Pumping Up the Volume in the NICU

The message is very clear now: Human babies drink human milk! In every talk I give, and every NICU I visit, I see a greater commitment to using mother’s own milk over infant formula. The rising use of human milk in the NICU is the major driver for the commercial and non-profit enterprises in donor human milk banking, one of the most exciting developments in infant nutrition this past decade. In 2008 we started the SPIN (Supporting Premature Infant Nutrition) program (http://spinprogram.ucsd.edu) to develop a Center of Excellence in human milk nutrition for the vulnerable preterm infant. Now seven years running, I can look back and see some clear areas where we were able to be successful. Here are a few lessons learned…

1. Build a strong nutrition-lactation team

As neonatology caregivers, we are used to playing in a team sport. So it was quite natural for us to create and manage a team of specialists and stakeholders who had a vested interest as well a bit of fire for change (aka early adopters) to tackle the human milk problem in the NICU. Our SPIN team was built with many different professionals including physicians, nurses, dietitians, lactation consultants, social workers, etc. but most importantly we merged both nutrition and lactation stakeholders together.

2. Get institutional endorsement

One of the first things we did was approach our administration regarding the need for a human milk nutrition program and that we required some additional resources such as a full time lactation coordinator (LC) and dietary technician. Although we have had challenges in the past regarding sustained LC and dietary support, having the FTEs to start off made a huge difference to our program. By the way, our nurses LOVED the diet technician because it took away the tedious and precarious task of mixing milk in the NICU. This positive windfall may have helped nursing buy-in when our program was getting off the ground. The amount of lactation support varies tremendously among institutions across the country. Some places have none, some rely on nursing to provide this information, some share their LC with newborn nursery, while some have only emergency LC support. We were fortunate to institutionalize LC support early on.

3. Be a Baby Friendly Hospital

We got a lot of mileage in developing SPIN from being one of the first academic Baby Friendly Hospitals in the West Coast. This took a solid five years of blood, sweat and tears by my colleague and newborn director, Dr. Lisa Stellwagen, and her newborn team to establish, but it set the stage for the SPIN program to start. Many of the staff had already been taught on the merits of human milk and breastfeeding including those in the NICU and Labor and Delivery areas. Moving this message to the NICU babies was that much easier.

4. Have high team visibility

Besides giving a name to a team, having regular rounds in the NICU, called SPIN rounds, on a weekly basis at first made a great impression with unit staff. A team of people would hover over each VLBW infant and parent(s) if present to discuss nutrition, lactation and feeding. This raised the importance of all aspects of human milk nutrition so that those around the bedside could hear the team processing the information and optimizing practice. I can’t stress enough how the presence of the parent during SPIN rounds empowered the mother in her role of milk production.

5. Pick your physician champion(s)

The medical team has a hierarchy that involves both decision making and leadership to flow with the neonatologist as the “quarterback” of this special team. It has been clear to me that systems that have not identified a committed human milk physician champion will simply not get very far. On rounds each day there needs to be a voice (or voices) coming from the physician team that asks about mother’s own milk, that speaks openly to parents about the importance of human milk and that advocates for more milk to be available for each preterm infant.

6. Leverage the role of the nurses

This is the single most important difference I see in our NICU that separates us from other units that have not been as successful in adopting human milk practices. One LC and one or two physician champions are simply not enough to reach out to all the mothers of our babies. Enlisting the full nursing team through educational teaching at the start with mandated blocked-out time was a great jump start. A number of our nurses joined our SPIN team, others picked up lactation educator training and some full IBCLC qualifications in this time period. It was powerful to see nurses encouraging mothers to pump, assist with lactation, and give out positive messaging of the importance of human milk every day.

7. Measure your milk to make more milk

The words of Lord Kelvin ring true: “If you cannot measure it, you cannot improve it.” We realized early that we could not figure out our lactation problems without knowing how much was actually being made. We record as much as possible a daily mother’s milk volume (MMV) and this enables the team to recognize early lactation issues and deal with them. This is now embedding in our EMR. Mothers can track their volumes in their logbooks and feel a sense of accomplishment, especially in the first weeks of lactation when MMV can rise rapidly.

8. Conduct human milk research

When we started our SPIN program, we conducted human milk research with several studies: the first human milk derived human milk fortifier and analyzing human milk macronutrient content with near infrared spectrophotometry. These very public studies brought home a great message… that human milk is so important that research is being done on it. Additionally, the donor milk study resulted in rapid unit acceptance of its use – previously somewhat scorned by many staff. This went far too with parental approval and we seldom had issues with consenting for these studies often exceeding 90% acceptance.

9. Provide the right equipment

The provision of adequate high quality electric pump supply is crucial to getting the most milk production from the mothers of preterm infants. We set a standard that no mother of a VLBW infant would be sent home without an electric pump. Negotiating when and where pumps can be found, the space where mothers can use them, and the workflow for parents and staff was critical. The fewer obstructions there were, the more likely mothers would spend time pumping. Looking to the future, there was an interesting movement started this past year called “Make the Breast Pump Not Suck” Hackathon started at M.I.T. that pushed innovative young minds to find even better solutions for optimizing breast pumping. (http://breastpump.media.mit.edu/)

10.  Donor milk

We started our SPIN program initially without the use of donor milk. We were developing policies and guidelines and were steadily building buy-in from our core faculty. Then we had one small preterm infant whose mother was crossing the border from Mexico and was not able to provide enough milk for her baby. The infant only consumed preterm formula and developed NEC throughout most of the bowel (aka NEC totalis) and died. I can tell you that tragedy made it a whole lot easier to change to using donor milk. We have not seen NEC totalis since then. Some people ask if the use of donor milk helped in promoting human milk. Interestingly, some mothers take a step back when they are told that we would prefer to offer their child donor milk instead of formula and get fired up to pump milk for their baby.  It is undeniable that a unit culture that puts human milk on the level of a drug and demands monitoring, tracking and collation of data, where active research goes on, sends a strong message.

The future is looking very promising in human milk nutrition, but if we really want to continue to make big changes and faster changes we need to engage the younger generation of healthcare providers. That means reaching out with more education in undergraduate schools, medical and nursing schools, in medical and pediatric residencies and fellowships to underline the important value of human milk and particularly as it benefits preterm babies.

I will end with a big plea to every new mother of a preterm baby out there to PLEASE pump up the volume so we can be deafened by the sound of milk being made!