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Breastfeeding: Promotion of a Low-tech

Anne Merewood, MPH,

Author Disclosure
Ms Merewood did not
disclose any financial
relationships relevant

Learning Objectives

After completing this article, readers should be able to:

1. Describe the preterm infants who were more likely to receive human milk in a recent
study in Massachusetts.
2. Describe the process of the Baby-Friendly Hospital Initiative and how it can affect
human milk feeding of infants in the neonatal intensive care unit.
3. Describe the role of personalized peer support in encouraging human milk feeding of

to this article.

Preterm infants are at higher risk from nonhuman milk feedings than term infants, but
according to a recent study, are less likely to receive human milk. Provision of human
milk to infants in the neonatal intensive care unit can be affected by numerous
maternal factors, but also by the culture of the unit. Encouragement and support from
clinicians, education about the benefits of human milk, training and provision of
electric breast pumps, and personal peer support have been shown to be effective
methods of increasing breastfeeding rates.

Human milk is the optimal form of infant nutrition, (1) and the impact of human milk
feeding is more significant among preterm infants than among term infants. In preterm
infants, the evidence demonstrates that, compared with breastfeeding, formula feeding is
associated with an increased risk of necrotizing enterocolitis (2) and sepsis, (3) delayed
brainstem maturation, (4) decreased scores on cognitive and developmental tests,
(5)(6)(7)(8) and delayed visual development. (9)(10) Consequently, interventions to
increase human milk consumption in the neonatal intensive care unit (NICU) are critical.
Compared with other frequently high-tech NICU treatments, interventions to improve
breastfeeding rates are relatively simple and low cost. (11)(12)(13)(14)(15)(16)

Whom Should NICU Breastfeeding Interventions Target?

National surveys that report annual breastfeeding rates do not include gestational agebased categories. (17)(18) African-American infants are almost twice as likely to be born
prematurely as Caucasian infants, (19) but no national data are available on rates of
breastfeeding initiation, duration, or exclusivity among preterm infants.
According to a recent study in Pediatrics, (20) based on birth certificate data on 67,884
infants born in Massachusetts in 2002, the data on breastfeeding are unpredictable.
Preterm infants were less likely than term infants to receive human milk, with the smallest
preterm infants receiving the least human milk. Overall, 8.2% of newborns in the analysis
had gestational ages of less than 37 weeks. Breastfeeding initiation rates were 76.8% among
infants born at 37 to 42 weeks gestation, 70.1% among infants born at 32 to 36 weeks
gestation, and 62.9% among infants born at 24 to 31 weeks gestation. Controlling for
mothers age, race, birthplace, and insurance, mothers of infants born between 32 and
*Assistant Professor of Pediatrics, Boston University School of Medicine; Director, The Breastfeeding Center, Boston Medical
Center, Boston, Mass.

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36 weeks gestation were less likely to provide human

milk compared with mothers of term infants, (adjusted
odds ratio [AOR] of 0.73; 95% confidence interval [CI]
of 0.68 to 0.79), and mothers of infants born between
24 and 31 weeks gestation were even less likely to
provide human milk compared with mothers of term
infants (AOR of 0.53; 95% CI 0.44 to 0.64). (20)
One unexpected finding was that United States-born
Caucasians were least likely to breastfeed either term or
preterm infants compared with any other racial or ethnic
group, including United States-born African-Americans.
The highest rates of breastfeeding initiation among preterm infants were among non-United States-born Hispanics, who had almost eight times the odds of breastfeeding a preterm infant compared with United Statesborn Caucasians (AOR, 7.61; 95% CI, 4.88 to 11.90).
A more predictable finding, in line with other published
breastfeeding data, was that among both preterm and
term infants, breastfeeding initiation increased significantly with increasing maternal age and private insurance
Such demographic findings are useful when targeting
interventions to increase breastfeeding among NICU
populations, but may vary from state to state and from
hospital to hospital. Within the individual NICU, it can
be helpful to document which local population groups
consistently do, or do not, breastfeed.
Low breastfeeding rates among preterm infants, with
the most vulnerable infants of lower gestational ages
breastfeeding the least, are of particular concern given
the importance of human milk for these infants.
(2)(4)(5)(6)(7)(8)(9)(10) However, such rates are not
unexpected. Breastfeeding a preterm infant is more complex than breastfeeding a term baby, requiring additional
education, support, and equipment such as a breast
pump. Women who have the least access to such resources presumably are the least likely to breastfeed, a
finding that was reflected in the previously mentioned
study, which showed lower breastfeeding initiation rates
among women who had public insurance. (20) It is
interesting to note, however, that where cultural traditions reinforce breastfeeding, as probably is the case for
non-United States-born Hispanics and for other nonUnited States-born groups in the same study, women
apparently overcome the odds to provide human milk for
their preterm infants. Indeed, in every ethnic/racial category examined, non-United States-born women were
more likely to breastfeed their preterm infants than
United States-born mothers. (20)(21)


