Breast-Feeding in the NICU: A Matter of Health and Economics

An Expert Interview With Shakira Henderson, MS, MPH, RNC-NIC, IBCLC

Elizabeth McGann, DNSc, RN

October 19, 2011

October 19, 2011 (Orlando, Florida) — Editor’s note: There are major health benefits and economic advantages to breast-feeding infants in the neonatal intensive care unit (NICU). However, barriers to breast-feeding in this environment do exist. "Current Strategies to Improve Breastfeeding Outcomes in the Neonatal Intensive Care Unit (NICU)" was featured as a podium presentation at the National Association of Neonatal Nurses (NANN) 27th Annual Educational Conference held here September 14-17, 2011.

To find out more about how best to support breast-feeding in the NICU, Medscape Medical News interviewed Shakira Henderson, MS, MPH, RNC-NIC, IBCLC. Ms. Henderson is a NICU nurse specialist at South Miami Hospital in Miami, Florida. She oversees lactation management in the NICU and coordinates the hospital breast-feeding initiatives. Ms. Henderson is an international board-certified lactation consultant (IBCLC). She is the 2010 NANN leadership award winner for a novel evidence-based approach to NICU lactation support. Ms. Henderson is pursuing a doctoral degree with a research focus aimed at improving breast-feeding outcomes in the NICU.

Medscape: Why is breast-feeding in the NICU so important?

Ms. Henderson: Exclusive breast-feeding decreases the risk of infants acquiring diarrhea and pneumonia, which are the leading causes of infant mortality worldwide. There also appears to be a protective factor against sudden infant death syndrome (SIDS). Breast-feeding decreases the risk of allergy development and enhances cognitive and social development. Exclusively breast-fed babies have higher IQs at age 7 than their formula-fed counterparts. Long-term breast-fed babies appear to have better dental health, toddler health, and have a lower risk of developing childhood cancers, obesity, and even diabetes mellitus.

The benefits of breast-feeding also extend to the mother. The US Breastfeeding Committee reports that that mothers who breast-feed have a decreased incidence of postpartum hemorrhage, diabetes, obesity, osteoporosis, and cardiovascular complications. There is also evidence to suggest that the breast-feeding mother will have a decreased incidence of ovarian, uterine, and breast cancer. However, the most essential advantage of breast-feeding is the nurturing of the mother-infant bond.

Breast-feeding is economical since it eliminates the cost of expensive formula. Since breast-fed babies are healthier children, parents lose fewer working days and spend less on medical costs associated with common illnesses such as ear infections. It is estimated that if 90% of American mothers were to breast-feed, this would save the US economy $13 billion in direct and indirect costs. It could also prevent 911 infant deaths per year and the lost potential lifetime wages of $10.56 million per infant death. Breast-feeding is ecological. There is less use of natural resources (eg, plastic) and less waste for landfills. Breast-feeding is the "green" option.

Medscape: How do the benefits of breast-feeding differ for neonates in the NICU compared with healthy infants discharged to home?

Ms. Henderson: Preterm and sick infants have a special need for their mother’s milk. NICU infants tend to have respiratory and/or gastrointestinal compromise. The antibodies, cells, and hormones in the milk help to prevent infections. Colostrum has the highest concentration of these unique, protective, immunologic factors. There is evidence to support that the leading gastrointestinal infection in this population, necrotizing enterocolitis (NEC), which is a medical emergency, can be prevented by breast milk. Breast milk is the ideal fuel for brain growth. The brain is the most rapidly developing organ in the newborn. Preterm infants have less developed brains than term infants. Thus, it is essential that whenever possible, preterm infants be provided the best option for brain development. These infants have more developmental hurdles to overcome than term infants. Evidence has shown that breast milk can improve mental and psychomotor development, behavioral outcomes, and decrease rehospitalization rates in preterm infants.

Medscape: How does the breast-feeding rate in healthy newborns compare with newborns in the NICU?

Ms. Henderson: Infants admitted to the NICU have lower breast-feeding initiation rates than infants not admitted to the NICU. In the United States, the breast-feeding initiation rate among NICU infants is estimated to be about 35% on average. The breast-feeding initiation rate among healthy newborns is about 75%.

Medscape: How well is breast-feeding promoted, protected, and supported in NICU environments?

Ms. Henderson: Based on the low breast-feeding initiation rates in the NICU, there is a need for improvement in breast-feeding promotion, protection, and support in NICU environments. Breast-feeding promotion focuses on the advantages of breast-feeding to the mother-baby dyad and to the community. Generally, NICU healthcare teams are well versed on the benefits of provision of breast milk to the NICU infant but not on the benefits of breast-feeding. There is also controversy over allowing these infants to establish breast-feeding as the sole method of feeding.

