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Original Research

Expressing Human Milk in the NICU

Coping Mechanisms and Challenges Shape the Complex Experience of Closeness and Separation

Bujold, Maude MSc(A), RN; Feeley, Nancy PhD, RN; Axelin, Anna PhD, RN; Cinquino, Claudia BScN, RN, IBCLC

Section Editor(s): Dowling, Donna PhD, RN; Section Editors; Thibeau, Shelley PhD, RNC-NIC; Section Editors

Author Information
doi: 10.1097/ANC.0000000000000455
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Abstract

Human milk has been shown to have protective properties for health problems such as respiratory and gastrointestinal infections, sudden infant death syndrome, obesity, and type 1 diabetes.1 For preterm infants, human milk consumption can also reduce the risk of necrotizing enterocolitis, sepsis, and retinopathy of prematurity and lead to better neurodevelopmental outcomes.1 In 2014, there were 15,045 infants hospitalized in neonatal intensive care units (NICUs) in 31 hospitals across Canada. Only 35.4% of these babies exclusively received human milk, and 38.5% received both human milk and formula at discharge.2 This is below the 75% exclusive human milk goal of the Baby Friendly Hospital Initiative3 supported by the Canadian Pediatric Society.4 As the World Health Organization recommends exclusive human milk in the first 6 months of life, many NICU infants may not receive optimal nutrition for their development.5

One factor that may play a role in low rates of exclusive human milk feeding for NICU infants is the challenges mothers confront in manually expressing their milk. Mothers who choose to give human milk to their infant usually must express their milk for the time the infant is unable to effectively suck and feed directly at the breast.6 They typically use a hospital-grade electric pump to initiate lactation,7 and then store the milk until it is given to the infant by enteral or bottle feeds.8 To attain and maintain adequate milk production, mothers need to start milk expression within the first hour after childbirth,9,10 and continue to do so every 2 or 3 hours.11,12 In the first few days, milk flows slowly and in small quantities, which can be frustrating for mothers.6,13 Milk production can be difficult to maintain, as many mothers find expression exhausting14,15 and time-consuming.15 There is some evidence that women with lower socioeconomic status, those with lower levels of education, and teenage mothers are less likely to persist with lactation until NICU discharge.16–19

Although studies of the overall lactation experience of mothers of NICU infants provide some knowledge of their perceptions of milk expression, very few studies have focused explicitly on milk expression during a NICU hospitalization. The few existing studies suggest that there is a wide spectrum of possible experiences. Some studies describe positive aspects of providing human milk, as it was a way for mothers to bond, care, and feel close to their child.20,21 Some mothers find it provides structure in a time of uncertainty and a routine that included the infant, despite the separation engendered by hospitalization.21 Some mothers feel connected to their infant while expressing and this gives them motivation to persevere.22 It is also seen by some as an opportunity to relax.22

In contrast, evidence suggests that some women find milk expression to be unpleasant or troublesome.20,21,23 The process is considered tedious and women find ways to distract themselves while expressing, so they continue to do so frequently and maintain production.22 The pressure of meeting expectations about quantities of milk produced can cause distress.12 Milk expression can also become a burden because of a sense of obligation, or failure if they feel unable to continue.12

There is also recent evidence that some mothers experience mixed feelings. In a study by Hurst et al,24 mothers describe providing human milk as a paradoxical experience. The breast pump represents detachment from their child, but also is an important way to provide for the child and feel connected.24 The authors highlight the need for further research to understand the complex paradoxical nature of milk expression to enable the development of appropriate interventions to support mothers.

Studies of NICU mothers indicate they need to be close to their hospitalized infant and to feel like a caring mother, not a visitor.25 Closeness can be emotional and physical, and these are not necessarily interrelated. Physical closeness refers to being spatially close, while emotional closeness refers to parental feelings of being emotionally connected to the infant.26 Emotional and physical closeness have physiological and psychological benefits. A review by Flacking et al26 shows that closeness between NICU infants and their parents can improve child brain development and later cognitive development. Moreover, when closeness is promoted, mothers report better mental health.27 Treherne et al28 explored parents' experience of closeness with their infants in the NICU, and expressing human milk was found to engender both closeness and separation for mothers. More research is needed to develop a deeper understanding of the closeness and separation experience of mothers expressing human milk.