Basics of Interventions
Both attitudes of NICU clinicians and day-to-day NICU
routines are absolutely critical contributors to the success
of breastfeeding for mothers of preterm infants. Many
who work in the NICU probably have participated in
exchanges between professionals regarding whether a
mother can bear the extra burden of providing human
milk, (22) or whether a mother should be allowed to
pump for a nonviable infant. In other cases, an infant may
receive formula simply because no one realized human
milk was in the freezer, a clinician may undermine the
value of human milk by trialing formula for a sick baby,
or a preterm infant may be bottle-fed just moments
before his or her mother arrives in the NICU to breastfeed. Mothers, working hard to pump their milk, take
such messages to heart.
In contrast, encouragement and support from clinicians in the NICU can increase the rate of breastfeeding
initiation among mothers of preterm infants. A landmark
article on lactation counseling and maternal stress in the
NICU demonstrated how effectively encouragement
and education can increase breastfeeding initiation and
put the maternal anxiety myth to rest. (22) After
NICU-specific breastfeeding counseling, 85% of 81
women who initially planned to formula-feed initiated
breastfeeding in their preterm infants, and 100% of
women who intended to breastfeed were able to do so,
raising the overall rate of breastfeeding initiation in the
NICU to 94%. Moreover, in psychological testing, neither the women who had originally planned to breastfeed
nor the women who had planned not to showed additional stress after the counseling or during the human
milk feeding. In fact, anxiety levels among both groups
of women fell in the first 6 weeks. (22) Such results were
not surprising to many clinicians, who hypothesized that
the mothers who were expressing milk for their infants
were doing something for their infants; in comparison,
doing nothing actually may be more stressful.

The Baby-Friendly Hospital Initiative (BFHI)

BFHI is a World Health Organization/UNICEF program that awards Baby-Friendly status to hospitals meeting standards of breastfeeding promotion and support
outlined in the Ten Steps to Successful Breastfeeding. (23)
The goal of this initiative is to make hospital-wide
changes that institutionalize breastfeeding support and
promotion. Although not specifically aimed at the NICU
population, the sweeping impact of BFHI and the BabyFriendly designation may increase breastfeeding initiation rates in the NICU.
Boston Medical Center became a Baby-Friendly
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hospital in 1999. Breastfeeding initiation rates at this

inner city hospital among term infants rose from 58% in
1995 to 86.5% in 1999, and exclusive breastfeeding rates
increased from 5.5% to 33.5% over the same period. (24)
Between 1995 and 1999, breastfeeding initiation rates
also rose in the NICU, from 34.6% to 74.4% (P0.001).
(25) Rates among United States-born African-American
NICU infants rose from 35% to 64% (P0.03) and
among non-United States-born African-American infants rose from 27% to 81% (P0.001). Among 2-weekold hospitalized preterm infants in the NICU, the proportion receiving any human milk rose from 27.9%
(1995) to 65.9% (1999) (P0.001), and the proportion
receiving human milk exclusively at 2 weeks of age rose
from 9.3% to 39% (P0.002). (25)
Of particular interest is the increase in human milk
feeding rates among non-United States-born AfricanAmericans. As later research demonstrated, non-United
States-born women in all ethnic and racial categories in
Massachusetts in 2002 were more likely than their
United States-born peers to breastfeed. (20) However,
to expect such mothers to change their approach without
any assistance is unrealistic. In practical terms, the impact
of the Baby-Friendly designation on our NICU was
systemic, in that all doctors and nurses were better educated about breastfeeding, hospital routines were in place
to support breastfeeding, and mothers were counseled
actively to breastfeed. Because of the clinician training
required for Baby-Friendly certification, nursing staff on
both the postpartum and NICU units were adept at
electric breast pump setup, which could be managed by
the postpartum nurse while the NICU nurse dealt with
potentially life-threatening crises in the admission of the
neonate to the NICU. Clinicians were better equipped
to discuss the importance of breastfeeding for all NICU
infants, and the atmosphere on the postpartum unit
where the mothers stay supported breastfeeding, with no
free formula distribution, breastfeeding-friendly artwork, and effective lactation support. This system-wide
breastfeeding upgrade appeared to be particularly important for non-United States-born women, who might
have been afraid or unable to ask for support due to legal
or linguistic status.
A simultaneously established program in the NICU
was Pumps for Peanuts, funded by a hospital-based
charity, that provides a free electric breast pump to all
mothers of NICU infants, regardless of their insurance
status or ability to pay. (26) An informal survey had
indicated that 40% of all women who had NICU infants
in our urban setting were either uninsured or had insurance that did not pay for a breast pump. The cost of an
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effective electric pump, which starts at about $200, created a problem among poor women. We believe that
providing electric pumps for these women had a significant impact on breastfeeding duration; few, if any,
women were hand expressing in the absence of a pump,
and to make adequate milk, women must express milk
regularly. The offered pump was chosen because of the
hospitals pump contract with the manufacturer and
because of the cost and difficulty of retrieving rental
pumps from an often transient population. (26)

