Enhancing Mother’s Own Milk Volume in the First 14 Days Postpartum for Very Low Birth Weight Neonates: A Quality Improvement Initiative in a Predominantly Outborn NICU in India
Restricted accessResearch articleFirst published online 2026
Enhancing Mother’s Own Milk Volume in the First 14 Days Postpartum for Very Low Birth Weight Neonates: A Quality Improvement Initiative in a Predominantly Outborn NICU in India
Providing mother’s own milk (MOM) for very low birth weight (VLBW) neonates, especially in outborn settings, is challenging due to factors such as mother–infant separation, communication gaps and limited breastfeeding support at referring hospitals.
Methods
This quality improvement initiative used the Point of Care Quality Improvement (POCQI) framework, with sequential Plan–Do–Study–Act (PDSA) cycles to increase MOM volume in mothers of VLBW neonates. This study was conducted in three phases—baseline, intervention and sustenance—from August 2022 to July 2023. Each phase enrolled different mother–infant dyads (non-concurrent cohorts), and outcomes were compared across phases. We aimed to increase cumulative MOM over postnatal days 1-14 by 25% during a 1-year implementation period using sequential PDSA cycles. Interventions included lactation education, a standard operating procedure for lactation counselling, provision of free manual breast pumps and a short course of domperidone.
Results
Among 48 mother–infant dyads, cumulative MOM (median [IQR]) increased from 1,105 mL (281-2,680) at baseline to 2,847 mL (1,912-3,170) in the sustenance phase. This increase reflects between-phase cohort comparisons and does not represent within-mother longitudinal improvement. Across phases, median daily MOM approached the infant feeding volume by day 3 and exceeded it from day 7 onwards. Exclusive breastfeeding at discharge improved from 50% (5/10) at baseline to 87.5% (7/8) in the sustenance phase, though not statistically significant (P = .24).
Conclusion
Using the POCQI framework with sequential PDSA cycles, higher MOM volumes were observed across successive phases in our predominantly outborn VLBW population; interpretation of sustainability is limited by the small sustenance cohort (n = 8).
McClellanHL, MillerSJ, HartmannPE.Evolution of lactation: nutrition v. protection with special reference to five mammalian species. Nutr Res Rev. 2008;21(2):97–116. doi:10.1017/S0954422408100749
2.
BallardO, MorrowAL.Human milk composition: nutrients and bioactive factors. Pediatr Clin North Am. 2013;60(1):49–74. doi:10.1016/j.pcl.2012.10.002
3.
SiskP, QuandtS, ParsonN, TuckerJ.Breast milk expression and maintenance in mothers of very low birth weight infants: supports and barriers. J Hum Lact. 2010;26(4):368–375. doi:10.1177/0890334410371211
4.
ParkerLA, SullivanS, KruegerC, KelechiT, MuellerM.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(3):205–209. doi:10.1038/jp.2011.78
5.
KulkarniD, NaikV, BashirT, . Enablers and barriers for enteral feeding with mother’s own milk in preterm very low birth weight infants in a tertiary care neonatal intensive care unit. Turk J Pediatr. 2021;63(4):564–574. doi:10.24953/turkjped.2021.04.003
6.
Fernández MedinaIM, Fernández-SolaC, López-RodríguezMM, Hernández-PadillaJM, Jiménez LasserrotteMDM, Granero-MolinaJ.Barriers to providing mother’s own milk to extremely preterm infants in the NICU. Adv Neonatal Care. 2019;19(5):349–360. doi:10.1097/ANC.0000000000000652
7.
FugateK, HernandezI, AshmeadeT, MiladinovicB, SpatzDL.Improving human milk and breastfeeding practices in the NICU. J Obstet Gynecol Neonatal Nurs. 2015;44(3):426–438. doi:10.1111/1552-6909.12563
8.
GrzeskowiakLE, WlodekME, GeddesDT.What evidence do we have for pharmaceutical galactagogues in the treatment of lactation insufficiency?—A narrative review. Nutrients. 2019;11(5):974. doi:10.3390/nu11050974
9.
MeierPP, PatelAL, HobanR, EngstromJL.Which breast pump for which mother: an evidenced-based approach to individualizing breast pump technology. J Perinatol. 2016;36(7):493–499. doi:10.1038/jp.2016.14
10.
MondkarJ, ChawlaD, SachdevaRC, . Impact of mother-baby friendly initiative plus approach on improving human milk feeding for neonates in hospital: a quality improvement before-and-after uncontrolled study. Eur J Pediatr. 2022;181(1):107–116. doi:10.1007/s00431-021-04141-9
11.
KulkarniDV, MurkiS, PawaleD, . Quality improvement initiative to improve mother’s own milk usage till hospital discharge in very low birth weight infants from a tertiary care NICU. J Perinatol. 2020;40(8):1273–1281. doi:10.1038/s41372-020-0707-0
12.
BaggaN, KurianS, MohamedA, ReddyP, ChirlaDK.A quality initiative to improve mother’s own milk feeding in preterm neonates. Breastfeed Med. 2020;15(10):616–621. doi:10.1089/bfm.2020.0033
13.
ParkerMG, StellwagenLM, NobleL, . Promoting human milk and breastfeeding for the very low birth weight infant. Pediatrics. 2021;148(5):e2021054272. doi:10.1542/peds.2021-054272
14.
