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BREASTFEEDING PRACTICES IN THE NEONATAL INTENSIVE CARE UNIT
BEFORE AND AFTER AN INTERVENTION PLAN
ROBERTA GITTENS PINEDA
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
Roberta Gittens Pineda
This dissertation is dedicated to all the mothers who have premature and medically
fragile infants in the neonatal intensive care unit (NICU). It is hoped that this and other
works with infants and mothers in the NICU will give you the hope, courage, and
information needed to "mother" in the complex environment of the NICU, during your
infant's first precious days. This dissertation is also dedicated to my husband, Jose, for
his endless source of love and inspiration. It is also dedicated to my children, Alan and
Marissa, whose early birth made me realize the importance of education and support for
mothers, as well as to my daughter Abigail, whose premature birth in the middle of this
research gave me the extra steam to see it through. This dissertation is especially
dedicated to my mom, Barbara Gittens Valentine, whose expertise with mothers and
babies was critical during my own son's hospitalization.
This research would not have been possible without the support and guidance of
Dr. Lorie Richards, who has been my advisor, mentor, and friend. I want to thank Lorie
for having faith in me and inspiring me to do my best. I would like to thank the nurses
and health care professionals at Shands Hospital who participated in this research
endeavor. In particular, I give special thanks to Annmarie Brennan, who enabled this
research project to occur in the neonatal intensive care unit (NICU) at Shands and
supported the project every step of the way. I also would like to thank Cammy Pane, the
co-author of the Educational Module; Stephanie Meeks for your hours of work on "A
Mother's Gift", and other members of the Lactation Committee at Shands who helped
with my research: Elayne McNamara, Sandra Sullivan, Brenda Owens, Sheila Walker
and Jeannette Sexton. I want to give special thanks to Susan Frazier from Medela for
your support at the inservices. I also want to thank all those who provided donations as
incentives for participation: Sonny's Barbeque, Atlanta Bread Company, Scholotsky's
Deli, and TGIF. I want to thank Dr. David Burchfield, the medical director of the NICU
at Shands, for assisting with this project. I thank Sarah Boslaugh for guiding me through
the statistics and for all your patience from the many questions that came up along the
way. I would also like to thank my committee for sticking with me through the years,
and the move to St. Louis and the addition of the new baby. I appreciate your endless
patience, high expectations and sincere enthusiasm for my interests and work. I want to
thank Drs. Richards, Foss, Krueger, Seung, and Rosenbek!
I would finally like to thank my parents who always showed unconditional love and
always motivated me to strive to do better. I extend special thanks to my husband, Jose,
for always being there when I needed you most and giving me patience and love every
step of the way. You enabled me to go back to school and were there when it came to
crunch time. You have made this all possible and I am eternally grateful for your love
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ................................................................................................. iv
LIST OF TABLES ........ ..... ... .... .......... ........... .......... ..... viii
LIST OF FIGURES ......... ........................................... ............ ix
A B STR A C T ................................................. ..................................... .. x
1 IN TR OD U CTION ............................................... .. ......................... ..
The Importance of Breast Milk and Breastfeeding....................................................2
Health Benefits of Breastfeeding for the Full Term Infant ................................
Health Benefits of Breastfeeding for Premature Infants ....................................
Long Term Benefits of Breastfeeding .....................................................5
Developmental Benefits of Breastfeeding............... .......... .................5
Benefits of Breastfeeding for the M other............... ...................... .............6
Current Breastfeeding Recom m endations ........................ ......... .................... ... 7
Why More Women Are Not Giving Their Infants the Benefits of Breast Milk...........8
G general B reastfeeding B barriers ........................................ ......... ............... 9
Barriers to Breastfeeding Prem ature Infants .......................................................9
Health Care Professionals Can Hinder the Breastfeeding Process in the
Neonatal Intensive Care Unit........... ........... ... .................. .. 14
Treatments to Foster Improved Breastfeeding Rates.............................................16
Need for an Educational Package for Health Care Professionals and Mothers of
Infants in the Neonatal Intensive Care Unit................................. ..... ............. ...19
Synactive Theory and Breastfeeding Interventions in the Neonatal Intensive Care
U nit................................... ........... ....... ....... ............ 20
Theory Governing the Behavior of Health Care Professionals ............................. 25
Transtheoretical Model of Behavior Change and Methods of Education ..................31
Sum m ary and R research Questions ........................................ ........................ 33
2 M E T H O D O L O G Y ............................................................................ ................... 35
P a rtic ip a n ts ........................................................................................................... 3 5
R research Interventions................ .. .. .................. .......... ............ ........ 36
Intervention 1: Breast Pump Loaner Closet ....................................... .......... 36
Intervention 2: Health Professional Education Initiative .................................37
Intervention 3: Breastfeeding Guideline ........................ .....................38
Intervention 4: Educational Pamphlet for New Mothers of Neonatal
Intensive Care Unit Infants .......................... ........................ 38
Intervention Plan Modification..................................................... 39
Design .............. ........ .................................39
P ro c e d u re s ..................................................................................................... 4 0
Program Evaluation ....... ... .. ...... .... ... ........... .. .... .... .......41
D ata C o lle ctio n ..................................................................................................... 4 2
D ata A nalysis................................................... 42
H y p oth eses ..............................................................4 3
Adjusting the Alpha Level ............. ... ......... ............. 44
3 R E S U L T S .............................................................................4 6
Intervention Im plem entation .............................................. ............... 46
The Sample ......................... .............................48
Inter-Rater Agreement ............. ......... .......... ........ 50
Demographics ...... .................. ........................ 50
Investigation for Selection Differences ..................................................... 52
Results Per Research Question................... ......................52
4 D IS C U S S IO N ......... ....................................................... .......................................59
The Effect of the Interventions on Breastfeeding Practices in the Neonatal
Inten siv e C are U nit ..................................................................... .....................59
Lim stations ................. ............. ... ......... ..................... .................64
Recommendations for Further Research ............................................... ......69
C conclusions ....................................... ........ .... .. ........ .......... 71
A OUTLINE OF THE EDUCATION MODULE.......................................................73
B OUTLINE OF ITEMS ADDED TO THE INDIVIDUALIZED CARE PLAN.........75
C OUTLINE OF THE EDUCATIONAL BOOKLET FOR MOTHERS...................76
L IST O F R E F E R E N C E S ......... .. ............... ................. ................................................78
B IO G R A PH IC A L SK E TCH ..................................................................... ..................87
LIST OF TABLES
1-1 Stages of change in which particular processes of change are emphasized.............28
2-1 Hypothesis testing according to dependent variable............................. .............43
3-1 Demographics of the pre-intervention and post-intervention groups with test
statistics for selection differences ........................................ ......... ............... 51
3-2 B reast m ilk feeding initiation rates ........................................ ....................... 53
3-3 Comparison of rates of breastfeeding after 30 weeks gestation.............................55
3-4 Rates of ever breastfed in the neonatal intensive care unit ......................................56
3-5 Rates of breast milk feedings at discharge........................... ...............57
LIST OF FIGURES
3-1 Number of times breastfed per day after 30 weeks gestation .............................54
3-2 Proportion of the stay that breast milk was provided.............................................58
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
BREASTFEEDING PRACTICES IN THE NEONATAL INTENSIVE CARE UNIT
BEFORE AND AFTER AN INTERVENTION PLAN
Roberta Gittens Pineda
Chair: Lorie Richards
Major Department: Rehabilitation Science
The benefits of breastfeeding for both mother and infant are cited extensively in the
literature. Premature infants hospitalized in the neonatal intensive care unit (NICU) have
a great need for the benefits that breast milk offers, due to their fragile health states.
However, mothers of very low birth weight infants hospitalized in the NICU have
magnified barriers to the breastfeeding process due to the complexity of medical
conditions that warrant admission to the NICU and the separation of the infant from the
mother to enable medical care. Studies have cited lack of education about lactation
among health care professionals and discrepancies in education dissemination to mothers
as a major barrier to the breastfeeding process. A three-part intervention within the
NICU was implemented that consisted of an educational initiative for health care
professionals who instruct and support mothers, modifications to the individualized care
plan that included a new breastfeeding pathway, and an educational booklet for mothers
with infants hospitalized in the NICU. Change in breast milk feeding initiation rates,
breastfeeding rates, breast milk at discharge rates, and proportion of the hospital stay that
breast milk was provided was investigated between pre-intervention and post intervention
groups. Results indicated general positive trends in all variables, but only one variable
achieved statistical significance. The percentage of infants who were ever breastfed
while in the hospital increased from 25.9% before the intervention to 44.4% after the
intervention, and this reached statistical significance with ap value of .025. Full
implementation of strategies learned in the interventions was questionable. This study
provides partial support of the three-part intervention in facilitating breastfeeding in the
NICU. Possible reasons for lack of change across all variables, as well as other possible
interventions that could affect change, are explored.
