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Noteworthy Professional News

Section Editor(s): Stokowski, Laura A.

doi: 10.1097/ANC.0000000000000115
Noteworthy Professional News

Fairfax Station, Virginia.

Correspondence: Laura A. Stokowski, RNC, MS, 8317 Argent Circle, Fairfax Station, VA 22039 (

The author declares no conflict of interest.

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The by now well-known Baby-Friendly Hospital Initiative was originally developed to promote breastfeeding through the application of “Ten Steps to Successful Breastfeeding.” Although geared toward the healthy newborn, these steps also had important lessons for promoting breastfeeding and encouraging mothers to supply expressed milk for their infants in the neonatal intensive care unit (NICU). NICUs have used the original recommendations to increase rates of breastfeeding and breast milk expression for preterm infants.

Babies in the NICU, and their mothers, however, have needs and challenges that differ from those of a healthy term newborn population. Therefore, the baby-friendly hospital experts have now created a set of steps for baby-friendly neonatal intensive care that take these differences into account and offer mechanisms for staff to promote breastfeeding and human milk feeding in the NICU. These recommendations, recently published in the Journal of Human Lactation, include the following:

  1. Have a written breastfeeding policy that is routinely communicated to all healthcare staff.
  2. Educate and train all staff in the specific knowledge and skills necessary to implement this policy.
  3. Inform hospitalized pregnant women at risk for preterm delivery or birth of a sick infant about the management of lactation and breastfeeding and benefits of breastfeeding.
  4. Encourage early, continuous, and prolonged mother-infant skin-to-skin contact (kangaroo mother care) without unjustified restrictions.
  5. Show mothers how to initiate and maintain lactation and establish early breastfeeding with infant stability as the only criterion.
  6. Give newborn infants no food or drink other than breast milk, unless medically indicated
  7. Enable mothers and infants to remain together 24 hours a day.
  8. Encourage demand feeding or, when needed, semidemand feeding as a transitional strategy for preterm and sick infants.
  9. Use alternatives to bottlefeeding at least until breastfeeding is well established and use pacifiers and nipple shields only for justifiable reasons.
  10. Prepare parents for continued breastfeeding and ensure access to support services/groups after hospital discharge.

These steps were developed around the 3 guiding principles known to influence the outcomes of breastfeeding: (1) The staff attitude to the mother must focus on the individual mother and her situation; (2) The facility must provide family-centered care, supported by the environment; and (3) The healthcare system must ensure continuity of pre-, peri-, and postnatal care and postdischarge care.

1. Parker M, Burnham L, Cook J, Sanchez E, Philipp BL, Merewood A. 10 years after baby-friendly designation: breastfeeding rates continue to increase in a US neonatal intensive care unit. J Hum Lact. 2013;29:354–358.

2. Nyqvist KH, Haggkvist AP, Hansen MN; Baby-Friendly Hospital Initiative Expert Group. Expansion of the baby-friendly hospital initiative 10 steps to successful breastfeeding into neonatal intensive care: expert group recommendations. J Hum Lact. 2013;29:300–309.

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Mothers who wish to breastfeed their preterm infants and have embarked on pumping can become discouraged by low expressed milk volumes, and some will even cease pumping as a result. Therefore, interventions to increase pumping volumes are important in encouraging mothers to continue to provide milk for their hospitalized infants. Most NICUs support pumping in many different ways, one of which is providing pumping rooms located conveniently to the NICU.

But could we do even better? A recent study asked whether location matters in pumping. Does the volume of milk pumped by mothers of VLBW infants vary as a function of proximity to the infant, and can pumping volumes be increased by the use of skin-to-skin positioning during the actual expression of milk?

This prospective cohort study was conducted in 26 mother-infant pairs. Mothers who were pumping were given a diary, in which they recorded the milk volumes obtained and the location of milk expression for 10 consecutive days. Possible locations included the mother's home, a remote pumping room at the hospital, within the NICU beside the infant's incubator, or within the NICU during or after skin-to-skin (kangaroo) care.

They found that mean milk volumes were significantly higher when expression took place in proximity to the infant compared with expression in a remote pumping room or at home. When only milk expressions conducted in proximity to the infant were considered, volumes obtained during skin-to-skin care (107.7 mL, range 91.8-123.5 mL) and after skin-to-skin care (117.7 mL, range, 99.0-136.5 mL) were significantly higher than those obtained beside the incubator (96.9 mL, 79.9- 113.9 mL), respectively (P= .0030 and P= .0024).

This study has several limitations, including its small size, and the fact that milk volumes were measured by the mothers, not by the investigators, without blinding to pumping location. However, the consistent trend toward higher expressed volumes the closer the proximity to the infant provides evidence for the design of NICUs with sufficient space and equipment to facilitate bedside pumping. The finding that pumped volumes are highest when pumping takes place at the bedside immediately after skin-to-skin care will be useful to nurses in supporting milk expression efforts by mothers of preterm infants.

1. Acuna-Muga J, Ureta-Velasco N, de la Cruz-Bertolo J, et al. Volume of milk obtained in relation to location and circumstances of expression in mothers of very low birth weight infants. J Hum Lact. 2014;30:41–46.