Data from studies on mothers' overall lactation experience provide some knowledge about possible factors that can influence when and where women express milk. Dowling et al29 report that mothers are most comfortable expressing milk in their home for privacy, comfort, control of the environment, and absence of interruptions. The second preferred place is the infant's bedside, since it allows them to be close to their infant, and the last choice is the NICU's milk expression room.

Clinicians need to understand how to optimize the milk expression experience of NICU mothers so that they continue to provide human milk. A better understanding of mothers' experience and the factors that shape whether they feel close or separate from their infant could lead to nursing practices to promote closeness. Thus, the purpose of this study was to explore whether mothers perceived expressing human milk for their infant in the NICU to be a closeness or separation experience and what factors gave rise to these perceptions.

What This Study Adds

  • Mothers of neonatal intensive care unit infants who are expressing human milk experience both closeness with their infant and a feeling of separation, and this can fluctuate in the short-term over time.
  • How mothers cope with the challenges of milk expression plays a role in their ability to view milk expression in a positive light, and feel close to their infant.
  • The environment in which mothers express can have an impact on whether they feel closer or more separated from their infant.

METHODS

A qualitative descriptive design was chosen to document maternal experiences expressing human milk for their infant in the NICU as a closeness or separation experience. A qualitative descriptive study is useful to capture a rich understanding of the experience of the participants and to develop nursing practices adapted to people's needs in a specific circumstance.30

The study was conducted in a level III urban Canadian NICU, which is a combination of 6-bed pods and single-family rooms, and approved by the hospital's Research Ethics Committee. At the study site, all nurses receive 20 hours of basic mandatory lactation training, and 7 members of the nursing staff are lactation consultants. Women can express in 1 of the 2 designated milk expression rooms in the NICU and at the infant's bedside behind a privacy screen. In each pod of 6 infants, there are 2 to 3 pumps per pod, each single-family room has a pump, and there is 1 pump in each of the 2 milk expression rooms. Thus, there are a total of 24 pumps for this 34-bed unit. There is no milk bank. While at the hospital, mothers typically use these hospital-grade pumps. To express elsewhere, women can choose to purchase or rent a hospital-grade pump similar to the one at the hospital; or choose a portable, more compact and travel-friendly electric pump.

Convenience sampling was used to recruit mothers who were expressing while their infant was hospitalized. Mothers were eligible if their infant had been in the NICU for more than 48 hours regardless of gestational age, birth weight, or reason for admission; was in stable condition; and expected to be hospitalized at least 1 more week. Exclusion criteria were an infant diagnosis of grade 4 intraventricular hemorrhage, trisomy 21, and being in palliative care or foster care, as these are situations with major challenges beyond the NICU hospitalization that could affect mothers' milk expression experience.

Research phones with the HAPPY (Handy Application to Promote Preterm infant happY-life) application were loaned to participants. This smartphone application allows participants to describe their thoughts and feelings via voice recording. It has been used in studies with NICU parents and nurses, and was acceptable, and provided rich qualitative data.28,31,32 Verbal and written instructions for the application were provided. Mothers were asked to use the application while expressing or soon after, at the location where they expressed, for 48 hours. They first choose the “closeness” or “separation” button to describe whether they felt close or separated from the infant while expressing. No definition of these concepts was provided to encourage them to use their own interpretation. After selecting the word representing their current feeling, they verbally described their milk expression experience. Confidentiality of data was protected, as audio data could only be decoded on the research computer. Mothers completed a demographic questionnaire with a subject number, and the infant's medical chart was reviewed to retrieve data for sample description.