Breastfeeding is an important part of the occupation of mothering. However,
mothers of infants admitted into the neonatal intensive care unit (NICU) are not able to
function in the traditional role of mother. They are usually separated from their infants,
and the role of caregiver shifts to health care professionals. In addition, many infants
may be attached to life-saving or monitoring equipment, which can be intimidating for
new parents. Even more intimidating is that many of these infants are fragile or lack
neurological maturity, which affects how the mother will interact with and care for her
infant. This environment presents significant barriers to the provision of breast milk,
including the fragility of the infant, the separation of the infant from the mother, and the
behavior of the health care professionals who are focused on the medical interventions
necessary for these infants. This is unfortunate, because the established benefits of breast
milk may be even greater in these medically fragile and maturationally immature infants.
The rate of breastfeeding in the United States, despite repeated advertisement of
its benefits, is only 71.4% (Li, Darling, Maurice, Barker, & Grummer-Strawn, 2005).
Unfortunately, due to the many barriers to breastfeeding in the NICU environment, this
percentage is significantly lower for infants discharged from the NICU, with breast milk
feedings in premature infants reaching only approximately 50% (Espy & Senn, 2003).
However, despite the medical complexities of the NICU and the shift of care to health
care professionals, with adequate circumvention of barriers, mothers can be supported in
the occupation of mothering through support of breastfeeding.
Studies have identified that health care professional support is predictive of success
with breastfeeding (Swanson & Power, 2005). However, health care professionals must
be given the tools to foster breastfeeding in the complex NICU environment. Therefore,
the aim of this study was to test the efficacy of an intervention to support breastfeeding
practices in the NICU. The intervention centered on health care professional behavior
change through an educational initiative for health care professionals, modifications to
the individualized care plan (ICP) with a breastfeeding protocol, and educational
materials for mothers with infants in the NICU. It was hypothesized that the intervention
plan would foster change in health care professionals, which would then enable positive
changes in breastfeeding practices in the NICU.
The Importance of Breast Milk and Breastfeeding
Breast milk can be provided to the infant either directly through infant suckling at
the breast (breastfeeding) or by having the mother express the breast milk with a pump
and providing the milk via enteral feedings or bottle (breast milk feedings). The health
benefits of breastfeeding for the infant are cited in the literature extensively (Wolf, 2003).
Breast milk has a protective effect against many childhood health problems. Breast milk
differs from formula in that it has unique ingredients that are difficult, if not impossible,
to duplicate. Important components of breast milk are IgA antibodies, which aid in
preventing infection by creating a non-inflammatory response in body cells. This enables
a more active immune system, which demonstrates better defense against infection.
Other factors in breast milk, such as lactoferrin and oligosaccharides have also been
isolated and are believed to prevent mucous attachment, the origin of most infections
(Hanson, 1998; Hanson et al., 2002).
Infant formulas continue to strive to be similar to breast milk and have become
nutritionally advanced in the last decade, however, research continues to illustrate that
breast milk is far superior to formula (Agostoni & Haschke, 2003; Baker, 2003; Wold &
Adlerberth, 2000). Thus far, formula companies have been unable to replicate the exact
ingredients of breast milk. Perhaps predominantly due to the IgA antibodies found in
human milk, breastfed infants have superior protection from many ailments that
compromise health and prevent optimal functioning.
Health Benefits of Breastfeeding for the Full Term Infant
When comparing babies who are fed breast milk to those who are formula fed,
there is a significant reduction in respiratory infections, diarrhea, necrotizing
enterocolitis, meningitis, sepsis, urinary tract infections, atopic dermatitis, celiac disease,
and inflammatory bowel disease in the breastfed babies (Dai & Walker, 1998; Hanson,
1998; Hylander, Strobino, & Dhanireddy, 1998; Laubereau et al., 2004; Marild, Hansson,
Jodal, Oden, & Svedberg, 2004; Wold & Adlerberth, 2000). Although preliminary
studies have not been conclusive, it is also suggested that allergies and asthma are also
diminished among breastfed babies (Kemp & Kakakios, 2004; Oddy et al., 2004).
Breastfed babies have a diminished risk of sudden infant death syndrome (Alm et al.,
2002; McVea, Turner, & Peppler, 2000), as well as a significantly lower risk of mortality
after the neonatal period (Chen & Rogan, 2004).
Because it is associated with less infant illness, breast feeding may cut medical
expenses for the infant. Ball and Wright (1999) addressed excess medical costs for 3
common childhood illnesses: gastrointestinal infection, respiratory tract infection and
otitis media among breast fed versus formula fed infants in the first year of life. There
was evidence that children who were never breast fed incurred significantly more office
visits, hospitalizations, prescriptions and subsequently had higher health care costs (Ball
& Wright, 1999). Thus, the health advantages associated with breastfeeding create less
financial burden as health care costs diminish (Ball & Wright, 1999) and, more
importantly, they improve the quality of life and health status among mother-infant
There have been a multitude of studies that have also investigated health and
developmental benefits of breast milk for premature and high risk neonates (Callen &
Pinelli, 2005). The fragile health states of these infants make them more susceptible to
infection, gastrointestinal problems, and life threatening illnesses than full term infants
(Lanari et al., 2001; Lugo-Vicente, 2003). Therefore, breast milk is perhaps more
important in this fragile population, because it diminishes the risk of multiple medical
problems, which can complicate the medical course and put them at a higher risk of
Health Benefits of Breastfeeding for Premature Infants
Breast milk fed infants from the NICU differ significantly from formula fed infants
in incidence of infection and diagnosis of sepsis/meningitis (Hylander et al., 1998),
necrotizing enterocolitis, and retinopathy of prematurity (Hylander et al., 1998; Hylander,
Strobino, Pezzullo, & Dhanireddy, 2001; Schanler, Hurst, & Lau, 1999). Breast fed
premature babies have been noted to experience less stress than bottle fed infants as
evidenced by fewer episodes of oxygen desaturation and temperature instability (C. H.
Chen, Wang, Chang, & Chi, 2000). Breastfeeding has been cited as an intervention that
has lasting, long term benefit beyond discharge from the hospital (Harrold & Schmidt,
2002), and studies have detected significant reductions in length of stay among breastfed
premature infants (Gomez, Acosta, Sevillano, Curbelo, & Alvarez, 1997).
Long Term Benefits of Breastfeeding
More recent studies are suggesting that the effects of breast milk extend beyond the
period of infancy and early childhood, and promote long term immunity and protection
from chronic diseases. Lower risk of developing childhood cancers, obesity, type I
diabetes, and cardiovascular disease have been cited as long term benefits of
breastfeeding (Davis, 2001; Hanson, 1998; Schack-Nielsen & Michaelsen, 2006; Singhal,
Cole, Fewtrell, & Lucas, 2004). Studies of long term effects of breast milk on premature
infants have also found benefits with lower blood pressure readings in adolescence
(Owen, Whincup, Odoki, Gilg, & Cook, 2002). Despite concerns that breastfeeding
results in suboptimal growth in infancy, studies have demonstrated an increased growth
velocity in late childhood in breastfed groups (Schack-Nielsen & Michaelsen, 2006).
Additionally, improved parental attachment in the teenage years has been linked to
breastfeeding (Fergusson & Woodward, 1999).
Developmental Benefits of Breastfeeding
Research also points to the importance of breastfeeding on infant development.
Breastfeeding results in improved oral motor development and orthodontics (Page, 2001),
with early weaning increasing the risk of malocclusion, mouth breathing, dysfunctional
oral motor development and subsequent suboptimal speech development (Neiva, Cattoni,
Ramos, & Issler, 2003; Viggiano, Fasano, Monaco, & Strohmenger, 2004). Breastfed
infants have improved visual motor skills (Birch et al., 1993), have better responses to
pain (Gray, Miller, Philipp, & Blass, 2002) with improved neurobehavioral organization
(Hart, Boylan, Carroll, Musick, & Lampe, 2003) and have demonstrated improved scores
on mental functioning (Gomez-Sanchiz, Canete, Rodero, Baeza, & Avila, 2003).
