Improving Health Outcomes for Vulnerable Infants

Irene Murphy Zoppi, RN, MSN, IBCLC / June 2019


Without question, human milk is the preferred nutrition for all infants. This is especially true for vulnerable, premature infants in the NICU, as human milk contains numerous components that are beneficial in preventing many morbidities associated with prematurity.1-7

All around the world, nurses, doctors, and healthcare providers want to assist breastfeeding families in meeting their goals. They want to provide breastfeeding support, but they struggle with how to do this. Healthcare providers seek workable, evidence-based solutions that can make a difference in providing breastfeeding support.

In 2004, Dr. Diane Spatz, Nurse Researcher and Director of the Lactation Program at Children’s Hospital of Philadelphia (CHOP), developed an alternative model of breastfeeding care and support to educate health professionals on the best practices for the use of human milk and breastfeeding in vulnerable infants. Entitled, “Ten Steps to Promote and Protect Human Milk and Breastfeeding in Vulnerable Infants,”8 the model provides clinicians with the framework and tools to change practice and achieve measurable results that are personalized, convenient, cost-effective, and innovative.

The 10-Step Model consists of:

1.      Informed decision

2.      Establishment and maintenance of milk supply

3.      Human milk management

4.      Oral care and feeding of human milk

5.      Skin-to-skin care

6.      Non-nutritive sucking

7.      Transition to breast

8.      Measuring milk transfer

9.      Preparation for discharge

10.  Appropriate follow-up

This model has been implemented for more than a decade at CHOP, and replicated in other neonatal intensive care units across the U.S., around the world, and was recently adopted at the model of care for all NICUs throughout the country of Thailand. Additionally, the 10-Step Model received the prestigious “Edge Runner” designation from the American Academy of Nursing based on achieved outcomes when the model was implemented.

The following paragraphs highlight Dr. Spatz’s 10-Step Model.

Step 1: Informed Decision

The 10 Steps follow an important sequence starting with informing families about the science of human milk, which is the foundation for the remaining steps.

All mothers who have given birth to premature infants need to be educated about the value of human milk for their infants. Families should be aware of the very scientific and very specific components of human milk that can help protect their infants. Mothers need to hear that their bodies are capable of producing human milk – milk perfectly suited to the needs of their sick babies. They need to know that their milk is not only a food to help their infants grow but can be considered a medicine which will help protect their babies throughout their NICU stay and beyond. This evidence-based information should provide specific examples about how their breast milk will be of benefit.

Mothers of NICU babies may not have planned to breastfeed. The decision to breastfeed may be considered later. The most important message that needs to be conveyed is that mothers’ milk is the best medicine, is needed by the NICU staff to treat their infants, and that they’re capable of producing it. The mother needs to know that she is an essential part of her baby’s care and that she is the only person who can produce this potent medicine. The discussion should center around pumping milk now and, if desired, thinking about breastfeeding later.

Dr. Spatz’s research demonstrates that when moms have this evidence, they make the decision to pump milk and provide it to their infants.

Step 2: Establishment and Maintenance of Milk Supply

The first few days after birth are critical in establishing the mother’s milk supply. All her caregivers need to prioritize milk expression as part of her care. Before initiating pumping, mothers need to understand the process of milk production and that they are likely to obtain very small amounts of colostrum in the first 1 to 3 days.

Mothers of NICU babies should be encouraged and supported to begin pumping as soon as possible with a hospital-grade, double electric breast pump. Just as mothers with healthy term babies are urged to begin breastfeeding within the first hour after delivery, moms with premature or ill infants need early breast and nipple stimulation to have optimal milk production. Use of the patented breast pump Initiation Technology™ inherent in Medela’s Symphony Plus® Breast Pump provides sucking patterns similar to early newborns. In several studies this pumping pattern has been demonstrated to help pump-dependent mothers produce milk more quickly and to produce higher daily volumes of milk later on.

Step 3: Oral Colostrum Care

The next step is to explain the rationale and significance for oral immune therapy with expressed colostrum to the birth mother. She should be coached on how to properly perform oral care in order to provide the infant his initial exposure to human milk, and encourage active involvement in the care of her hospitalized infant.

Step 4: Storage and Feeding Breast Milk

Human milk collection, storage, and feeding is the next step. When the infant first begins enteral feeds, the recommendation is to start with colostrum in the order the colostrum was expressed. This can be accomplished by using colored stationery dots and numbering the first four days of expressed milk collected for each mother. Using a color-coded numbering system makes identification of colostrum easier.

Step 5: Skin-to-Skin Care

Skin-to-skin care, sometimes known as Kangaroo Mother Care, is another practice described in the Model that enhances human milk delivery.  In addition to improving the bonding experience for parents and their babies, it reduces stress, improves oxygenation, and weight gain for infants. It also improves maternal milk volumes.

Steps 6 through 10: Non-nutritive Sucking, Transition to Breast, Measuring Milk Transfer, Preparation for Discharge, and Appropriate Follow-up.

The remaining five steps in the model explain how breastfeeding can be managed when mothers desire to direct breastfeed. The use of interventions such as nipple shields and test weights are further described, along with how to prepare for discharge from the NICU still receiving human milk.

Dr. Spatz’s proven 10-Step Model has received worldwide attention and implementation. It provides workable, evidence-based solutions for improving clinical practices that can make a difference in providing breastfeeding support. Such support ensures vulnerable infants receive human milk, especially mother’s own milk, that impacts both short- and long-term health outcomes.

Have you begun implementation of the 10-Step Model in your NICU? What successes have you witnessed since adopting the Model? Tell us in the comments below!



  1. American Academy of Pediatrics Committee on Nutrition. Pediatric Nutrition Handbook, 7th Edition. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
  2. American Academy of Pediatrics Committee on Nutrition. Chapter 5: Nutritional needs of the preterm infant. In Kleinman. In: Kleinman R, Greer F, eds. Pediatric Nutrition, 7th Ed. 7th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
  3. Agency for Healthcare Research and Quality. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, AHRQ Publication No. 07-E007. Rockville, MD: US Dept. Health and Human Services; April 2007.
  4. Patel AL, Johnson TJ, Engstrom JL, et al. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol 2013;33:514-9.
  5. Cacho NT, Parker LA, Neu J. Necrotizing Enterocolitis and Human Milk Feeding: A Systematic Review. Clin Perinatol 2017;44:49-67.
  6. Bharwani SK, Green BF, Pezzullo JC, Bharwani SS, Bharwani SS, Dhanireddy R. Systematic review and metaanalysis of human milk intake and retinopathy of prematurity: a significant update. J Perinatol 2016;36:913-20.
  7. Patel AL, Johnson TJ, Robin B, et al. Influence of own mother’s milk on bronchopulmonary dysplasia and costs. Arch Dis Child Fetal Neonatal Ed 2017;102:F256-F61.
  8. Spatz DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Peinat Neonatal Nurs. 2004; 18(4):385-96.


About the Author

Irene joined Medela in 1999 as a clinician for the Breastfeeding Division. She currently serves as a Clinical Education Specialist focusing on Advocacy Outreach. In this role, she acts as a vital resource for groups assisting breastfeeding mothers and infants. She has been frequently interviewed on radio and online regarding breastfeeding issues for mothers and clinicians.

Irene spent many years caring for new families in antenatal, labor and delivery, postpartum and NICU settings and was involved in direct patient care and family-based education. Irene has extensive experience teaching in a variety of nursing education programs.  She produced a video presentation on nursing students’ involvement in Community Health Nursing for the National League of Nursing.