A thematic content analysis process was used to analyze the data, which is consistent with the descriptive qualitative design.33 Data analysis was an iterative process, as codes were continuously compared with data gathered in subsequent recordings. Data collection continued until saturation was achieved, and this was evident after 13 participants were enrolled. Audio files were transcribed, and data were read several times to acquire a general overview of the participants' perspectives. Qualitative data analysis software (NVivo) was used to manage data. Our analysis was structured around the topic of this inquiry—closeness and separation—so these were the major categories. Our findings describe the subcategories that emerged within each of these major categories. Salient segments of text were identified and coded according to the main idea expressed. Coded segments were regrouped into subcategories based on similarities and differences. These were corroborated with new information from subsequent recordings. Credibility was ensured by peer debriefing: the team met weekly to discuss the data and acquire different perspectives. Confirmability was addressed by initiating an audit trail documenting decisions, analysis products, and reflexive notes.33 Dependability, the stability of data over time and conditions, was ensured by coding checks: that is coding data and then recoding 2 weeks later to compare.34 Using a team of researchers with some members familiar with qualitative methods as well as the study field ensured confirmability.35 Adequate description of participants and setting allows readers to determine transferability or extent to which findings can be applied in other settings.33 Francophone participants' quotes included as examples in this report were translated into English.

FINDINGS

The 15 participants had preterm infants born at an average of 29 gestational weeks (range = 23-32), who were on average 37 days of life (range = 5-94) on the first day of data collection. They weighed an average of 1171 g at birth (range = 590-1730). Mothers' mean age was 32 years (range = 26-44). Ten of the 15 were first-time mothers. They had been expressing for an average of 38 days (range = 5-93). Additional sociodemographic characteristics are presented in Table 1.

TABLE 1. - Sociodemographic Characteristics and Feeding (N = 15)
Characteristic n (%)
Mother living with partner
Yes 13 (87)
No 2 (13)
Mother Canadian citizen
Yes 10 (67)
No 5 (33)
Mother's highest level of education
High school or less 3 (20)
Technical college 2 (13)
University 10 (67)
Mother currently working
Yes 2 (14)
No 12 (86)
Mother visiting infant every day
Yes 14 (93)
No 1 (7)
Time of the day when mothers visited NICUa
Day shift (7 am to 3 pm) 11 (73)
Evening shift (3 pm to 11 pm) 13 (87)
Night shift (11 pm to 7 am) 5 (33)
Room type where infant currently located
Single patient 5 (33)
Multiple patients (2-6 infants per room) 10 (67)
Maternal parity
Primiparous 10 (67)
Multiparous 5 (33)
Pregnancy
Single birth 13 (87)
Multiple 2 (13)
Previous breastfeeding experience
Yes 4 (31)
No 9 (69)
Breastfeeding attempted
Yes 9 (60)
No 6 (40)
Currently breastfeeding
Yes 8 (53)
No 7 (47)
Planning to breastfeed
Yes 15 (100)
Milk expression methoda
Hospital pump 14 (93)
Otherb 8 (53)
Type of milk infant currently receiving
Human milk 10 (67)
Formulac 1 (7)
Human milk and formula 4 (26)
Abbreviation: NICU, neonatal intensive care unit.
aTotal of percentages is more than 100 because participants could choose more than 1 response.
bOnly 1 participant reported manually expressing at home.
cOne infant was temporarily receiving strictly formula to rule out human milk as a contributing factor to a health issue. Mother stated that she could start giving human milk again soon.

Expressing human milk was a difficult experience for all, and all experienced varying degrees of closeness and separation while expressing. Most mothers described both positive and negative feelings, and feelings fluctuated over time (see Figure 1). Fluctuation in feelings was influenced by 3 factors: namely coping mechanisms, perceived challenges, and mothers' location and environment while expressing milk. Some women described mostly positive feelings and closeness experiences, as they seemed to have found effective coping mechanisms. In contrast, other mothers felt overwhelmed by challenges, had difficulty coping, and felt separated. Some mothers who had previously found ways to cope encountered new challenges that provoked negative feelings and separation.