Premature infants have a greater risk of poor neurological outcome, which suggests
that breast milk may be critical to enable optimal developmental functioning. Research
has demonstrated improved cognitive and motor functioning scores among premature
infants who had breast milk feedings (Lanari et al., 2001; Schanler et al., 1999). Studies
demonstrate improved cognitive scores and intelligence quotients that continued to be
evident through middle childhood among breastfed infants (Lucas, Morley, Cole, &
Gore, 1994; Lucas, Morley, Cole, Lister, & Leeson-Payne, 1992; Morley, Cole, Powell,
& Lucas, 1988; Smith, Durkin, Hinton, Bellinger, & Kuhn, 2003).
Benefits of Breastfeeding for the Mother
In addition to the benefits given to the baby through breastfeeding, there are also
benefits for the mother. Women who succeed with breastfeeding comment on the special
bonding experience (Torgus, Gotsch, & La Leche League International., 1997). Women
who breastfeed have less postpartum bleeding (Chua, Arulkumaran, Lim, Selamat, &
Ratnam, 1994) and have a faster rate of pregnancy related weight loss (Dewey, Heinig, &
Nommsen, 1993). Women who breastfeed also postpone ovulation (Rea, 2004), and
breastfeeding has been demonstrated to serve as a natural and effective birth control
method in the postpartum period ("How breast-feeding postpones ovulation," 1985;
"What is best birth control to use after having a baby?," 1989). In addition, women who
succeed with breastfeeding lower their risk of osteoporosis (Chantry, Auinger, & Byrd,
2004), obesity (Rooney & Schauberger, 2002), ovarian cancer, breast cancer (Mikiel-
Kostyra, 2000), diabetes and rheumatoid arthritis (Rea, 2004).
Mothers of preterm infants have additionally reported an improved sense of well
being, as they feel that they are actively contributing to the health of their babies
(Schanler et al., 1999). Having an infant in the NICU is a difficult challenge. Mothers
may feel shut off from their infant as the nurses take on the role of primary caregiver.
Being able to provide the best source of nutrition can be one task that embraces the
mother in her role and fosters parental involvement, as it is something only she can do for
Current Breastfeeding Recommendations
The health benefits of breastfeeding for mother, baby and health care systems are
evident and extensive. Therefore, the American Academy of Pediatrics (AAP), as well as
the American Dietetic Association, have responded to the benefits of breastfeeding for
mother and baby by recommending exclusive breastfeeding for the first 6 months with
breastfeeding and supplemental solids until the infant is 1 year old ("Breastfeeding and
the use of human milk. American Academy of Pediatrics. Work Group on
Breastfeeding," 1997). The World Health Organization recommends breastfeeding for at
least 2 years ("The optimal duration of exclusive breastfeeding: results of a WHO
systematic review," 2001). However, breastfeeding statistics continue to demonstrate a
gap between these recommendations and how the general population of mothers in the
United States chooses to feed their infants (Li et al., 2005).
Some women never breastfeed, some breastfeed exclusively, some supplement
breastfeeding with bottle feeds of human milk, some supplement breastfeeding with
bottle feeds of formula, some bottle feed formula only, some bottle feed breast milk only,
and some women start out breastfeeding and completely wean once formula is
introduced. Statistics from the year 2003 indicated that 71.4. % of women in the general
population initiated breastfeeding while in the hospital, and 35.1% of mothers were still
breastfeeding when their babies turned 6 months of age. At one year of age, 16.1%
continued to provide some breast milk for their infants (Li et al., 2005). Variable rates of
breastfeeding have been reported for infants in the NICU. The rates for infants receiving
some breast milk at some point range from 50% to 83% (Byrne & Hull, 1996; Espy &
Senn, 2003; Meier, Engstrom, Mingolelli, Miracle, & Kiesling, 2004; Smithers, McPhee,
Gibson, & Makrides, 2003; Yip, Lee, & Sheehy, 1996). However, studies have found that
the rates of breast milk feeds at discharge are 64%, with the rate of breastfeeding being
38% (Yip et al., 1996). One study found that at 4 months of age, only 24% of infants born
at less than 33 weeks gestation continue to receive some breast milk feedings (Smithers et
al., 2003). Subsequently, breastfeeding rates at hospital discharge for infants born
prematurely are significantly lower than those of full term, healthy infants (Yip et al.,
To understand the suboptimal breastfeeding rates for premature and high risk
neonates, it is beneficial to investigate the barriers to breastfeeding. By understanding
the barriers to breastfeeding, appropriate interventions can be developed and
implemented to facilitate improved breastfeeding practices.
Why More Women Are Not Giving Their Infants the Benefits of Breast Milk
Maternal demographics are strong predictors of breastfeeding. Women with higher
socioeconomic status, more education, previous children but smaller family size,
Caucasian race, and women who are married are more likely to succeed with
breastfeeding (Bueno et al., 2003; Kronborg & Vaeth, 2004; Mitra, Khoury, Hinton, &
Carothers, 2004). However, perinatal medical condition is also an important predictor of
successful breastfeeding (Espy & Senn, 2003; Powers, Bloom, Peabody, & Clark, 2003).
Scott (2006) discovered that the infant being admitted to the intensive care unit was the
strongest predictor of not being exclusively breastfed at discharge (Scott, Binns, Graham,
& Oddy, 2006). Other studies have concluded that having a cesarean section, as well as
having a low birth weight infant, makes a woman less likely to breastfeed (Hwang,
Chung, Kang, & Suh, 2006). Demographic factors as well as medical condition and type
of delivery have been shown to be strong influences on the decision to breastfeed and the
success of breastfeeding.
General Breastfeeding Barriers
The barriers to breastfeeding full term, healthy infants include lack of family and
spouse support and perceptions of lack of support; (Arora, McJunkin, Wehrer, & Kuhn,
2000; Matthews, Webber, McKim, Banoub-Baddour, & Laryea, 1998; Scott et al., 2006),
social withdrawal and isolation (Stewart-Knox, Gardiner, & Wright, 2003), perceived
inconvenience (Zimmerman & Guttman, 2001), perceived inadequacy to provide
adequate nutrition (Arora et al., 2000; Matthews et al., 1998), early supplementation or
first feeding of formula (Wheeler, Chapman, Johnson, & Langdon, 2000), lack of
appropriate education (Arora et al., 2000), functional problems with the process of
breastfeeding; (Bick, MacArthur, & Lancashire, 1998), intent to return to work (Arora et
al., 2000; Matthews et al., 1998; Piper & Parks, 1996; Ryan, Wysong, Martinez, &
Simon, 1990), and maternal illness (Black & Hylander, 2000; Riskin & Bader, 2003).
Barriers to Breastfeeding Premature Infants
Breastfeeding challenges are stronger and even more numerous for the high risk
neonate, despite these babies having an even greater need for human milk. Mothers of
infants who are born prematurely have unique challenges to successful breastfeeding.
One barrier to breastfeeding the premature infant is that when an infant is born
prematurely and warrants admission into the NICU, the mother is separated from her
baby (Black & Hylander, 2000). The time after birth is very different for these mothers
compared to those with full term infants. There is usually not a period of being able to put
the baby to breast immediately after birth, and breastfeeding may not be possible for
several weeks or months, depending on the infant's level of prematurity and medical
When visitation is possible, mothers may visit their baby in the intensive care unit.
Here, they may have difficulty with the transition to motherhood as the doctors and
nurses make decisions related to the care of the baby, including whether or not the mother
may hold her new baby (Holditch-Davis & Miles, 2000; Lupton & Fenwick, 2001). The
machines and equipment present and being utilized by the baby in the NICU can be
overwhelming for many parents (Wheeler et al., 2000), and this environment is very
different from the quiet, home-like environment one would typically envision during the
first days of the baby's life. An additional barrier is that the ability to achieve let down, in
which breast milk begins to flow during infant feeding and pumping, is hindered by the
inability to relax in this stressful environment (Beresford, 1984; Nyqvist, Ewald, &
Sjoden, 1996; Wheeler, Johnson, Collie, Sutherland, & Chapman, 1999).
Many low birth weight infants are unable to breast feed for several weeks or
months following birth (Hill, Andersen, & Ledbetter, 1995). Their gastrointestinal
systems are immature and feedings can be dangerous or life threatening. During the first
days, a baby may be fed intravenously or through an orogastric or nasogastric tube, in
which feeds may be slowly introduced and advanced. When the gastrointestinal system is
ready for bolus feeds directly into the stomach, the baby's immature central nervous
system may not enable consistent presentation of sucking and swallowing responses to
enable safe oral feeding (Nyqvist, Sjoden, & Ewald, 1999; Ziemer & George, 1990).
