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23 Larger state-wide initiatives that report increased rates of HM feedings at NICU discharge have included multidisciplinary teams to provide education and advocacy for HM provision, to support establishing and maintaining HM supply, and to provide a consistent and comprehensive nutritional monitoring program. 24 Other initiatives have focused on developing a NICU nursing lactation team, increasing availability of hospital grade breast pumps, and implementing lactation rounds. Successful initiatives to improve the maintenance of lactationĪ handful of multi-institutional quality initiatives have demonstrated higher rates of HM provision at NICU discharge by adopting multidisciplinary infant nutrition and lactation teams that incorporate clear protocols for premature infants. 25– 28 Furthermore, it is likely that some mothers, especially those whose initial pre-birth intent was to formula-feed, revert back to their pre-birth feeding goals, especially as the infant’s condition improves and the mother perceives that “HM has done its job” of protecting from acquired morbidities. 14 It has been proposed that the profound dislike and inconvenience of long-term HM expression, maternal stress and fatigue, insufficient encouragement and assistance from family and friends, and inconsistent advice in the NICU all play a role in mothers’ discontinuation of HM provision prior to NICU discharge. 20– 27 In a prospective cohort study, Hoban et al reported that mothers of very low birthweight (VLBW <1500 grams birthweight) infants changed their HM feeding goals over the course of the NICU hospitalization, and became increasingly unlikely to achieve their goals for exclusive or partial HM as the hospitalization progressed. The maintenance of lactation, usually measured by whether the infant is still receiving partial or exclusive HM at the time of NICU discharge, (HM continuation through NICU discharge), remains a global problem with only a handful of best practices demonstrated to be effective. 5, 15– 17 Specific talking points for sharing the science of HM with families of preterm infants have been published, and can standardize evidence-based messaging about providing HM within the NICU.
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12, 13 Although black and/or low-income mothers have been especially likely to change from formula to HM after speaking with their infant’s care providers, 12– 14 black preterm infants in the United States remain less likely than their Caucasian counterparts to receive any HM, especially if their mothers are low-income. 12– 14 Studies have confirmed that NICU messaging about the superiority of HM does not make mothers feel guilty or coerced, but instead is interpreted as needed information to make the best feeding decision for their infants. The past decade is characterized by an increasing proportion of mothers who initiate lactation (begin providing HM) for their preterm infants, 3, 10, 11 many because they change the decision from formula to HM due to information they received from NICU health care providers. 9 This chapter reviews data on the initiation and maintenance of lactation for mothers of preterm infants summarizes best practices for protecting maternal HM volume during the NICU hospitalization delineates predictable, preventable problems in the feeding of HM, and details quality indicators that measure the effectiveness of NICU HM feeding programs. 8 As a result, many mothers of preterm infants fail to achieve their HM feeding goals, and infants receive either donor human milk or formula, neither of which achieves similar reduction in disease burden and cost. Although multiple studies have revealed effective interventions for modifying barriers to maternal lactation and HM feeding in this population, economic and ideologic concerns have limited their wide-scale adaptation.
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1– 7 However, this evidence must be translated into NICU best practices that target barriers to high-dose HM feedings if preterm infants and their mothers are to receive the benefits of this knowledge. Human milk (HM milk from the infant’s own mother) feedings during the neonatal intensive care unit (NICU) hospitalization represent a cost-effective strategy to reduce disease burden and associated costs in preterm infants.