FIGURE 1
FIGURE 1

Closeness and Positive Feelings

Thirteen of 15 mothers (87%) reported closeness experiences at some point during data collection, and 9 of those mothers (60%) reported more episodes of closeness than separation. Closeness was associated with positive thoughts, feeling relaxed, and feeling a special connection with the infant. Several reported being more motivated to express when they felt close to their child. “When I'm with my baby, ... it's very motivating to have your baby close, and sometimes I even have him on me while expressing my milk...” (P05). Nonetheless, physical proximity was not necessary to feel close. Using the milk expression room after having held the infant was typically described as a closeness experience. Merely thinking about being with the infant, either before or after a visit, made some mothers feel close. “I still feel close to my baby because I went to see him this morning... When I think of him... pleasant thoughts come to me. I know he's okay... that he'll have good milk.” (P06).

Finding Ways to Cope With Milk Expression Helps Mothers Feel Close

Mothers utilized a variety of strategies to help them cope with the challenges of milk expression. Usually, by utilizing these strategies, they could achieve closeness.

Considering milk expression as a way to feel useful as a mother. Mothers could cope, felt more positive about milk expression, and emotionally close when they considered expressing made them feel useful in their infant's care. It gave them purpose. One mother explained:

I think it's so important to give him his milk ..., this is the only way you can feel like you are close to the child because he is sick and he is away in the NICU and pumping and giving him milk is like a way to feel like you are important for your child. You feel you're a mother. (P09)

They considered milk expression as something they owed the infant. They wanted to give human milk to their vulnerable babies because of its benefits; they believed that providing milk formed a privileged bond. “Expressing milk brings me closer to my baby, because it's like a privileged bond we have. Instead of breastfeeding him, I'm giving ... him the best possible start”. (P05)

Using self-talk. Mothers described how they talked to or encouraged themselves, reminding themselves of their motivation, the need to persevere and not get discouraged. They reflected on the need to persist towards their goal of lactation, to be resilient and determined to continue expressing human milk despite the numerous challenges confronted over time. For example, one mother noted: “It's motivating to remind myself that I'm doing this for her, when I see her and I know she's going to drink this milk” (P08).

Thinking about their infant. Most mothers purposefully thought about their infant while expressing, whether at home or at the bedside. As one woman explained: “I like to think about my baby, it brings positive thoughts. I know ... he will get good milk” (P06). If they were with the infant while pumping, they would look at her/him or hold her/his hand to feel close. If they were not physically close, they would look at the infant's picture or grasp an object that belonged to their infant such as a blanket with the infant's smell. Thinking about the infant could stimulate milk production, and observing their milk production increase was a source of motivation.

Reframing Milk Expression as a Part of the Lactation Process

Mothers described being able to cope with milk expression and feeling close to their infant when they considered milk expression as a stepping stone to their goal of lactation. “Pumping my milk, well it is part of the breastfeeding process. We've now started to feed him at the breast, it's very motivating for me, it definitely makes me feel closer to my child” (P01). Most were more motivated to express when they started feeding at the breast and when their infant's feedings progressed, as they perceived they were closer to their lactation goals and their efforts were successful.

Integrating Milk Expression Into Daily Life

Women also coped with milk expression by doing so while addressing other demands. As one stated, “I sit at home and I can help my other children while telling myself that I'm helping the one who isn't present at that moment” (P06). Milk expression with the infant's siblings present gave some women a sense integrating the hospitalized infant into the family. Mothers felt more positive about milk expression when they found ways to integrate it into their daily routine and simultaneously meet their own personal needs (e.g., by spacing night-time milk expression sessions to enable them to get rest). Finding a pump that allowed them to express anywhere, and made it easier to integrate milk expression into their daily life, was important.

Using Distractions to Pass the Time

While some mothers preferred to think about their infant while expressing, others relied on distractions to pass the time and help them cope. While expressing milk, they would watch television, play on their phone, listen to music, or talk to someone.