Although breastfeeding may not be possible initially, breast milk can be expressed by the
mother with a breast pump, and the infant can be advanced on gastric feeds with breast
Just as the first feeding by breast is a good predictor of sustained breastfeeding in
full term infants, timely pumping for those mothers who are unable to put the baby to
breast is an important predictor of sustained breastfeeding in the premature baby (Jaeger,
Lawson, & Filteau, 1997). Women of premature babies may express their breast milk and
supply it to hospital staff so that the baby may be tube fed with human milk instead of
infant formula (Meier & Brown, 1996). Additionally, this process establishes and
maintains a milk supply so that the mother will not have diminished or absent milk
supply, when the baby is stable enough to engage in the breastfeeding process. Barriers to
breastfeeding related to this early process include increased amounts of stress (Docherty,
Miles, & Holditch-Davis, 2002; Miles, Funk, & Kasper, 1992) and time constraints
placed on these new mothers, difficulty in acquiring hospital grade breast pumps for milk
expression, lack of special bonding and emotional feedback received from using a pump,
delayed initiation of milk expression, separation from the infant, reliance on medical
technology to feed the baby, and psychological adjustment to the idea of not being able to
breastfeed for weeks or even months (Byrne & Hull, 1996). With the mother
experiencing stress associated with coping with her sick baby (Miles et al., 1992) and a
shift of care from the mother to the baby after the birth, there may be delayed initiation of
pumping and lack of accessibility of hospital grade pumps to promote milk supply in an
New studies are highlighting the importance of investigating barriers at different
time periods during an infant's hospitalization (Callen & Pinelli, 2005). If a mother
successfully overcomes the challenge of maintaining her milk supply, there are additional
challenges as an infant approaches discharge from the hospital. Poor central nervous
system maturity may initially prevent complete success with breastfeeding, and
dysphagia is common in this population (Hill, Hanson, & Mefford, 1994). The literature
cites problems with the mechanics of breastfeeding a premature baby as a barrier to
breastfeeding (Kavanaugh, Mead, Meier, & Mangurten, 1995). Once discharge is
approaching, there frequently is little time to enable a mom and baby to achieve
successful breastfeeding (Meier & Brown, 1996). Bottle feeding is often preferred as it
allows nurses to orally feed the baby when the mother is not present and the exact amount
ingested can be accurately measured (McGrath & Braescu, 2004). Additionally, infants
can be fed more passively with bottle feeding compared to the active process of
breastfeeding. Although this can have negative side effects of desaturations and
bradycardic events as well as increased risk of gastroesophageal reflux, it is frequently
preferred because of the efficiency of oral feeding. However, breastfeeding can be
achieved in this population despite the preferences of health care staff and the challenges
that must be overcome.
Infants in the NICU are fed according to a schedule, typically every 3 to 4 hours,
and may be fed via bottle, tube or breast to optimize the nutritional status. The inability
of a preterm baby to breastfeed on demand in an environment with scheduled feedings
via different modes is a significant barrier to breastfeeding (Black & Hylander, 2000). It
undermines the typical procedures associated with breastfeeding a full term infant which
involves feeding a baby when he/she shows hunger signs and not supplementing until
breastfeeding is well established. This allows for the infant to ingest a smaller feeding
and thus become hungrier and to have a more rigorous, larger feeding for the next one.
However, scheduled feedings of specific amounts can affect the transition to active
breastfeeding in the NICU. If the infant typically receives a prescribed amount of breast
milk by bottle or nasogastric tube and the mother attempts to breastfeed, not knowing the
exact amount of breast milk ingested by breastfeeding may result in the health care
professional doubting if there was adequate intake. Thus supplementation frequently
occurs, which inhibits the next breastfeeding session, decreases the demand for breast
milk produced by the mother and diminishes milk supply, and thus becomes a cyclic
Diminished milk supply is cited extensively in the literature as one of the
significant barriers to breastfeeding in the NICU (Callen & Pinelli, 2005). Among the
earliest of premature infants, the average duration of providing breast milk is 4-5 weeks
(Byrne & Hull, 1996). Lack of ability to engage in active breastfeeding due to the health
status of the infant, lack of presentation of sucking and swallowing capabilities of the
infant and the need for the mother to demonstrate consistent milk expression via a breast
pump to establish and maintain a milk supply all contribute to diminished milk supply in
mothers of infants hospitalized in the NICU.
Infants who are born prematurely have different nutritional needs than full term
infants. Thus, there are premature infant formulas that are utilized in the neonatal period
and many are used until one year of life. When gastric feeds are being established,
physicians are concerned with establishing a good weight gain trend. If an infant is not
gaining weight as desired, the physician may increase caloric density or add lipids to
infant formula or expressed breast milk to foster weight gain. Frequently nutrients and
calories are added to human milk by the way of human milk fortifiers (Chan, 2001),
which promote establishment of a good weight gain curve. However, this is a barrier to
breastfeeding as the mother perceives that the composition of her breast milk is not
adequate to promote the health of her child. She may perceive that formula or fortified
breast milk by bottle is essential to enable the appropriate milk composition (Kavanaugh
et al., 1995). However, studies suggest that mother's milk of premature babies differs
from that of full term infants with the most notable differences evident between 4-6
weeks after delivery (Gross, David, Bauman, & Tomarelli, 1980). Additionally, the use
of hind milk, the milk at the end of a breastfeeding session that is very high in fat content,
has been shown to facilitate weight gain in premature babies (Slusher et al., 2003).
Research is identifying that there are factors in the hospital setting that influence
breastfeeding decisions. The site of care is a strong predictor of choice and success with
breastfeeding (Powers et al., 2003). In addition, literature is highlighting the important
role of health care professionals on the decision to initiate and continue breastfeeding
(Nyqvist, Sjoden, & Ewald, 1994; Swanson & Power, 2005).
Health Care Professionals Can Hinder the Breastfeeding Process in the Neonatal
Intensive Care Unit
There are many inconsistencies in what parents are educated about and many
disparities in what parents are instructed to do by health care professionals, and this can
be confusing and frustrating for new mothers (Byrne & Hull, 1996; Nyqvist et al., 1994).
One study identified that 48% of mothers reported receiving conflicting advice about
breastfeeding in the NICU (Jaeger et al., 1997).
Mothers rely on health care professionals in the NICU to provide accurate,
complete, and consistent information about breastfeeding their high risk infant. Many of
the mothers of preterm infants have not had an opportunity to fully prepare for
motherhood before the birth of their baby. Some may have planned on taking a
breastfeeding or parenting class, but the early arrival dampened these plans. In addition,
the NICU is a medically complex environment, and parents need guidance on how to
function in their role as mother with the environmental constraints. The literature
suggests that there is a lack of health care professionals who are trained in lactation and
breastfeeding with premature babies, and that many health care professionals have
incorrect knowledge and negative beliefs about lactation (Berens, 2001; Pantazi, Jaeger,
& Lawson, 1998; Register, Eren, Lowdermilk, Hammond, & Tully, 2000; Spicer, 2001).
Yet, it is the health care professionals in the NICU, despite lack of education, who are
teaching and instructing these new mothers on breast milk feedings and breastfeeding.
Health care professionals can influence breastfeeding behaviors, and their own
values and beliefs concerning breastfeeding can have supporting or damaging results on
the breastfeeding process (Ekstrom, Matthiesen, Widstrom, & Nissen, 2005). Studies
have identified that education and training can affect attitudes and knowledge about
breastfeeding (Bernaix, 2000; Siddell, Marinelli, Froman, & Burke, 2003; Swanson &
Power, 2005). However, to date, there are no studies that have investigated the indirect
impact of health care professionals' behavior change with acquisition of knowledge and
attitude change on breastfeeding outcomes in mothers and infants in the NICU.
The American Academy of Pediatrics issued a statement in February 2005 that
stated that breastfeeding or human milk feedings are recommended for all healthy,
premature and high-risk infants for whom breastfeeding is not specifically
contraindicated. It further states that health care professionals should provide complete,
current and accurate information to parents on the benefits and techniques involved with
breastfeeding (Gartner et al., 2005). However, to date there has been no specific,
standard set of tools developed and utilized to achieve education of health care
professionals to enable consistent information dissemination to parents.
Treatments to Foster Improved Breastfeeding Rates
The United States Surgeon General, David Satcher, identified breastfeeding as a
national health priority and released the "Health and Human Services, Blueprint for
Action on Breastfeeding" in October 2000. In response to this, The World Health
Organization in conjunction with UNICEF is promoting breastfeeding through the baby
friendly hospital initiative. To be designated as "baby friendly," the hospital must follow
the ten steps to successful breastfeeding:
Every facility providing maternity services and care for newborn infants should:
* Have a written breastfeeding policy that is routinely communicated to all health
* Train all health care staff in skills necessary to implement this policy.
* Inform all pregnant women about the benefits and management of breastfeeding.
