A Breast Milk Pump at the Bedside: A Project to Increase Milk Production in Mothers of Very Low Birth Weight Infants

Abstract

The amount of milk production in mothers of babies admitted to the neonatal intensive care unit (NICU) is mostly determined by some actions focused on the first hours and days after birth. Working for an improvement in our previous results in terms of maternal expressed breast milk (MEBM) production, we designed a pilot project and a small observational study. After increasing the number of breast milk pumps to allow full-time availability and implementing educational strategies and updated information for parents, the volume of MEBM production by day 14 after birth was doubled and increased to >500 mL per day. The rate of exclusive breastfeeding at discharge improved from 26.67% to 76.19%. The cost of the use of donor milk per patient decreased by 15.7%. This study is an example of a cost-beneficial quality improvement strategy. It demonstrates the importance of an optimal supply of breast milk pumps in NICU and educational interventions focused on enhancing MEBM production.

Background

The human milk has a protective effect on multiple morbidities related to prematurity.^1–8 The benefits of maternal expressed breast milk (MEBM) on the neonatal outcome of very low birth weight infants (VLBWI) are superior to the donor milk ones, mainly on weight gain.^9,10 Neonatal intensive care units (NICUs) should promote MEBM production starting immediately after birth. The amount of milk production in mothers of babies admitted to the NICU is determined by the quality of care delivered, related to the time of first pumping and frequency of pumping thereafter, and to the availability of breast milk pumps immediately after birth.¹¹

Insufficient MEBM volume has its origins in the first 2 weeks postpartum, a critical period during which the mammary epithelial cells appear to undergo programming processes that regulate long-term MEBM synthesis.^12,13 Interventions to prevent low MEBM volume in this population should be targeted to the first week after delivery and more intensively to the first postpartum hours, the so-called early critical window for the establishment of an adequate long-term MEBM production.

Our NICU receives about 35 admissions a year of VLBWI (<1,500 g). Before February 2019, only one breast milk pump was available for all mothers, and the collection kits and milk containers had to be bought by the mothers, as they were not offered free of charge. When MEBM is not enough to feed VLBW infants, donor milk is offered for the first 4 weeks of life to all babies <1,500 g or <32 weeks of gestational age (GA). With those practices, the volume of MEBM obtained by 2 weeks after delivery was low, as low was the rate of exclusive breastfeeding at discharge.

Methods

A project and a small pilot study to increase the amount of milk produced by mothers and to reduce donor milk use were developed.

After an internal review of the main factors related to the MEBM production and a simple survey answered by the mothers, we identified several opportunities for improvement: the time for the first breast pumping was delayed and the frequency of pumping was lower than recommended. Both were considered to be related to the lack of available breast milk pumps and the refusal of the mothers to buy the collection kits. Most of them preferred to buy their breast pumps in external commercial sites, usually not before 24 hours after birth.

The target population was premature babies with a birth weight <1,500 g or a GA <32 weeks. A bundle of practices was implemented: (1) the number of available breast milk pumps in the NICU was increased from one to five (one for each site in the area where the most premature babies are cared for the first weeks, ensuring the immediate availability for any mother of a new admitted baby). They are double breast pumps with two different options of programming: initiate program for the first days of colostrum extraction, and maintain program once the milk production is established. (2) After the project was presented and approved by the hospital managers, the collection kits and containers were offered free of charge for all the mothers (the cost was assumed by the hospital as disposable material). (3) Educational strategies targeted to the staff were developed through: learning capsules offered to all nurse shifts, internal diffusion of updated guidelines about “Breast milk production in mothers of babies admitted to the NICU.” (4) Updated written information was delivered to all mothers. (5) A working group was created under the motto “Nutrition of premature babies, an emergency.”

A small prospective observational study was designed. The main outcome was the amount of milk produced by day 14 after delivery, reported by the mothers. Secondary outcomes were as follows: rate of exclusive breastfeeding at discharge, obtained from the nursing charts, and the report of the mothers who were instructed to measure and register the volume of every extraction during 24 hours, and donor milk expenditure, calculated by the pharmacist. Two periods were compared: P1, previous to the implementation of the quality improvement bundles (from September 2018 to February 2019), and P2, with the project ongoing (from March 2019 to December 2019). The project was submitted to the Department for Hospital Quality and was approved by the Commitee on Research and Ethics. Written informed consent was obtained from all the participants enrolled in the study.

