Preterm Nutrition Consensus, Lactation Recommendations Brief Synopsis  
Date of Initial Publication: May 2022   
Revision Date:   
Contact Author: Sarvin Ghavam   
Contributing Authors: Donna More; MSN, IBCLC; Pam Britland BSN, RNC-NIC, IBCLC; Lori Carpenter BSN, RN, IBCLC

Abstract  

Lactation and breastmilk are an integral part of preterm nutrition. A team approach to encouraging mothers of preterm neonates to initiate and maintain breastmilk supply is key, along with appropriate IBCLC staffing ratios for NICUs. Identifying women at risk for failure in lactogenesis, appropriate initiation of pumping and addressing pumping problems are crucial in successful lactogenesis. Colostrum oral care has important immune-protective properties and should be initiated early. Milk production has a U-shaped curve early on, with initial volumes during early sessions and then dropping to extremely little supply prior to surging between day 2-5. By day 14, maternal milk production should be approximately 750-1000 mls/24 hour period. Promotion of non-nutritive breast feeding can lead to successful breastfeeding when neonates show clinical stability and are able to transfer milk. Infant driven feeding is a method to achieve successful feeding by using physiological signs from the neonate and has been shown to decrease length of hospital stay. Appropriate milk delivery by only using the exact amount of breastmilk needed decreases waste, while using appropriate syringe orientation can ensure delivery of nutrients. 

Consensus Goals  

• Provide guidelines for appropriate lactation support in the NICU
• Provide guidelines for pumping, colostrum, and breastmilk use

Background  

Lactation is an important part of neonatal ICU care. Maternal breastmilk, with its immuneprotective components, is known to be protective for neonates, especially in the prevention of NEC. Establishing, supporting and troubleshooting breastfeeding in the NICU is ultimately a team approach but relies heavily on an appropriately staffed IBCLC team within the NICU. Guidelines to promote pumping, utilize appropriate breastmilk feeding techniques and provide support of both non-nutritive and nutritive breastfeeding are essential for success in the NICU & beyond. 

Previous Consensus Statement or Data from Division of Neonatology (if applicable)  

None

Consensus Statement and Clinical Recommendations  

• Pump early, pump often – start within 1 hour of delivery. Continue 8 times a day. Ensure mom is meeting target volumes of 750-1000ml/24hrs by day 14
• Colostrum oral care within 6 hours
• Dedicated team to support moms get a strong start.
• Early skin to skin holding.
• Non-nutritive suck (NNS) as soon as cues present & infant is medically stable even on CPAP, high flow, & NC
• Dedicated period of time for breastfeeding only before introduction of bottles
• IDF protocol to promote safe and positive oral feedings especially for the fragile feeder
• Bar code scanning and have a dedicated space for milk preparation
• FIFO (First in First out): fresh colostrum, frozen colostrum, fresh milk, frozen milk
• Use of eccentric syringes and silicone feeding tubes. No extension sets. Follow feeding with priming volume of air.
• Condense feeds whenever possible
• Separate foremilk from hindmilk for higher caloric feeds for weight gain.
• Consider other human milk-based products for growth.
• If ample colostrum, consider saving a bottle for future use in the event of NPO status to restart feeds. 

Further Goals  

• Continue the inter-hospital collaboration between Lactation Specialists
• Consider further guideline development to improve breastfeeding rates across the CHOP Network 

QI Metrics  

• Evaluate use of maternal breastmilk across Network sites
• Evaluate use of maternal breastmilk and NEC rates across Network sites 

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The Neonatology Consensus Statements (“Statements”) are based on a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These Statements are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.  

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