* Help mothers initiate breastfeeding within half an hour of birth.
* Show mothers how to breastfeed, and how to maintain lactation even if they should
be separated from their infants.
* Give newborn infants no food or drink other than breast milk, unless medically
* Practice rooming-in (i.e., allowing mothers and infants to remain together) 24 hours
* Encourage breastfeeding on demand.
* Give no artificial teats or pacifiers (also called dummies or soothers) to
* Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic.
Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of
Maternity Services, a joint WHO/UNICEF statement published by the World Health
These ten steps specifically involve how health care professionals and the hospital
system will deal with mother-infant dyads on regular maternity floors within a hospital.
Once these ten steps are put into practice, the hospital may apply for designation as a
baby friendly hospital. Hospitals that have been through the process of baby friendly
designation have demonstrated improvement with breastfeeding rates (Philipp, Malone,
Cimo, & Merewood, 2003). For example, Boston Medical Center was designated as
baby friendly in 1999, with increased breastfeeding rates of 58% in 1995 to 86.5% in
1999. Breastfeeding rates were maintained at this high rate from 1999 to 2001.
Although the baby friendly designation is specifically for the maternity floors of a
hospital system and not designed for the unique needs of the high risk population, there
have been positive effects on breastfeeding practices in the NICU following designation
(Vannuchi, Monteiro, Rea, Andrade, & Matsuo, 2004). However, a program specifically
designed for the high risk population with its significant barriers to breastfeeding, could
have the potential for greater enhancement in breastfeeding rates in the NICU Premature
infants are a unique population and warrant individualized breastfeeding strategies and
interventions (Kavanaugh et al., 1995; Meier, 2001)
Many hospitals have implemented practices that will educate and promote
breastfeeding practices for infants within the NICU. However, only a few have evaluated
their programs for effectiveness. The Rush Mother's Milk Club has proven to be
effective in increasing breastfeeding rates (Meier et al., 2004) by enabling free access to
hospital grade breast pumps, by offering lactation support 24 hours a day, by use of cue
based feeding when an infant consumes at least 50% of feeds orally, and by providing of
breastfeeding peer support. Other studies have found positive increases in breastfeeding
initiation with the introduction of counseling as well as contact with lactation consultants
among mothers with low birth weight infants (Pinelli, Atkinson, & Saigal, 2001; Sisk,
Lovelady, Dillard, & Gruber, 2006). A workbook program introduced at 2 different time
periods during the hospital stay was also shown to have positive effects on breastfeeding
with premature infants in one hospital setting (Jang, 2005).
Many papers have documented specific protocols to instruct mothers and promote
breastfeeding (Isaacson, 2006; Premji, Paes, Jacobson, & Chessell, 2002; Spicer, 2001),
but no research has been conducted to determine the effectiveness of such
recommendations. Although studies have shown increased knowledge acquisition by
health care professionals in the NICU following an education plan (Siddell et al., 2003),
there are no studies that have investigated the effect of education of health care
professionals coupled with protocols and standard written information for parents on
changes in breastfeeding practices in the NICU.
Of all interventions for breastfeeding with the high risk neonate, the Rush Mother's
Milk Club is probably the most well known. The health care providers in the NICU at
Rush University have an increased level of knowledge regarding breastfeeding in the
NICU. With this knowledge, they are able to implement advanced strategies, such as
putting breast milk in a centrifuge to modify the fat content to promote weight gain
(Meier, 1998). Many studies have been conducted to evaluate the effectiveness of the
Rush Mother's Milk Club with positive results (Meier et al., 2004). However, the high
level of education about breastfeeding among health care professionals at Rush
University likely underlies the capability to implement the more advanced interventions.
For many hospitals, basic education on lactation with high risk infants is lacking. In
addition, many interventions that have proven to be effective, including the use of free
access to pumps and accessibility to lactation counseling, have associated costs, which
many hospitals do not have budgets to support.
Need for an Educational Package for Health Care Professionals and Mothers of
Infants in the Neonatal Intensive Care Unit
Breastfeeding and human milk feedings are possible and beneficial in the NICU,
however, there is significant support and education that must occur to enable success
among mothers in the NICU (do Nascimento & Issler, 2004). Education and treatments
should be based on research with premature and high risk infants, as they have unique
needs in the breastfeeding process (Meier, 2001). The use of developmental care
practices can drive the understanding of appropriate breastfeeding interventions based on
infant readiness cues (Karl, 2004).
Although there have been many articles and books written on the subject of
breastfeeding with the high risk neonate, there was no up to date, comprehensive,
evidence based education packet with complementary information for both parents and
health care professionals available on the market. By understanding each of the
challenges to breastfeeding the medically fragile infant and the specific developmental
and nutritional needs of the high risk infant, an education initiative can be developed and
then evaluated for efficacy.
Synactive Theory and Breastfeeding Interventions in the Neonatal Intensive Care
While investigating, developing and implementing appropriate interventions
targeted to improve breastfeeding rates, it is important to consider the vulnerability of the
special population in the NICU and the impact of environmental stressors on this
population. One theory that can be used to guide appropriate interventions in the NICU
is the synactive theory, which identifies the process of neurobehavioral maturation of the
infant. Breastfeeding interventions should be individualized, based on infant readiness
cues and tailored to the responses of the infant (Blackburn, 1998). Review of the
synactive theory and its application to breastfeeding should be part of any education
initiative for health care professionals who serve the vulnerable infants in the NICU.
The synactive theory was developed by Heidelese Als in the early 1980's (Als,
1982). The process of developmental care, related to the synactive theory, is intended to
facilitate a well organized, stable infant who may optimally grow and develop.
Developmental care has been instituted in many neonatal intensive care units around the
country as a developmental care initiative. It provides a framework for interacting with
these fragile infants without jeopardizing health. The synactive theory of development
describes the process of neurobehavioral maturation related to an infant's internal and
external environment. As the infant attempts to interact with the external environment, a
dynamic process occurs internally among 5 different subsystems. The dynamic process
among the 5 subsystems can explain the behaviors and responses exhibited by the
premature infant and can guide appropriate interventions.
The 5 distinct, yet interdependent subsystems are physiological or autonomic,
motor, state organization, attention and interaction, and the state regulation subsystems.
These subsystems are believed to impact the functional organization of the infant's
system in an ordered fashion. The subsystems are not hierarchical, but they are believed
to be ordered and interdependent (Als, 1982; Als, 1994).
The physiological subsystem is considered the core of the system. It is the
foundation for which all of the other systems gain stability. This physiological subsystem
allows the infant to have control over autonomic functions such as voiding, breathing,
maintaining steady vital signs, and processing nutrition. The motor system provides
control over movement, muscle tone, and posture. The state subsystem gives the infant
control over his/her level of consciousness. It enables the infant to move through
identifiable states and move smoothly from one state to another. The
attentional/interactive subsystem enables control over functional responses to stimulation
in the environment and governs the ability to interact. The state regulation subsystem
gives the infant the ability to balance environmental stressors and recover by modulating
all the other systems (Als, et al, 1982). While the autonomic subsystem serves as the
foundation of the system, the state regulation subsystem serves as the gate keeper and is
achieved with increasing maturity.
A cone shaped diagram is used to represent the complex development of the infant
as it relates to the five subsystems (Als, 1982). The cone has its tip at the bottom with the
funnel going upward. The five subsystems can be viewed at the top of the open cone. At
the smallest center is the physiological subsystem with the remaining (motor, state,
attentional/interaction) forming layers outside the center, much like an onion. The
youngest fetus is represented at the bottom of the cone and has with it only components
(not yet a fully developed system) from the autonomic subsystem. This indicates that
infants who are born early are unable to integrate the higher order systems. Stressors
within the system interfere with the physiologic capabilities of the infant. Subsequently,
early premature infants are incapable of any interaction and need all their energy to
maintain homeostasis of the system to sustain life. There is also instability in the
physiologic system, which is why premature infants frequently have medical or
physiological problems when born early and have to contend with the stressful
With the earliest fetus at the bottom of the cone, increasing gestational age is
associated with increasing maturity spreading out to the other layers of the system. With
increasing gestational age and thus maturity, the infant may extend its control out to the
next level, the motor subsystem. The infant may demonstrate improved muscle tone and
postural control. This concept parallels the literature, which demonstrates improvement
in muscle tone and reflex development with increasing gestational age (Allen & Capute,
1990). Further maturity may extend the infant's control out to the state subsystem
enabling the infant to demonstrate some awake periods and to smoothly transition from
one state to another. As maturity continues, the infant may be able to achieve some
attention and interaction with caregivers and the environment. Lastly, as the infant
approaches term and achieves more maturity, he/she will be able to tolerate stressors,
cope with them, reorganize and continue interaction without being knocked down to
functioning at the lower subsystems.