Results

A total of 37 patients were included: 15 in P1 and 22 in P2. There were no significant differences between either period in the characteristics of mothers (age, ethnicity, obstetric pathologies, parity, and C-section) and babies (average GA, birth weight, and multiples, as shown in Table 1). A nonsignificant higher percentage of mothers admitted to the intensive care unit (ICU) in the first days after delivery was observed in the P2. All the mothers cared for in the obstetric department of this hospital belong to a medium or medium-high socioeconomic class.

Table 1.

Population Characteristics

Population characteristics: mean ± SD or %	First period	Second period	p
Population characteristics: mean ± SD or %	n: 15	n: 22	p
Maternal age (years)	34.5 (32–40)	36 (34–40)	0.868
No maternal pathologies (%)	64.2	64.71	0.110
Maternal intensive care unit admission (%)	7.14	29.4	0.185
C-section (%)	73.33	66.67	0.729
Primiparous (%)	64.29	70.59	1.00
Previous breastfeeding experience (%)	0	27	0.008
Gestational age (%)			0.992
<28 weeks	28.57	23.53	0.992
29.0–32.6 weeks	57.4	70.59
33.0–36.6 weeks	14.29	5.88
Birth weight (g)	1,320 (600–1,720)	1,235(900–1,570)	0.305
Multiples (%), all twins	33.33	42.86	0.732
Sex (% female)	46.67	42.86	1

SD, standard deviation.

The results are summarized in Table 2. They were calculated by using the Mann–Whitney U test.

Table 2.

Results

Results: mean ± SD or %	First period	Second period	p
Results: mean ± SD or %	n: 15	n: 22	p
Time of first pumping (hours after birth)	19 (12–24)	11 (9–21)	0.351
Time at first drops of colostrum (hours after birth)	39 (36–48)	34 (18–58)	0.448
Volume of milk at day 14 (mL)	230 (160–320)	510 (450–710)	<0.001
Breastfeeding at discharge (%)
Exclusive breastfeed	26.67	76.19	0.018
Supplemental formula < own mother's milk	20	13.6
Supplemental formula > own mother's milk	26.6	4.5
Only formula	26.6	4.5

The mean time of first pumping after delivery was 19 hours in P1, and 11 hours in P2 (p = 0.351), and the first colostrum was obtained at 39 hours in P1 and 34 hours in P2 (p = 0.448).

The daily milk average volume obtained by day 14 was significantly higher in P2: 510 versus 230 mL (p < 0.001), and so was the rate of exclusive breastfeeding at discharge: 76.19% in P2 versus 26.67% in P1 (p = 0.018). There was a difference in the percentage of mothers with previous breastfeeding experience between the periods (0% in P1 and 27% in P2); a subanalysis was performed to compare the subgroup of mothers with no previous experience, and the difference in the main outcome was also significant (320 versus 520 mL of milk obtained by day 14; p < 0.001).

The calculated cost in donor milk per patient decreased from 604 € in P1 to 509 € in P2. No cases of necrotizing enterocolitis were seen in any of the two periods.

Discussion

Our baseline population is characterized by mothers with an average age >30 years, a high number of primiparous, and a high rate of C-section and multiple pregnancies, similar to that reported in the Spanish SEN1500 network for babies <1,500 g.¹⁴ The medium-high socioeconomic and educational level is in the range expected in mothers giving birth in a private hospital.

The global incidence of any maternal pathology that could influence MEBM production (gestational diabetes, hypertensive disorders, and others) did not significantly differ between the two periods. But maternal ICU admission increased fourfold in the second period (7.14% in P1 versus 29.41% in P2), with a potential negative impact on the measured outcomes. The average GA was similar between both periods, with a similar proportion of extremely premature births between periods. The GA at birth influences MEBM production, which has been reported to be inferior in lower GAs.^15,16

This is a noncontrolled observational study, and we found the number of mothers with previous breastfeeding experience was significantly higher in the P2. When the subgroups of mothers with no previous breastfeeding experience were compared, the difference in milk production by day 14 remained significant. The impact of previous breastfeeding experience on milk production seems to have a moderate impact on MEBM, lower than the one of the C-section.¹⁷

The times of first pumping and first colostrum collection were longer than desired and little improvement was seen in the second period. The high rate of maternal admission in the ICU could be a possible explanation for this finding. Mothers in ICU receive advice and breast milk pump after delivery, but their condition usually prevented early and frequent pumping. Despite this, with the implemented bundles, the volume of MEBM obtained by day 14 was 2.2 times higher in P2 (from 230 to 510 mL), and the volume on day 14 on P2 was in the range defined as optimal to predict exclusive breastfeeding at discharge.¹⁵ Our results confirm this, as the rate of exclusive breastfeeding at discharge was 2.56 times higher in P2.