Breast-feeding protection focuses on the social responsibility to assure that breast-feeding can compete with commercial interests. This is definitely a challenge in the NICU. This is due again to the general lack of comfort with sole breast-feeding of the NICU infant.

Breast-feeding support focuses on the provision of breast-feeding assistance through counseling services and program development and implementation. Due to the high demands of patient care, it is often difficult for NICU nurses to provide adequate breast-feeding support. Moreover, the specialized knowledge needed to provide this support might not have been part of a nurse's undergraduate education or their NICU training. Unfortunately, there is no gold standard for lactation management in the NICU. Every unit is unique, and efforts to improve breast-feeding support needs to be tailored to that unit.

Medscape: What factors are important in helping the mother-baby dyad in the NICU be successful at breast-feeding?

Ms. Henderson: Factors that are important in assisting the NICU mother-baby dyad to be successful are maternal expectations of breast-feeding, maternal personal support system, current maternal health, infant medical condition and gestational age, healthcare team aptitude toward breast-feeding support, availability of specialized personnel in breast-feeding and lactation management, and a breast-feeding-friendly environment.

Medscape: What barriers to breast-feeding exist for mothers of newborns in the NICU?

Ms. Henderson: Challenges to breast-feeding this infant population stem from environmental barriers such as mother-baby separation, lack of privacy, lack of pumping space, lack of support from nursing staff due to heavy patient workload, and a lack of support from the medical team. Other barriers stem from infant factors, such as developmental immaturity and medical complications. Maternal factors such as stress from the infant admitted to the NICU, an inadequate maternal support system, poor maternal health, and fear of being a breast-feeding failure are also barriers.

Medscape: What are some current strategies to improve breast-feeding outcomes in the NICU?

Ms. Henderson: Strategies to improve breast-feeding in the NICU can be considered at the administrative, staff, and nursing care levels. Administrative-level strategies can include implementation of a breast-feeding policy, lactation rounding to high-risk maternal units, parent breast-feeding support group, and the adoption of practices that promote family-centered care (24-hour visitation), a lactation room, supply pumps at the bedside, breast-feeding pillows, and breast-feeding signs. At the staff level, strategies can include the employment of certified lactation consultants (IBCLCs) and mandatory breast-feeding education for all staff. At the nursing care level, development of a feeding protocol that supports breast-feeding, which includes kangaroo care (skin-to-skin), early and regular pumping, suckling during nasal or oral gastric feedings, parent-centered care, and flexible feeding schedules.

Medscape: What major challenges do nurses face in promoting and supporting breast-feeding in the NICU?

Ms. Henderson: The 3 major challenges that nurses face in promoting breast-feeding in the NICU are time constraints, lack of training, and lack of support by the medical team and fellow nurses. Breast-feeding teaching is time-consuming and requires special training. Nurses who advocate for breast-feeding are often met with resistance from the medical team and their own peers. Breast-feeding first is not a popular concept in the NICU. There is still general uneasiness around exclusive breast-feeding of preterm infants.

Medscape: What resources are available to healthcare professionals and the public related to the special issues surrounding breast-feeding neonates in the NICU?

Ms. Henderson: There are many resources available to the healthcare professionals and the public. Many are not NICU-specific; however, the general breast-feeding strategies are still helpful in the NICU environment. The CDC [Centers for Disease Control and Prevention], US Breast-feeding Committee, and Joint Commission have breast-feeding intervention guidelines and initiatives. Medical organizations, such as the American Academy of Pediatrics, and neonatal nursing professional organizations, such as the National Association of Neonatal Nurses and the Association of Women's Health, Obstetric and Neonatal Nurses, have position statements on human milk in the NICU. Lactation and breast-feeding professional organizations, such as the International Lactation Consultant Organization and the US Lactation Consultant Organization, have several educational materials and Webinars. UNICEF/WHO [World Health Organization] provide support through the Baby Friendly Hospital Initiative. Human Milk in the NICU by L. Arnold, published in 2010 by Jones and Bartlett, is an excellent book that focuses on policy and practice related to human milk in the NICU.

Medscape: What were the 2 most significant aspects of your presentation?

Ms. Henderson: There is clear evidence to support the health benefits of breast-feeding in the NICU infant population that extend to the mother and society. These health benefits translate into significant economic advantages. Consequently, it is imperative that efforts are made to seek out strategies that will improve breast-feeding promotion, protection, and support in the NICU.

Ms. Henderson has disclosed no relevant financial relationships.

National Association of Neonatal Nurses (NANN) 27th Annual Educational Conference. September 14-17, 2011.


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