The term synaction refers to the relationship between all the subsystems and how
instability in one system has the potential to affect all the other subsystems and thus the
integrity of the child's health and well-being (Als, 1982). On the right side of the cone
are gestational ages that reflect the increasing maturity of the system (dependent on the
subsystems) with increasing gestational age. On the left side of the cone are influences of
the environment on the maturation of the system, with a break in the intrauterine and
extrauterine environment before term to indicate the premature birth, thus representing
the role of environmental stresses before full maturity occurs. With earlier birth and
more stressors from the environment, there will be a resultant decrease in
When an infant is stressed from the environment, he/she may initially demonstrate
stress reactions based on the predominant level of neurobehavioral maturation. If he/she
is primarily functioning in the physiological state, he/she may demonstrate bradycardic
events, oxygen desaturations, hiccups, stooling, or spitting up. If he/she is primarily in
the motor state, he/she may demonstrate grimacing, arching, saluting, finger splaying, or
sitting on air. If he/she is in the state subsystem he may shut down or move to a light
sleep state. If he/she is in the attentional/interactive subsystem, he/she may avoid
interaction by turning away. The infant has the capability to re-achieve organization with
time outs or specific strategies designed to help him cope. Interventions designed to help
infants cope with stressors include providing boundaries, swaddling, positioning in
flexion, bringing hands to mouth, minimizing environmental stimulation, non nutritive
sucking, and enabling grasping. Infants additionally will demonstrate approach signals
such as smiling, mouthing, ooh face, cooing, quiet and alert state, and soft and relaxed
facial expressions when they are ready for interaction (Hussey-Gardner, 1996). Once
reorganized and demonstrating approach signals, the stressor may be reintroduced slowly.
The synactive theory defines the subsystem along with stress and coping signs
consistent with each of the subsystems to enable caregivers to identify and respond to
behaviors appropriately. When stress signs are recognized, the caregiver can then
withdraw the stressor that contributed or help facilitate the infant to cope. Once a time
out is given and the infant reorganizes, the treatment or interaction can continue. This
"give and take" enables the infant to function optimally within the environment and
allows him/her to continue to benefit from interaction and stimulation, including
breastfeeding, as he/she tolerates. The synactive theory proposes an approach for each
individual child that is adapted to fit the needs of that infant. It promotes infant
development to occur as normally as possible, despite medical complications and
immaturity brought on by an early birth.
Infants born at earlier gestational ages and with decreased neurobehavioral
maturation are not capable of handling environmental stressors typically experienced by
newborns. When interventions for these neurobehaviorally immature infants are done
without respect for readiness cues, the infant is at risk for regressing to one of the more
primitive states, putting them at risk of developmental and medical sequelae.
Breastfeeding is an environmental stressor. Without observing infant readiness cues and
introducing breastfeeding at the appropriate time individualized for each infant, optimal
responses to the environment as well as optimal neurological maturation are delayed.
Therefore, breastfeeding cannot be introduced at a prescribed time or introduced in the
same way that it would be for a full term infant, but it must be based on the
neurobehavioral maturation of the infant and advanced according to stress and readiness
cues. These concepts need to be in any educational program for both health care
professionals and for mothers of infants in the NICU to help them implement the best
breast milk feeding program for these infants.
While the synactive theory defines the appropriate time and way to introduce
interventions, it also assists with understanding that many extremely low birth weight
infants and low birth weight infants are too neurologically immature and fragile to
engage in any breastfeeding. Subsequently, mothers of infants in the NICU need
equipment that will enable them to achieve and maintain a milk supply, in the absence of
infant suckling at the breast, until the infant is appropriate for nutritional breastfeeding.
Hospital grade breast pumps that will enable long term milk expression are necessary for
mothers with infants in the NICU to maintain adequate milk supplies while they are
waiting for their babies to become medically and developmentally stable enough to
engage in feeding at the breast.
Understanding the synactive theory and implementing developmentally supportive
care can instruct and guide interventions and NICU practices as they relate to
breastfeeding the premature infant. One case study in the literature highlighted the
significant benefits of a developmentally supportive plan on the breastfeeding process in
a premature infant (Nyqvist et al., 1996). The synactive theory should guide the
development of any educational module and inservice for health care professionals who
serve infants in the NICU.
Theory Governing the Behavior of Health Care Professionals
Studies have identified that there is a lack of education about lactation and lack of
consistent support and instruction about breastfeeding among health care professionals in
the NICU (Ekstrom, Widstrom, & Nissen, 2005; Pantazi et al., 1998). Having educated
health care professionals will not necessarily impact breastfeeding practices. It is how
those health care professionals respond and utilize that education to execute new
interventions that will foster change and subsequent improvement in human milk
feedings. The behavior of health care professionals in the NICU needs to change to
support the breastfeeding process. Studies have shown that behavior change is much
more successful when interventions are matched to the stage of readiness to change
(Prochaska, Prochaska, & Levesque, 2001). The transtheoretical model (TTM) provides
a description of how the individual's state of readiness to change translates into
The premise of the TTM is that there are several stages associated with behavior
change. Individuals go through these stages on their way to making a change. They may
start anywhere along the continuum of the 5 stages and they may move forward or
backward or skip stages, but there is some progression through the stages on their way to
behavior change. The TTM has been used to describe many health behavior changes,
such as use of sunscreen, use of condoms, self examination breast checks, smoking
cessation and initiating an exercise plan. Appropriate interventions can be tailored to the
stage of readiness to change.
The five stages of the TTM are precontemplation, contemplation, preparation,
action and maintenance. Each stage identifies if the individual has an intention of
changing behavior and identifies how significant the intention to change behavior is
(Prochaska & DiClemente, 1983). Someone in the precontemplation stage does not
intend to take action within 6 months. A person in the contemplation stage intends to
take action within the next 6 months. Someone in the preparation phase intends to take
action in the next 30 days. The action stage refers to persons who have made obvious
changes less than 6 months ago. The maintenance stage refers to individuals who have
made significant changes more than 6 months ago.
Interventions that are implemented to enable behavior change should be conducted
in such a way that the intervention matches the stage an individual is in, or should be
tailored to how ready the person is for change. Ten fundamental processes that can affect
change have been identified along with interventions that can be matched to the stage of
readiness to change (Table 1-1) (Prochaska et al., 2001). Certain interventions will only
be effective if they are appropriate for the stage of readiness for behavioral change of the
individual. For example if someone is in the precontemplation stage, interventions should
be focused on educational initiatives and strategies to promote reflection about how the
change may impact the person's situation and how it will benefit others, while
interventions for the person in the contemplative stage should be about supporting and
motivating the person to actually initiate the intended behavioral change. These latter
interventions provided to the precomtemplater would not be effective because the person
has not yet formed the conviction that change is needed or desired and could actually
create significant resistance and prevent behavioral change from succeeding (Prochaska
et al., 2001). By enabling stage matched interventions, education and strategies can be
implemented to foster movement across stages to enable successful change.
The TTM has been used to address behavior change within organizations by
targeting employees. By providing stage matched interventions, all employees can be
given opportunities to participate in the change process. Although stage matched
interventions have been shown to facilitate movement toward action, not all employees
may achieve action. Change at the organizational level should include interventions that
are stage matched to each stage of change to give all employees the opportunity for
participation in the change initiative (Prochaska et al., 2001).
Table 1-1. Stages of change in which particular processes of change are emphasized
Precontemplation Contemplation Preparation Action
To foster behavior change regarding support and information dissemination about
breastfeeding within the NICU, the TTM can be utilized to structure an intervention
program. By matching breastfeeding interventions to stages of readiness to change, all
health care professionals can have the opportunity to participate in the change process.
By introducing interventions that can target health care professionals in each stage of
readiness to change, a meaningful intervention plan can be implemented to foster change
at the organizational level. A breastfeeding intervention for the NICU with 4 parts could
theoretically target individuals in all of the stages of readiness to change.
For those health care professionals in the pre-contemplation stage, there is no
intention of making a behavior change. Health care professionals in the contemplation
stage intend to make a change within the next 6 months. Both of these stages describe
individuals who are not yet ready for action, and interventions for those in either of these
stages would be the same. Interventions for those in these stages should be two-fold.
One intervention, education, would be aimed directly at the health care professional.
With education, conscious raising can be fostered. With it, it is hoped that health care
professionals will have the resources needed to become aware of the need for
breastfeeding support in premature infants and will start to see solutions to the problem.