For example, one participant described what she was doing while expressing milk in a designated milk expression room in the unit: “I'm alone in a small room so I check my phone, check social media, or play games... findings ways to pass time because I need to pump for 15 minutes. But I will go back to my baby right after” (P01).

Seeking and Using Support

Mothers sought and received support from several sources, including nurses, lactation specialists, their partner, friends, or family, and this helped them cope. The bedside nurse was identified as a key support to foster closeness. Mothers were motivated to express when they perceived that milk expression was equally important to their infant's nurse. One mother described how she appreciated being encouraged to express by the nurse and felt less guilty putting her infant back into the incubator to express when nurses reminded her to do so. Mothers also appreciated receiving support from the lactation specialists who taught them milk expression methods, and gave them tips to make milk expression less painful, easier, and more efficient, such as to massage their nipple to elicit a milk ejection reflex, or to apply warm compresses to the breasts prior to milk expression.

Mothers also recognized the importance of sharing their experience with other women in the same situation. Observing another mother expressing was encouraging. They experienced increasing motivation to persist when their partners provided encouragement and support. “He [husband] is encouraging me a lot. He supports and understands and appreciates what I'm doing for our child. This is for me the power to continue pumping” (P09). Women could feel isolated when expressing milk, and finding someone to be with them while doing so could diminish isolation.

Separation and Negative Feelings

Fourteen of 15 mothers (93%) reported separation experiences at some point during data collection, and 6 of those (40%) reported more episodes of separation than closeness. Physical separation was typically linked to emotional separation and negative feelings such as sadness, loneliness, frustration, and a longing for their infant. In these moments, they felt demotivated and perceived milk expression as an obligation. Mothers felt emotional separation when they had to leave their infant's side to express. Discomfort and pain led to feelings of separation.

Being Overwhelmed by the Challenges and Feeling Separated

While all mothers had to deal with challenges related to milk expression, some perceived the challenges as overwhelming. When mothers were unable to find effective coping mechanisms to overcome the inherent challenges, they experienced milk expression as an emotional separation.

Having a Negative Perception of Milk Production

Some mothers felt pressure about the quantity of milk they could express. They worried about their milk supply and were fearful of not having enough to feed their infant. “I'm not feeling very close, just feeling stressed out that I'm not producing enough milk” (P13). In contrast, other mothers were producing too much milk, exceeded their infant's needs. Due to limited storage space for milk, they experienced feelings of separation and decreased motivation while expressing because they knew the infant would probably not be given that milk and it might be thrown out.

Considering That Milk Expression Is Not Breastfeeding

Mothers had difficulty coping with the demands of milk expression when they compared it to feeding at the breast. Milk expression was a reminder that they were separated from their child and could not feed directly at the breast. They were less motivated to wake at night to express compared with if they had to wake to breastfeed their child. “Of course, I've never experienced it, so it's hard to say, but it's less appealing to express your milk at night than to wake up to breastfeed your baby” (P01).

Mothers described feeling frustrated when comparing milk expression with breastfeeding their previous children, as they did not experience the same closeness. For some mothers who had started feeding their infant at the breast, they felt more separated when expressing milk compared with when they were not feeding at the breast: “These days, I'm not feeling emotionally connected. In the beginning, I remember really feeling like I had a mission and I was doing this [pumping] for my infant and it was one of the only things that I could really ... do for him ...” (P11).

An Exhausting Schedule

Mothers explained how difficult it was to feel close to their child while expressing milk when they had to rush and juggle competing demands with milk expression. It was difficult to plan their day around their milk expression schedule. It was also time-consuming to set up equipment, express, store the milk, and then wash and sterilize equipment. Mothers experienced fatigue when milk expression disturbed their sleep. They reported more separation and less motivation in evenings and at nights due to fatigue. One mother explained: “That's really when I feel the most alone, the furthest away. I don't think there's really anything to help at that hour. You need willpower to get up, express your milk. Then you tell yourself, I'm tired, why am I doing this?” (P06).

