediatric Clinics of North America, 48(2), 425-443.
16. Hill, P., Aldag, J., & Chatterton, R. (2001) Initiation of Pumping and Milk Production in Mothers of Non-Nursing Preterm Infants. J Hum Lact 17(1), 9-13.
17. Klithermes, P., Cross, M., Lanese, M., Johnson, K., & Simon, S. (1999) Transitioning Preterm Infants with Nasogastric Tube Supplementation: Increased Likelihood of Breastfeeding. JOGNN, 28(3), 264-273.
18. Hale, T. (2004) Medications and Mothers' Milk - A Manual of Lactational Pharmacology, 11th Edition, Pharmasoft Publishing, Amarillo, Texas.
19. Howard, C., & Lawrence, R. (1999) Drugs and Breastfeeding, Clinics in Perinatology, 26(2), 447-478.
20. Simpson, K. & Creehan, P. (2001) AWHONN Perinatal Nursing, Edition 2, Lippincott, 571.
21. Chantry, C. (2002) Colostrum: “Liquid Gold” ABM News and Views The Newsletter of the Academy of Breastfeeding Medicine. 8(4) 29-32.
22. Morton J. (2003) The role of the pediatrician in extended breastfeeding of the preterm infant. Pediatric Annals 32(5).
23. Hartmann, P., Cregan, M., Ramsay, D., Simmer, K., & Kent, J. (2003) Physiology of lactation in preterm mothers: Initiation and maintenance. Pediatric annals 32(5).
24. The Academy of Breastfeeding Medicine (2004) ABM Clinical Protocol #12.
25. Powers, N (2001) Part II: The Management of Breastfeeding. How to Assess Slow Growth in the Breastfed Infant: Birth to 3 months. Pediatric Clinics of North America 48(2), 345-362.
26. Meier, P., Engstrom, J., Fleming, B., Streeter, P. & Lawrence, P. (1996) Estimating milk intake of hospitalized preterm infants who breastfeed. J. Human Lact, 12(1), 21-26.
27. Griffin, T., Meier, P., Bradford, L., Bigger, H. & Engstrom, J. (2000) Mothers’ performing creamatocrit measures in the NICU: Accuracy, reactions and cost. JOGNN, May/June, 249-257.
28. Kirsten, G., Bergman, N. & Hann, M. (2001) Kangaroo mother care in the nursery. Pediatric Clinics of North America. 48(2).
29. Meier, P. & Brown, L. (1997) Breastfeeding a preterm infant after NICU discharge: reflections on Ryan's story. Breastfeeding Abstracts, 17(1), 3-4.
30. Meier, P., Engstrom, J., Murtaugh, M., Vasan, U., Meier, W. & Schanler, R. (2002) Mother’s milk feedings in the Neonatal Intensive Care Unit: Accuracy of the creamatocrit technique. Journal of Perinatology, 22.
31. Garpiel, S. (2004) Preterm Infant Transition to Effective Breastfeeding: A comparison of four supplemental methods. (unpublished)
32. Hill, P., Ledbetter, R., & Kavanaugh, K. (1997) Breastfeeding patterns of low-birth-weight infants after hospital discharge. JOGNN 26(2), 189-197.
33. Wight, N. (2004) Post-Discharge Nutrition for the Breastfed Former NICU Infant. Breastfeeding Update, 4(1).
©Michigan Breastfeeding Network July 2005
Reproduction for educational purposes permitted