However, because those in the pre-contemplation stage have no intention of making a
behavior change, there would be no motivation to participate in an educational initiative.
Likewise, those in the contemplation stage also may need incentives to push them to
participate. Therefore, incentives on annual review, food, prizes and continuing
education units could serve as motivation for participation among those who lack
motivation to attend without some perceived personal benefit. With the participation in
the educational initiative, they would be exposed to content of the education that
highlights the great benefits of breast milk and the need for support and education among
mothers. With this increased awareness of the problem and possible solutions, behavior
change could be fostered.
The other intervention should be aimed at achieving some level of support and
education for the mothers. Materials that provide consistent and thorough information
could be issued to all new parents in the NICU to ensure that all mothers receive
information about initiating and sustaining breast milk feedings in the NICU. Although
this intervention would serve to enable education of mothers, it also may serve as a
conscious raising effort for the health care professional, who may be asked for guidance
and support by the mother on information contained in the educational materials. The
health care professional may then better understand the problem and the need for
behavior change to facilitate success with the breastfeeding process.
Individuals in the preparation phase intend to make a change in the next 30 days.
These individuals are ready for action oriented interventions. Therefore, clinical
pathways or protocols could foster change in how they deal with breastfeeding mothers.
Protocols or pathways, which become a part of required paperwork, could theoretically
facilitate professionals to make a commitment to change by giving protocols that
Those in the action and maintenance stages have already made changes. The
mother's positive experiences could serve as motivation from the environment, and there
could be other motivators for continued compliance from within the organizational
structure, such as acknowledgement on the annual review and identification as one who
has expertise in breastfeeding with high risk infants. Those in the action and preparation
phase also may take an active part in motivating others and facilitating more positive
change related to breastfeeding interventions in the NICU.
Thus based on the TTM, an educational initiative that includes educational
materials to parents, opportunities for education with incentives for health care
professionals, and protocols or pathways of care could be effective in facilitating change
in breastfeeding practices in the NICU, and each is theoretically matched to all of the
stages of readiness to change.
Although the primary focus of the intervention for this research is health care
professional behavior change, interventions structured to enable change in breastfeeding
practices also must target behavior change in the mothers. Theoretically, developed
interventions for the health care professionals can also be matched to mothers in each
stage of readiness to change. An educational booklet for new mothers could enable
conscious raising for mothers in the precontemplation and contemplation stages. A
breast pump loaner closet as well as milk expression guidelines and a breast milk log
(that could be included in the educational booklet) could be appropriate interventions for
those in the preparation and action stages. Appropriate interventions for those mothers in
the action and maintenance stages would include concepts such as the first feeding being
at the breast and enabling breastfeeding while in the hospital to support continued breast
milk feedings in the presence of the decision to initiate breast milk feedings.
Interventions targeted at health care professional change can be structured to
move mothers to decide to breastfeed and help them maintain that behavior once they
start. Theoretically, interventions including a breast pump loaner closet, an educational
booklet for new mothers, a breastfeeding pathway, and an educational initiative for health
care professionals can support behavior change in two different groups, the health care
professionals as well as the mothers. The health care professional group functions as a
primary support for the mothers to initiate and sustain breastfeeding.
Transtheoretical Model of Behavior Change and Methods of Education
Equally important with providing stage matched interventions for health care
professionals is consideration of what mode of learning to utilize for the conscious
raising strategy. Self learning modules can be considered easy to implement and enables
staff to participate in the learning initiatives at their own pace, enables them to take
modules home if work responsibilities prevent participation during working hours, and is
rather inexpensive when compared to other modes. The literature reflects good success
with self-directed learning modules, with good performance on post tests and learning
retention (Coleman, Dracup, & Moser, 1991). When compared with lecture-discussion
formats, self learning methods were comparable in achieving the educational objectives
being targeted within the nursing field (Nikolaj ski, 1992).
Computer based training is another method of education gaining increased
acceptance and use in the last several years with the increasing capabilities of technology.
Harrington and Walker (2004) discovered that, although both groups significantly
improved their post test scores, a group of individuals who engaged in computer based
training did significantly better than individuals in an instructor led course on fire safety
(Harrington & Walker, 2004). Research and experience are beginning to define computer
based learning as a viable option for educational purposes. However, the access to
technology and to the people who format and design the computer systems is a significant
barrier to widespread use of such learning practices today.
Not all individuals have the same learning style. While some may prefer self paced
methods, others may be more motivated and embraced in a face to face lecture and
discussion with peers. Goldrick, Gruendemann, and Larson (1993) found that 64% of
nurses in a pediatric intensive care unit had an abstract learning style and preferred self
learning modules. However, there remained 36% who preferred more traditional methods
(Goldrick, Gruendemann, & Larson, 1993).
Self directed learning, through an educational module, is an effective form of
educating health care professionals. However, not all individuals possess the learning
style necessary for successful completion of self learning modules and prefer lecture-
discussion formats. By providing both forms of educational opportunities, more health
care professionals could be encouraged to participate in an educational initiative.
Computer based training could also be effective if access to technology can be achieved.
Summary and Research Questions
The provision of breast milk has important benefits to infants, especially those in
the NICU who are less healthy and less mature at birth than full term infants. Yet
significant, but not insurmountable, barriers to breast milk feedings and breastfeeding
exist in the NICU. Health care professionals are a powerful influence (Swanson &
Power, 2005). It is proposed that change from the health care professionals can enable
mothers and infants to overcome many of the barriers to breastfeeding, and subsequently,
positive changes in breastfeeding practices can occur in the NICU. Therefore, in this
study, the effect of a 4-pronged education and support intervention to promote
breastfeeding in the NICU, based on the synactive theory and transtheoretical model of
behavior change, will be explored. The four parts of the proposed intervention are a
breast pump loaner closet, a breastfeeding pathway on the individualized care plan, an
educational booklet for mothers, and an educational initiative for health care
professionals who work with infants and mothers in the NICU. The research questions
Is there a significant difference in breast milk feeding initiation in very low birth
weight (VLBW) infants admitted to the NICU before and after implementation of
the intervention plan?
Is there a significant difference in the rate of breastfeeding in the hospital among
women with VLBW infants hospitalized in the NICU before and after the
implementation of the intervention plan?
Is there a significant difference in breast milk feedings at discharge in VLBW
infants admitted to the NICU before and after the implementation of the
* Is there a significant difference in the proportion of the hospital stay that breast
milk is provided in VLBW infants admitted to the NICU before and after the
implementation of the intervention plan?
The purpose of this study was to test the efficacy of a 4-part intervention on
improving breastfeeding practices in the neonatal intensive care unit (NICU). The
overall goal was to attempt to develop an effective intervention to assist mother-infant
dyads in the complex NICU environment.
Very low birth weight (VLBW) infants (<1500 grams) were included in the study if
they were 1) admitted to the Level II or III nursery at Shands Hospital during the study
periods and 2) had a length of stay greater than or equal to 7 days, 3) were admitted to the
NICU within the first 3 days of life, 4) were hospitalized less than 4 months, 5) achieved
full gastric feeds during their stay, and 6) had a hospital stay that did not cross over from
the pre-intervention group time period into the education initiative time period. Very low
birth weight infants were excluded from the study if they 1) had a length of stay less than
7 days, 2) were transferred to Shands Hospital after the third day of life, 3) were
hospitalized greater than 4 months, 4) did not achieve full gastric feeds during the
hospital stay, 5) had a hospital stay that crossed over from the pre-intervention group
time period to the education plan time frame, or 6) had conditions that would make
breastfeeding contraindicated as established by the physician.
Power indicates the probability of rejecting the null hypothesis, if a condition
exists. With a power of 80%, which is frequently used in the literature, there is a 20%
chance of failing to reject the null hypothesis when it should be rejected.
Prior to conducting the study, a power analysis was conducted to determine the
appropriate sample size. The mean and standard deviations of breast milk feeding
initiation were unavailable from other studies to compute an effect size and subsequently
a sample size. Therefore Cohen's Criteria was utilized to make sample size estimations
(Cohen, 1988). According to Cohen, a .2 standard deviation change is a small effect, a .5
is a medium effect, and a .8 is a large effect. For the purposes of this study, a medium
size effect was selected. By using Cohen's criteria and determining the sample size
necessary with a power of 80%, alpha of .05, and looking for a medium size effect of .5,
Cohen's Criteria indicated a needed sample size of 82 per group. Therefore the research
plan consisted of intent to conduct quota sampling with participants enrolled from the
beginning study dates for both the pre-intervention and post-intervention groups until 82
were achieved in each group.