Lacking Adequate Support

When mothers perceived that support from their partner, family, or staff was inadequate, they felt less able to cope and separated. For some, even if their partners were supportive, they felt lonely and isolated as the person going through this tedious process. They sometimes wished they would have more communication with nurses while they were expressing milk, to reduce isolation and to have someone answer questions. However, it was confusing when they received different advice from different nurses. Some considered that nurses were often not proactive in providing teaching or not sufficiently trained to provide needed help. For example, one mother described: “I'm at the hospital every day with my daughter... I understand that they're there for the baby's needs, but we are here all day too. We have work to do so that this baby can grow, and I think we aren't helped enough” (P07).

Location and Environment

Mothers' location and environment were factors that could affect closeness and separation while expressing milk, but these could also affect coping mechanisms and resources that were available. Mothers expressed in 4 locations: at home (n = 14), at the home of friends or family (n = 2), the infant's bedside (n = 13), and in the NICU milk expression rooms (n = 6). Mothers identified more milk expression episodes as separation when they were expressing milk at home (n = 10).

For some, being physically separated from their infant at home contributed to feeling an emotional separation. As one explained: “I'm at home pumping... I feel isolated from our infant because we're not there. He's over at the hospital and we're here and it feels strange to be doing something for him when he's not in our home” (P13). For some, they felt more separated while expressing milk at home without the infant when they had just visited in hospital, and felt sad picturing their infant alone in the hospital. In contrast, other mothers found home to be a more comfortable environment, where they could relax and express. One mother recreated the environment she had when breastfeeding her previous children at home: she chose a quiet and comfortable place to express to create the same positive and calm mindset she would have if she was with the infant.

Physical closeness was often associated with emotional closeness. For example, being able to express at the bedside while looking at or holding the infant's hand, one explained: “I pump my milk next to my baby's isolette. I'm able to look at my baby. It's a nice moment for me, I feel very close to him” (P01). Paradoxically, the desire for physical closeness could prevent mothers from milk expression. One mother explained that, at the hospital, she felt guilty when she had to express instead of holding her infant. She would prefer not to express, choosing physical closeness over milk expression.

The environment also played a role, particularly privacy. In the hospital, it was possible for women whose infant was in a multibed pod to erect a screen to provide more privacy. Nonetheless, a few mothers still felt a lack of privacy due to comings and goings of health professionals. If they desired greater privacy, they would go to a dedicated milk expression rooms away from the bedside. They also expressed in these rooms if they wished to let the nurse provide the infant's care, take a break and relax, eat while expressing, listen to music, or talk on the phone.

DISCUSSION

This study found that while expressing their human milk mothers did not experience only closeness with their infant or separation, but they experienced both, and for most their feelings fluctuated over the 48 hours of their participation. We observed fluctuations, as participants were asked to describe each milk expression session as either “closeness” or “separation.” Hurst et al24 found that milk expression was a paradoxical experience for American mothers: the pump was a wedge between them and their infant, as well as a link. Our study extends knowledge by revealing the dynamic nature of closeness and separation for NICU mothers. It is important to note that in our study procedures participants were asked to choose either the closeness or the separation button on the application to describe their experience at the time they made each of their recordings. However, there were some events where mothers chose one of the options but went on to describe both feelings of closeness and separation. Thus, although it seems that mothers can experience both at the same moment, our method of data collection did not allow us to fully capture this.

The current study also revealed that mothers' experience of closeness or separation was shaped by their perceptions or cognitions about milk expression, rather than the actual challenges they faced. Moreover, how mothers coped with challenges played a key role in their ability to view milk expression in a positive light, and feel close to their infant. Hallowell et al36 noted that, while lactation consultant availability is limited, bedside nurses are available at all times, giving them a critical role in lactation support. Furthermore, nursing support is associated with higher rates of NICU infants receiving human milk at discharge.37 Thus, if NICUs aim to help mothers reach their goal of lactation, it is imperative that nurses help mothers find and employ ways of coping that help them manage challenges and feel close to their infant.