FangL, WuL, HanS, ChenX, YuZ.Quality improvement to increase breastfeeding in preterm infants: systematic review and meta-analysis. Front Pediatr. 2021;9:681341. doi:10.3389/fped.2021.681341
15.
JohnsonTJ, PatelAL, SchoenyME, . Cost savings of mother’s own milk for very low birth weight infants in the neonatal intensive care unit. PharmacoEcon Open. 2022;6(3):451–460. doi:10.1007/s41669-022-00324-8
16.
OgrincG, DaviesL, GoodmanD, BataldenP, DavidoffF, StevensD.SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. BMJ Qual Saf. 2016;25:986–992. doi:10.1136/bmjqs-2015-004411
17.
MurphyL, WarnerDD, ParksJ, WhittJ, Peter-WohlS.A quality improvement project to improve the rate of early breast milk expression in mothers of preterm infants. J Hum Lact. 2014;30(4):398–401. doi:10.1177/0890334414544124
18.
BixbyC, Baker-FoxC, DemingC, . A multidisciplinary quality improvement approach increases breastmilk availability at discharge from the neonatal intensive care unit for the very-low-birth-weight infant. Breastfeed Med. 2016;11(2):75–79. doi:10.1089/bfm.2015.0141
KalluriNS, BurnhamLA, LoperaAM, . A quality improvement project to increase mother’s milk use in an inner-city NICU. Pediatr Qual Saf. 2019;4(5):e204. doi:10.1097/pq9.0000000000000204
21.
SachanR, ThomasS, VargheseB, SinghA.Encouraging the use of mother’s own milk as first feed for preterm and very low birth weight neonate admitted to the neonatal intensive care unit: a quality improvement initiative. J Clin Neonatol. 2019;8(2):110–115. doi:10.4103/jcn.JCN_29_19
22.
KaurS, KaurG, RawatHCL, . Quality improvement initiative: improving proportion of preterm infants on mothers only milk at the time of discharge. Int J Contemp Pediatr. 2019;6:2334. doi:10.18203/2349-3291.ijcp20194613
23.
ParkerMG, PatelAL.Using quality improvement to increase human milk use for preterm infants. Semin Perinatol. 2017;41(3):175–186. doi:10.1053/j.semperi.2017.03.007
24.
MallikarjunaA, NesargiSV, RaoSPN.Breast milk quality improvement bundle for very low birth weight neonates. Neonatal Netw. 2019;38(1):34–38. doi:10.1891/0730-0832.38.1.34
25.
MinjGM, NarayanaswamyV, NageshK.Quality initiative program to improve the percentage of very preterm neonates receiving expressed breast milk within 24 hours of birth in a tertiary care (level III-B) NICU. J Neonatol. 2024;38(1):29–35. https://www.researchgate.net/publication/377993495
26.
SewellCA, ChangCY, ChehabMM, NguyenCP.Domperidone for lactation: what health care providers need to know. Obstet Gynecol. 2017;129(6):1054–1058. doi:10.1097/AOG.0000000000002033
27.
AsztalosEV, Campbell-YeoM, daSilvaOP, KissA, KnoppertDC, ItoS.Enhancing breast milk production with Domperidone in mothers of preterm neonates (EMPOWER trial). BMC Pregnancy Childbirth. 2012;12:87. doi:10.1186/1471-2393-12-87
28.
AsztalosEV, KissA, da SilvaOP, . Pregnancy gestation at delivery and breast milk production: a secondary analysis from the EMPOWER trial. Matern Health Neonatol Perinatol. 2018;4:21. doi:10.1186/s40748-018-0089-x
29.
BrodribbW.ABM Clinical Protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeed Med. 2018;13(5):307–314.
30.
McBrideGM, StevensonR, ZizzoG, . Women’s experiences with using domperidone as a galactagogue to increase breast milk supply: an Australian cross-sectional survey. Int Breastfeed J. 2023;18(1):11. doi:10.1186/s13006-023-0541-9
31.
NairS, ShroffA, RaggalaY, DeshabotlaSK, VaradhelliV, OletiTP.Breast milk output and factors influencing sustained feeding with mother’s own milk in very preterm births: a prospective observational study. J Neonatol. 2025;39(1):58–63. doi:10.1177/09732179241254248
32.
HobanR, Medina PoelinizC, SomersetE, . Mother’s own milk biomarkers predict coming to volume in pump-dependent mothers of preterm infants. J Pediatr. 2021;228:44–52.e3. doi:10.1016/j.jpeds.2020.09.010
33.
WardL, AuerC, SmithC, . The human milk project: a quality improvement initiative to increase human milk consumption in very low birth weight infants. Breastfeed Med2012;7:234–240. doi:10.1089/bfm.2012.0002
34.
Cuevas-AsturiasS, MarionR, BatesS, . G200(P) early breast milk to optimise outcomes for preterm infants, a quality improvement project. BMJ. 2019;104:A81. doi:10.1136/archdischild-2019-rcpch.195
35.
LeemanKT, BarbasK, StraussJ, . Improving access to lactation consultation and early breast milk use in an outborn NICU. Pediatr Qual Saf. 2019;4(1):e130. doi:10.1097/pq9.0000000000000130