The hospital expense in donor milk decreased as expected, in an amount higher than the cost of the disposable devices offered for free to mothers in P2. The positive cost-benefit effect of the quality improvement project was confirmed.

The results of this study, obtained in a homogenous population of highly educated mothers, could be generalized to other populations. The socioeconomic and educational factors have demonstrated a less strong impact on milk production than the quality of the practices in the NICU.¹³

The study has several limitations. The use of self-reported data for the main outcome variable is probably the most important. The small sample size and the absence of mothers with previous experience in P1 constitute other weaknesses of the study.

Our experience with a limited number of patients should serve as a pilot project to a more ambitious quality improvement project. And is to be maintained as the standard of care.

Milk pumping should be seen as a priority of care when a new baby is admitted to the NICU, especially when born preterm and/or of very low birth weight. Information and milk pumping devices should be offered at an early stage to all mothers and should be available without any restriction.

Footnotes

Disclosure Statement

All the authors contribute to the design and the development of the project. N.M., R.P., and J.G. collected and analyzed the data. All the authors have reviewed and made contributions to the final manuscript.

Funding Information

The project did not receive any funding. In P2, the disposable cups and containers (collection kits) were charged to hospital expenses when the project and the results in P1 were analyzed and presented to the Department for Hospital Quality. And the breast milk pumps were offered by the commercial brand (Medela^©) as a leasing service related to the use of collection kits.

References

Sisk

, Lovelady

, Dillard

, et al. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol, 2007; 2:428–433.

Cristofalo

, Schadler

, Blanco

, et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr, 2013; 163:1592–1595.

Meinzen-Derr

, Poindexter

, Wrafe

, et al. Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. J Perinatol, 2009; 29:57–62.

Levy

, Comarsca

, Davidovits

, et al. Urinary tract infection in preterm infants: The protective role of breastfeeding. Pediatr Nephrol, 2009; 24:527–531.

Corpeleijn

, Kouwenhoven

, Paap

, et al. Intake of own mother's milk during the first days of life is associated with decreased morbidity and mortality in very low birth weight infants during the first 60 days of life. Neonatology, 2012; 102:276–281.

Spiegler

, PreuB

, Gebauer

, et al. Does breastmilk influence the development of bronchopulmonary dysplasia?. J Pediatr, 2016; 169:76–80.

Bharwani

, Green

, Pezzullo

, et al. Systematic review and meta-analysis of human milk intake and retinopathy of prematurity: A significant update. J Perinatol, 2016; 36:913–920.

Ginovart

, Gich

, Verd

. Human milk feeding protects very low birth weight infants from retinopathy of prematurity: A pre-post cohort analysis. J Matern Fetal Neonatal Med, 2016; 29:3790–3795.

Montjaux-Regis

, Cristini

, Arnaud

, et al. Improved growth of preterm infants receiving mother's own raw milk compared with pasteurized donor milk. Acta Paediatr, 2011; 100:1548–1554.

10.

Dritsakou

, Liosis

, Valsami

, et al. Improved outcomes of feeding low birth weight infants with predominantly raw human milk versus donor banked milk and formula. J Matern Fetal Neonatal Med, 2016; 29:1131–1181.

11.

Fewtrell

, Kennedy

, Ahluwalia

, et al. Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant. Arch Dis Child Fetal Neonatal Ed, 2016; 101:F502–F506.

12.

Meier

, Patel

, Hoban

, et al. Which breast pump for which mother: An evidence-based approach to individualizing breast pump technology. J Perinatol, 2016; 36:493–499.

13.

Parker

, Sullivan

, Krueger

, et al. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med, 2015; 10:84–91.

14.

SEN1500. Spanish Network for neonatal morbidity and mortality in babies born under 1500g. http://gandalf09.informance.es/SEN1500

15.

Parker

, Sullivan

, Krueger

, et al. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: A pilot study. J Perinatol, 2012; 32:205–209.

16.

Hill

, Aldag

, Chatterton

, et al. Comparison of milk output between mothers of preterm and term infants: The first 6 weeks after birth. J Hum Lact, 2005; 21:22–30.

17.

Hoban

, Bigger

, Schoeny

, et al. Milk volume at 2 weeks predicts mothers' own milk feeding at neonatal intensive care unit discharge for very low birth weight infants. Breastfeed Med, 2018; 13:135–141.