Previous studies have found, as we did, that some mothers consider milk expression as a way to feel useful as a mother12,20,38–41 and an important step in the lactation process.12,20,24 In contrast, other mothers deem that milk expression was not like breastfeeding. As with previous studies, mothers in the present study thought that milk expression was exhausting and time-consuming,20,22,24,42,43 and used distractions to pass the time.22,24 Relaxation techniques and listening to music may not only help mothers cope, but can also increase the quantity of expressed milk.44,45

Using positive self-talk, thinking about their infant, and perceiving milk expression as a way to provide for their infant were ways of coping that cast a positive light on and emphasized the importance of their efforts (Figure 2). Reframing milk expression as a necessary step toward lactation, integrating milk expression into their life, using distractions, and seeking support made them feel that they could manage the demands of milk expression. All these ways of coping boosted their motivation and helped them feel close to their child.

FIGURE 2
FIGURE 2

Nurses can encourage mothers to surround themselves with supportive individuals, as studies find that social support is associated with continued milk expression.46 Peer support has also been associated with maintaining lactation: a program of trained peer counselors who are former NICU mothers has been shown to also foster hope and coping, and increase knowledge.47

It is interesting that while some coping strategies described by participants supported closeness, the opposing coping behavior was associated with separation (Figure 2). For example, reframing milk expression as a step toward lactation was associated with coping effectively with challenges and closeness, while considering milk expression as not like lactation was linked to feeling overwhelmed and separated. Similarly, integrating milk expression into daily life was linked to coping effectively and closeness, and perceiving the demands as exhausting was linked to feeling overwhelmed and separation. Nurses are well placed to help mothers use ways of coping that help them manage the demands of milk expression, and feel close. In contrast, when mothers in the current study had predominately negative perceptions of milk expression and were overwhelmed by challenges, they felt separated. Many challenges encountered were related to their perceptions of milk expression or internal discourse, such as having a negative perception of their milk production or considering that milk expression is not breastfeeding. Hill et al48 found that mothers of preterm infants report greater psychological distress and negative mood than mothers of term infants. The challenges of milk expression and feeling separated might contribute to mothers' mood and distress.

Consistent with previous studies,6,20,38,41,42,49 we found that some mothers had negative perceptions of their milk supply. These could arise due to lack of knowledge of lactogenesis and the quantity of milk that their newborn requires,20 and could be addressed by nurses with teaching. Nurses can normalize these feelings and reassure mothers that milk expression is a difficult experience for most mothers. Ikonen et al50 suggest avoiding collective-use refrigerators and using opaque milk containers so that mothers cannot compare their production with that of others. Several mothers in our study perceived they were producing too much milk, and worried excess milk might be thrown away. The possibility of donating to a milk bank could be raised.

In the current study, most mothers preferred to express at the bedside concealed by a privacy screen, as they enjoyed being physically close to the infant, as this sustained their motivation, while other studies have found that they preferred to do so at home.29,41 In other studies,6,13,20,22,41 lack of privacy was a barrier to milk expression at the bedside. Unit design may account for differences in preferences across studies. Nurses need to ensure mothers' privacy while expressing milk at the bedside. Acuña-Muga et al51 found that mothers who expressed during or immediately after skin-to-skin contact produced more milk than those who expressed at the bedside or home. They also produced more if they expressed at the bedside compared with another hospital room. Thus, nurses can educate mothers about how physical proximity is beneficial for milk production. In our study, some mothers described choosing to remain in skin-to-skin contact and consequently forgoing milk expression sessions. In these cases, supporting mothers to express during skin-to-skin contact might be convenient, as well as beneficial for milk production.