Personalized Peer Support

Another effective intervention was the provision of personal peer support beyond the practical and system-wide
support of equipment or the BFHI. Well-designed peer
counseling programs have been demonstrated to increase breastfeeding initiation and duration for term
infants, especially among low-income women. (27)(28)
(29)(30) In a randomized, controlled trial, we sought to
determine whether peer counselors affected breastfeeding duration for preterm infants in a level III, 15-bed,
urban NICU. Between 2001 and 2004, we enrolled 108
mother-infant pairs born at the institution and admitted
to the NICU, limiting participants to otherwise healthy
preterm infants (26 to 37 weeks gestation). Study participants were randomized either to receive a peer counselor or to standard of care in a Baby-Friendly hospital.
The primary outcome measure was any human milk
feeding at 12 weeks postpartum. (31) Peer counselors
met with the mother in the hospital before her discharge,
educated her on NICU basics, helped her to pump,
accompanied her to the NICU, and, when possible or
appropriate, helped her to breastfeed. Meetings continued in person as long as the infant remained in the NICU
and by telephone after the infants discharge, up to
6 weeks after the birth. Peer counselors were trained at a
5-day breastfeeding course and on the unit.
At 12 weeks postpartum, women who had peer counselors had almost three times the odds of providing any
amount of human milk compared with women who did
not have peer counselors (odds ratio [OR], 2.81; 95%
CI, 1.11 to 7.14; P0.01). In further analysis, the number needed to treat at 12 weeks for any human milk
was four. In a subgroup analysis, at 12 weeks, AfricanAmerican mothers who had peer counselors had odds of
providing any human milk 249% greater than those for
African-American mothers who did not have peer counselors (OR, 3.59; 95% CI, 1.16 to 11.03; P0.03).
Additionally, women who had peer counselors were significantly more likely to be breastfeeding at 2, 4, and
8 weeks postpartum. However, women who received



Supporting Human Milk Feeding in the Neonatal Intensive Care

Unit (NICU)



Actively encourage and support breastfeeding

Explain how human milk prevents infection and
matters most for high-risk infants
Ensure access to a double electric breast pump in the
NICU and at home
Recognize that providing milk is the one thing a
mother can do to help in a frightening situation
Start milk expression in first 24 h after birth
Teach hand expression

Unintentionally sideline the importance of human milk

Assume the mother has made an informed feeding
choice prior to the birth
Assume insurance will cover a breast pump

Encourage milk expression 8 to 10 times per day

Check the freezer for milk
Educate new staff to support breastfeeding
Aim for the first oral feedings to be at the breast
Ensure the entire system supports breastfeeding
Remember that parents will remember every detail of
their experience forever

peer counseling were not more likely to breastfeed exclusively compared with those who did not receive counseling. This finding differs from the results of a recent
meta-analysis, in which lay support, including support
from peer counselors, was found to prolong exclusive
breastfeeding among term infants. (32)

Interventions to promote breastfeeding in the NICU are
relatively simple and inexpensive (Table), and evidence
demonstrates that they work. Proactive breastfeeding
counseling, support for breastfeeding from all members
of the health-care team, system-wide support such as the
Baby Friendly hospital designation, and personal assistance that includes peer counselors, are effective methods
of increasing breastfeeding rates.
The experience of one woman in the NICU is particularly illustrative. This Caucasian mother in her early 20s
had decided not to breastfeed, but then requested help in
obtaining a pump because she had changed her mind.
When asked what led to this reversal of her prenatal
decision, she said, When the baby was born early, the
doctor told me human milk was best for her. The nurse
helped me to breastfeed, and the insurance company paid
for a pump.

1. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding and
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Worry that mothers will feel guilty

Expect the mother knows how to operate a pump
Expect the mother to extract more than a few drops
of milk in the first day
Underestimate the effort needed to pump often
Feed formula if the mother is expected or available
Trial formula if the baby gets sick
Trial a bottle before the breast
Assume mothers know what to ask for
Patronize or offer advice that is not based on sound
medical evidence

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NeoReviews Quiz
7. When designing interventions to improve breastfeeding rates, it is useful to know which demographic
groups of women are more or less likely to breastfeed. Of the following, the most accurate statement
regarding breastfeeding rates based on maternal and neonatal demographics is that:
A. Breastfeeding rates decline significantly with increasing maternal age.
B. Breastfeeding rates are higher among women who have public insurance than those who have private
C. Hispanic women often have low breastfeeding rates.
D. Non-United States-born women often have higher breastfeeding rates than United States-born women.
E. Preterm neonates are more likely to receive human milk than term infants.
8. The Baby-Friendly Hospital Initiative may increase breastfeeding rates in the neonatal intensive care unit
(NICU) because it:
A. Does not permit formula to be used in the NICU.
B. Encourages regular skin-to-skin or kangaroo care in preterm infants.
C. Ensures staff in all hospital areas dealing with infant care are trained in breastfeeding management and
D. Is specifically aimed at the NICU population.
E. Provides funding for electric breast pumps.
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