Beverly Rossman

Supporting Breastfeeding in the Neonatal Intensive Care Unit : Rush Mother’s Milk Club as a Case Study of Evidence-Based Care

The translation of the evidence for the use of human milk (HM) in the neonatal intensive care unit (NICU) into best practices, toolkits, policies and procedures, talking points, and parent information packets is limited, and requires use of evidence-based quality indicators to benchmark the use of HM, consistent messaging by the entire NICU team about the importance of HM for infants in the NICU, establishing procedures that protect maternal milk supply, and incorporating lactation technologies that take the guesswork out of HM feedings and facilitate milk transfer during breastfeeding.

“They’ve Walked in My Shoes”: Mothers of Very Low Birth Weight Infants and Their Experiences With Breastfeeding Peer Counselors in the Neonatal Intensive Care Unit

The effectiveness of the breastfeeding peer counselor role is thought to be embedded in the relationship between new and experienced mothers. In this study, new mothers of very low birth weight infants emphasized that one of the most important aspects of their relationship with the breastfeeding peer counselors is the peer or shared experience of how difficult it can be to provide milk and breastfeed while coping with the emotional stress of having an infant in the neonatal intensive care unit. This study provides evidence for the promotion and facilitation of lactation for mothers of neonatal intensive care unit infants through the use of breastfeeding peer counselors who are peers by virtue of the shared experience of providing milk for an infant hospitalized in the neonatal intensive care unit.

I have faith in my milk: the meaning of milk for mothers of very low birth weight infants hospitalized in the neonatal intensive care unit.

Background: Mothers who deliver a premature infant often choose to provide milk because it is the “one thing that only the mother can do” to optimize her infant’s outcome, helps mothers feel a connection with their infants, and helps relieve the guilt associated with the preterm birth. Objective: The purpose of this study was to describe the meaning of milk for mothers who are providing milk for their very low birth weight (VLBW; < 1500 g) infants hospitalized in the neonatal intensive care unit (NICU). Methods: Using a qualitative descriptive design, in-depth semistructured interviews were conducted with 23 mothers of VLBW infants hospitalized in a level III NICU. Mothers were asked to share their perceptions about what providing milk meant to them. Results: Mothers had faith in the healing properties of their milk and equated providing milk with “giving life” to their infants, mitigating the effects of complications, keeping their infants healthy and stable, and helping themselves address the feelings of failure and guilt associated with the premature birth. Mothers’ faith in their milk to achieve these outcomes was a maternal motivator to continue pumping, even for mothers who had not intended to provide milk or who experienced the paradox of disliking pumping but wanting to provide their milk. Conclusion: The experiences of these mothers reflect the importance of acknowledging mothers’ faith in the healing properties of their milk as a motivating factor for sustaining lactation while coping with the stress and anxiety inherent during the infant’s NICU hospitalization.

Breastfeeding Peer Counselors as Direct Lactation Care Providers in the Neonatal Intensive Care Unit

In 2005, the Level III neonatal intensive care unit (NICU) at Rush University Medical Center initiated a demonstration project employing breastfeeding peer counselors, former parents of NICU infants, as direct lactation care providers who worked collaboratively with the NICU nurses. This article describes the conceptualization, implementation, and evaluation of this program and provides templates for other NICUs that wish to incorporate breastfeeding peer counselors with the goal of providing quality, evidence-based lactation care.

Depression, anxiety, and perinatal-specific posttraumatic distress in mothers of very low birth weight infants in the neonatal intensive care unit.

Objective: To compare the trajectories and determine the predictors of maternal distress defined as a continuous spectrum of symptomatology and elevated symptomatology, of depression, anxiety, and perinatal-specific posttraumatic stress (PPTS), in mothers of very low birth weight (VLBW) infants throughout the neonatal intensive care unit (NICU) hospitalization. Method: Sixty-nine mothers completed psychological questionnaires within the first month of their infants NICU hospitalization and again 2 weeks before NICU discharge. Multiple regression models determined maternal psychological, reproductive, sociodemographic, and infant medical predictors of maternal distress. Results: Perinatal-specific posttraumatic stress remained stable throughout the NICU hospitalization, whereas other aspects of distress declined. Previous psychological history and infant medical variables predicted higher PPTS but no other aspects of distress. Reproductive variables predicted anxiety and PPTS; history of fetal loss initially predicted lower PPTS but throughout hospitalization primipara status emerged as a predictor of higher anxiety and PPTS. Sociodemographic variables predicated initial, but not later, depressive distress. Conclusions: Psychological screening is important in the NICU. The PPTS profile suggests it may require distinct treatment. Primiparas should be targeted for intervention.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mothers HM.

Maternal psychological distress and visitation to the neonatal intensive care unit.

To examine associations between maternal neonatal intensive care unit (NICU) visitation rates, maternal psychological distress (‘distress’) and preterm infant outcome post‐NICU discharge in a contemporary cohort of very low birthweight (VLBW) infants.