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When maternal breast milk is not available or the supply is insufficient, the alternatives for feeding preterm infants are formula or donor human milk. The nonnutritive benefits of breast milk would seem to tip the scales in favor of using donor human milk in spite of the extra costs associated with processing, storage, and handling. However, formula has advantages as well, particularly a more consistent delivery of the optimal level of nutrients needed by preterm infants. So what is the best evidence-based choice?

A new Cochrane review supplies answers. A review of 9 trials involving 1070 preterm/low-birth-weight infants evaluated the effects of feeding with formula or donor breast milk (with or without fortification) on growth and development. Although methodological weaknesses were identified (such as a lack of blinding), these trials show that formula-fed infants had higher in-hospital weight gain and increases in head circumference, but these differences did not persist after discharge nor did formula influence neurodevelopmental outcomes. Compared with donor breast milk, formula feeding increased the risk for necrotizing enterocolitis. This review leads to the conclusion that feeding with formula achieves a higher rate of short-term growth, but the trade-off is a higher risk for necrotizing enterocolitis.

1. Quigley M, McGuire W Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2014;4:CD002971.

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Breastfeeding rates among African-American women have historically been lower than those among white or Hispanic women in the United States. Some of the differences may be cultural or arising from the influence of family or friends. Evidence also suggests that laws pertaining to breastfeeding in the workplace may differentially affect African Americans, making continued breastfeeding more difficult for these women. In spite of these obstacles, targeted educational interventions can increase breastfeeding rates in this population.

With this in mind, the Office of the Surgeon General has the It's Only Natural campaign ( aimed at increasing successful breastfeeding in African American women. Resources include pregnancy preparation for breastfeeding, overcoming breastfeeding challenges, dispelling breastfeeding myths, fitting breastfeeding into a woman's life, and building a network of support for breastfeeding. Specific topics include dealing with a lack of support for breastfeeding, involving fathers, breastfeeding for single mothers, and returning to work while breastfeeding. Nurses who work with new mothers should become familiar with these resources, which will continue to be valuable to African American mothers after they go home from the hospital.

1. Centers for Disease Control and Prevention. Progress in increasing breastfeeding and reducing racial/ethnic differences. MMWR Morb Mortal Wkly Re. 2013;62:77–80.

2. Street DJ, Lewallen LP. The influence of culture on breast-feeding decisions by African American and white women. J Perinatol Neonatal Nurs. 2013;27:43–51.

3. Smith-Gagen J, Hollen R, Walker M, Cook DM, Yang W. Breastfeeding laws and breastfeeding practices by race and ethnicity. Womens Health Issues. 2014;24:e11–e19.

4. Howell EA, Bodnar-Deren S, Balbierz A, Parides M, Bickell N. An invitation to extend breastfeeding among black and Latina mothers after delivery. Am J Obstet Gynecol. 2014;210:e1–e5.

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Sending formula home with mothers who have decided to breastfeed, however well-intentioned, can have a negative impact on breastfeeding success. It has been demonstrated that hospital “discharge packs” or “gift bags” containing formula samples or formula coupons, even when disguised as “breastfeeding packs” are associated with shorter duration of breastfeeding.1 Such “gifts” to new mothers are inevitably a form of marketing, and by handing them out, may imply that we endorse formula feeding in spite of the mother's acknowledged desire to breastfeed. A recent study shows that receiving formula discharge packs conveys a covert message to some mothers that they are expected to fail at breastfeeding.2 Some women receive subtle messages from formula advertising that formula is a solution for infant fussiness, spitting up, and crying, and are uncertain whether formula is inferior, superior, or equivalent to breastfeeding.2

The idea that formula marketing erodes a mother's confidence in her ability to breastfeed has prompted many hospitals and birth centers to discontinue the practice of sending home formula discharge packs with breastfeeding mothers.3 The state of Massachusetts took this a step further, banning the practice of distributing industry-sponsored discharge bags in each of the state's 49 maternity facilities.4 To find out how these facilities, and their patient populations, have reacted to the discharge bag ban, Hurwitz and colleagues4 conducted a survey of the state's birthing facilities (response rate 100%). They found that 59% of the facilities replaced the formula company bag with their own gift bag carrying the hospital's logo. These bags either were empty or contained educational materials and/or a gift such as a T-shirt or baby book. Another 14% gave a gift without a bag, and 27% gave no gift. The cost to the hospital ranged from $1 to $35 (mean = $10.67). These findings suggest that eliminating discharge gifts was a readily accepted and low-cost way to promote best practices in breastfeeding.

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1. Sadacharan R, Grossman X, Matlak S, Merewood A. Hospital discharge bags and breastfeeding at 6 months: data from the infant feeding practices study II. J Hum Lactation. 2014;30:73–79.
2. Parry K, Taylor E, Hall-Dardess P, Walker M, Labbok M. Understanding women's interpretations of infant formula advertising. Birth. 2013;40:115–124.
3. Public Citizen. Top hospitals formula for success: no marketing of infant formula. Published October 2013. Accessed March 15, 2014.
4. Hurwitz AG, Farrow PR, Preer G, Philipp BL. Bag free in the Bay State. Breastfeed Med. 2014;9:257–260.
© 2014 by The National Association of Neonatal Nurses