CONCLUSION

Mothers often experienced both closeness and separation while expressing milk, and their feelings fluctuated over 48 hours. Their perception of the challenges or their cognitions concerning milk expression, and the coping mechanisms utilized, as well as their location and environment, played a role in whether they experienced milk expression as making them feel close to or separated from their infant. Nurses can help mothers find effective coping mechanisms to feel close to their infant. They can motivate mothers to continue expressing milk by finding ways to integrate milk expression into daily life and to find support. Being aware of the challenges related to milk expression, nurses can assist mothers to manage difficulties to promote closeness with their infant.

As mothers with lower socioeconomic status, lower levels of education, and teenage mothers are less likely to persist with lactation until NICU discharge,16–19 they may benefit most from additional support and education from nurses to persist with milk expression. Lactation support from nurses can take many other forms as well, including checking bottles for proper labeling and expiration, thawing milk, gathering milk expression equipment and supplies, and providing education related to human milk expression, human milk or direct lactation.52 Providing nurses with adequate education on how to support expressing mothers can have benefits such as improving their knowledge, standardizing care, increasing their advocacy for the provision of human milk, and augmenting the lactation support they provide, which ultimately improves NICU care.53,54 Implications for practice are summarized in Table 2.

TABLE 2. - Implications for Practice
How to Help Mothers Cope With Milk Expression Strategies
Support and maintain mothers' motivation
  • Remind mothers to keep their goal of breastfeeding in mind

  • Encourage mothers to hold an object that belongs to the infant (blanket, clothes) while expressing milk

  • Encourage mothers to look at pictures of their infant while expressing milk

  • Teach mothers positive self-talk

  • Provide encouragement and positive reinforcement related to milk expression

  • Explain realistic expectations for amounts of milk needed

  • Suggest using a journal or smartphone application to track milk volumes and thoughts

  • Inform mothers of the possibility to donate excess milk

Help mothers integrate milk expression into daily life
  • Help mothers attain a comfortable environment in which to express

  • Encourage mothers to express while they are in or right after skin-to-skin contact

  • Find strategies to multitask while expressing milk (altering a sports bra to express hands-free)

  • Encourage mothers to use distractions to pass the time (television, music, games, social media)

  • Advise mothers to double express to reduce time needed to express

Help mothers obtain support for milk expression
  • Organize weekly parent support groups

  • Organize group milk expression sessions

  • Establish peer-to-peer mentoring programs

  • Encourage mothers to seek support from their nurse, partner, family, friends

  • Encourage visiting family to offer milk expression support to the mother

Provide NICU facilities to meet mothers' needs
  • Provide milk expression rooms that can accommodate mothers alone or in groups

  • Ensure privacy for mothers expressing milk at the bedside (knocking, providing screens or curtains, limiting disruptions)

Abbreviation: NICU, neonatal intensive care unit.

Our study has limitations that should be considered. Coincidentally, all our participants had given birth prematurely, and most were first-time parents, which may affect transferability of our findings. There was a broad range in infant postpartum age at the time of data collection, and mothers' milk expression experiences may be significantly different at postpartum day 5 compared with day 94. Infant health differences may also have played a role, and this was not explored. We did not collect data on mothers' actual milk production, so do not know how these shaped their milk expression experience. Moreover, we did not examine maternal depressive symptoms, anxiety, and posttraumatic stress disorder symptoms, and milk expression challenges may contribute to maternal mood and vice versa.55

This study did not explore whether mothers' milk expression experience in relation to closeness or separation varied based on their sociodemographic characteristics (ie, educational level and ethnicity), or previous feeding experience. This would be an important avenue for future research. There is a physiological difference in hormone production between lactation and milk expression.56 As current evidence suggests that the hormone oxytocin is implicated in maternal stress, mood, and mother–infant bonding,57 the effect of milk expression on oxytocin and feelings of closeness and separation requires further investigation. In future studies, the effect of environment and location on feelings of closeness and separation during milk expression should be examined more closely. This knowledge could help units make design and environment decisions to promote infant–mother closeness.

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Keywords:

human milk; milk expression; mothers; NICU; premature infants

© 2018 by the National Association of Neonatal Nurses.