“It’s Somebody Else’s Milk”: Unraveling the Tension in Mothers of Preterm Infants Who Provide Consent for Pasteurized Donor Human Milk

Background: Pasteurized donor human milk (DHM), rather than preterm infant formula, is recommended for premature infants when mother’s milk is not available. Objective: This study explored the maternal decision-making process in providing consent for DHM feedings. Methods: In-depth semistructured interviews were conducted with 20 mothers of premature (mean gestational age = 27 weeks, birth weight = 942 grams) infants hospitalized in the neonatal intensive care unit (NICU) in this qualitative, descriptive study. Conventional content analysis was used to analyze the data. Results: Although only 1 mother had any previous knowledge of DHM, all mothers provided consent for DHM because they “wanted what is best for my baby.” Mothers trusted that DHM was better than formula when their infant’s feeding requirements exceeded their own milk supply. However, most mothers described a tension between wanting their infants to receive only “their” milk and DHM being “somebody else’s milk.” This desire to be the only provider of human milk was more common than concerns about the quality and safety of DHM. The mothers’ tension was mediated by trusting the NICU clinicians’ recommendations, having adequate time to make an informed decision, observing the positive outcomes of DHM, and feeling empowered that they made the best decision for their infant. Conclusion: The experiences of these mothers reflect the importance of approaching mothers for consent only when DHM is needed, respecting mothers’ beliefs and values about DHM, and providing help in mediating any tension with regard to their infants receiving “somebody else’s milk.”

Parental perception of child vulnerability among mothers of very low birth weight infants: psychological predictors and neurodevelopmental sequelae at 2 years

Objective:The objective of this study was to examine the impact of maternal psychological distress on the development of parental perception of child vulnerability (PPCV) in mothers of very low birth weight (VLBW) infants; and to examine the impact of PPCV on neurodevelopmental outcome in VLBW infants in the second year of life.Study Design:This is a prospective study of 69 mothers and their VLBW infants recruited from 2011 to 2012 for whom maternal psychological data were collected during the neonatal intensive care unit (NICU) hospitalization. Maternal PPCV was assessed at 4 months corrected age (CA). Neurodevelopmental outcome was assessed at 20 months CA. Regression analyses modeled the development of PPCV and the impact of PPCV on neurodevelopmental outcome.Results:PPCV at 4 months CA was predicted by maternal anxiety and history of previous fetal loss reported during the NICU stay. Higher PPCV at 4 months CA was associated with lower language scores at 20 months CA.Conclusion:Targeted interventions aimed at reducing PPCV in the NICU are supported.

A wake-up call: persistent barriers to the provision of evidence-based lactation support and education in the NICU

Mothers who give birth to infants cared for in the neonatal intensive care unit (NICU) experience barriers to the achievement of their personal breastfeeding goals that are not shared by mothers of term, healthy infants. Specifically, these mothers are breast pump dependent, must cope simultaneously with the stress of the NICU hospitalization and the infant’s uncertain condition, and are frequently sick themselves. Even with evidence-based, NICU-specific lactation care, these mothers do not maintain lactation at rates that are comparable to healthy populations [1–3]. The primary reason for lack of achievement of individual breastfeeding goals is inadequate mother’s own milk (MOM) volume to meet their infants’ nutritional needs [4]. The extent to which inadequate MOM volume over the NICU hospitalization is due to maternal risk factors such as obesity and cesarean delivery, the profound dislike of breast pump use, the inability to use the pump frequently enough to regulate lactation processes, the stress and/or discouragement with low pumped MOM volumes, or lack of evidence-based information and support from NICU care providers is unknown. In this issue, Demirci et al. [5] studied a subgroup of NICU mothers—those who give birth to infants with complex surgical anomalies—and have chosen a qualitative methodology to report these 15 mothers’ perceptions and experiences with respect to providing MOM during the first 2 months post birth. In this 55-bed, Level IV NICU, mothers participated in one to three in-depth interviews during their infants’ NICU hospitalization and transition to home. Although the NICU had recently instituted a quality improvement initiative targeting improvement in MOM provision rates, the study reported that the mothers had a fundamental lack of understanding about the importance of MOM for their surgical infants. Most maternal perceptions and experiences were consequent to this lack of effective messaging. Among the mothers’ general desire for more help and information with all aspects of providing MOM, the primary specific concerns focused on why exclusive MOM feedings were necessary, MOM volume, assistance with the basics of direct breastfeeding, and emotional support and encouragement for coping with the lifestyle challenges inherent in breast pump dependency. The Demirici et al. [5] findings also highlight the difficulties in translating published research, such as the “Transition to Breast Pathway” [6], into practice. Few of the mothers in the Demirci et al. [5] study engaged in skin-toskin care, oropharyngeal colostrum administration, and nonnutritive sucking, strategies known to increase the probability that mothers of surgical infants meet their personal breastfeeding goals and directly breastfeed their infants prior to discharge [6]. Furthermore, the early post-birth period, which coincides with the early phases of lactation of initiation and coming to volume, is fraught with difficulties for all mothers, but is especially problematic for mothers of NICU infants because they often receive inappropriate advice and equipment (e.g., non-hospital-grade electric breast pumps), compromising long-term MOM volume and exclusive breastfeeding [7, 8]. In the absence of proactive evidence-based lactation care by NICU staff, it is likely that mothers’ dislike of and frustration with the lifestyle inconveniences with pumping play a role in decreased milk volumes and decisions to discontinue providing MOM. The Demirici et al. [5] results should serve as a wake-up call for all healthcare providers who work with mothers of surgical infants cared for in the NICU. Basic strategies to * Beverly Rossman brossman@comcast.net Beverly_Rossman@rush.edu