The planned pre-intervention group consisted of all very VLBW infants admitted to
Shands Hospital NICU from April 15, 2004 forward until 82 participants were enrolled in
the study. The intervention started on March 1, 2005 with conclusion of the educational
initiative on April 15, 2005. The planned post-intervention group consisted of all very
low birth weight infants admitted to Shands Hospital NICU after implementation of the
intervention plan, from April 15, 2005 until 82 were admitted into the study. Data from
participants were collected from the same time of year to account for seasonal confounds.
Intervention 1: Breast Pump Loaner Closet
Intervention 1 consisted of the development of a breast pump loaner closet for use
by mothers with infants hospitalized in the NICU. Hospital grade breast pumps could be
checked out by mothers who had infants in the NICU to enable them to express their milk
the recommended 8 to 12 times per 24 hour period. This would enable a supply of
expressed breast milk for initiation of breast milk feedings in the infant and would enable
the mothers to establish and maintain a milk supply until the infant was able to go
directly to breast.
Intervention 2: Health Professional Education Initiative
Although there are many different recommendations and published articles about
breast milk feedings and breastfeeding in the NICU, there was no up to date, available
educational plan that could be utilized for staff education. Therefore, an education
initiative encompassing key areas of education on breastfeeding special care babies was
developed to educate as many of existing staff in the NICU as possible. The initiative
consisted of education to staff on breastfeeding to enable health care providers to have
the education and tools to support mothers in the breastfeeding process. The education
was offered through completion of a self study educational module on breastfeeding in
the NICU or through attendance at an inservice on breastfeeding in the NICU.
Education topics contained in the self study module and discussed in the inservice
included the benefits of breastfeeding, the barriers to breastfeeding, the physiology of
lactation, use of breast pumps, pre feeding interventions based on the synactive theory
and breastfeeding interventions that acknowledge the readiness of the infant. All the
information contained in the module was based on an extensive literature review to
represent evidence based practice and was designed to foster success with breastfeeding
in the high risk neonate population while acknowledging their unique needs. The
educational module was reviewed by two individuals considered to be experts in the area
of breastfeeding for establishing validity of information provided. Minor adjustments
were made to the education plan based on the expert feedback. Refer to the outline of the
educational module, appendix A, or contact the author for further details. The successful
completion of the health professional education was defined as completion of the module
or attendance at one of the inservices and a passing score of at least 80% on a post test
that was identical for either form of the education.
Intervention 3: Breastfeeding Guideline
Each medical chart contains an individualized care plan (ICP) for documentation
by nurses. This ICP was modified to also have a pathway of care for providing
breastfeeding support to new mothers (appendix B). This ICP necessitated
documentation of education and support by nurses at critical times in the breastfeeding
process. The guideline called attention to and necessitated documentation on specific key
points that were identified in the literature to be predictive of success: achieving and
maintaining a milk supply, timely pumping, skin to skin contact, and first feeding being
at the breast. It also included areas to check off, date, and sign at the following critical
times in the breastfeeding process: within 6 hours of delivery, issue and instruct in proper
pumping and breast milk storage techniques; within 24 hours, ensure proper pumping and
storage technique; on day 3 to 5, ensure that the milk has come in and trouble shoot any
problems; weekly, foster continued pumping and skin to skin care; first oral feeding,
ensure that it is a breastfeeding session; 10 days, monitor milk supply and make referrals
Intervention 4: Educational Pamphlet for New Mothers of Neonatal Intensive Care
An educational pamphlet, "A Mother's Gift", for mothers who had an infant
admitted to the NICU was developed. The outline of the educational booklet (see
appendix C) addressed the following key points: benefits of breastfeeding, how to
express and store human milk, pre-breastfeeding strategies, and cue based breastfeeding
interventions. The back of this pamphlet also included a place for mothers to document
breast milk production to facilitate communication with nurses about their milk supply.
This educational pamphlet was developed to ensure that all mothers received a standard
set of educational points during their infant's hospitalization, and that the information
contained in it was consistent with the education that the health care professionals
Intervention Plan Modification
The original intervention plan consisted of 4 parts: a breast pump loaner closet, an
education module and inservicing, changes to the individualized care plan and an
educational booklet. Prior to the initiation date of March 1, 2005, it was learned that
external funding for the breast pump loaner closet could not be obtained. Therefore, this
prong of the intervention had to be deleted from the intervention program. The study was
then conducted with the following being the intervention/education plan: the education
initiative, the mother's educational booklet, and the breastfeeding pathway addition to the
individualized care plan.
This study was a quasi experimental, matched through cohort controls, design
(Shadish, Cook, & Campbell, 2001), investigating indirect changes in breastfeeding
practices following a 3-part breastfeeding intervention in the NICU. Through this design
the pre-intervention group consisted of a group of VLBW infants hospitalized in the
NICU before the implementation of the intervention plan. This group was then compared
to the post-intervention group, which consisted of a group of VLBW infants who were
hospitalized in the NICU after the implementation of the intervention plan.
The independent variable was the implementation of the intervention as described
above. Dependent variables included 1) breast milk feeding initiation rate (was breast
milk ever consumed/breast milk feeds initiated? (yes/no)), 2) breastfeeding rate (number
of times the infant was put to the mother's breast after 30 weeks gestation divided by the
number of days hospitalized after 30 weeks gestation), 3) breast milk feeding at discharge
rate (did the infant continue to have breast milk feedings at discharge? (yes/no)), and 4)
the proportion of the hospital stay that breast milk was provided (total number of days
into the hospitalization that breast milk was provided divided by the length of stay).
The educational intervention was implemented March 1, 2005 to April 15, 2005
with opportunities for health care professionals to complete the self study educational
module or participate in an inservice. "A Mother's Gift", the educational booklet for
mothers was issued to all new mothers with infants admitted to the NICU on or after
March 1, 2005. Last, the modified individualized care plan was used in the medical chart
on all new admissions after March 1, 2005.
To promote completion of the educational initiative, incentives were given to those
who participated in the breastfeeding education initiative by way of food, prizes,
continuing education credits and documentation on the annual review of their
performance. Following the six week educational initiative, completion of the self study
educational module on breastfeeding in the NICU became part of the orientation process
to enable the same education for those staff who were not employed at Shands Hospital
during the six week educational initiative.
The educational opportunities during the initiative dates included a self study
module and/or inservices. A breastfeeding module was available for health professionals
to check out and complete at home or work. Food and prize incentives as well as 2
continuing education credits were awarded for those who completed the educational
module. For those who preferred lecture-discussion formats for learning, 1 hour
inservices were offered at least one time per week throughout the education initiative
period. Those who attended the inservices were educated on the same information
contained in the education module, however in a condensed amount of time. Therefore
one continuing education credit, in addition to food and prizes, were awarded to those
who attended an inservice during the initiative dates.
The booklet entitled "A Mother's Gift" was issued to mothers with infants admitted
into the NICU after March 1, 2005. There was a central location at the reception desk
where nurses who had new admissions could access and issue them to mothers. Nurses
were instructed to issue these booklets during staff meetings, through the monthly
bulletin and in the breastfeeding inservice that occurred over the six week period.
The modified individualized care plan with the breastfeeding pathway replaced the
old ICPs and were placed in the chart as routine paperwork as of March 1, 2005. Nursing
staff were instructed to use it by way of a monthly written bulletin. It was also discussed
in staff meetings and further reminders were given to document on it during the
breastfeeding inservices that occurred over the six week period.
The desired impact of this program was increased breastfeeding in the NICU.
However, the intervention strategies used in the current study can only be effective if
they are implemented. The full implementation of the 3-pronged intervention was
evaluated in four ways. All the educational tools (the educational module, the inservice,
the educational booklet for he mothers and the modified ICP) stressed that the first oral
feeding should be at the breast. Therefore the primary outcome measure to determine
implementation of the intervention was whether the first oral feeding was at the breast.
Second, attempts were made to track the percentage of mothers of infants newly admitted
to the NICU to whom educational booklets were issued to determine if, in fact, most
mothers were being issued this educational booklet. Last, weekly communications with
the nursing administrator indicated the degree of compliance with educational key points
based on her monthly experiences as a bedside nurse, in which she worked directly with
mothers and their babies in the NICU.
Participants were recruited by way of a data base containing all admissions and
discharges from the NICU during the two different time periods. For each infant
admitted to the hospital during the applicable time periods, an extensive retrospective
chart review was conducted. Each identified chart was first investigated to ensure that the
infant did not have any exclusion criteria. Given that inclusion criteria were met, the
dependent variables as well as demographics were collected and recorded on a laptop
Inter-rater reliability was determined in 3 different participants to ensure that
accurate variables were collected from the charts. This occurred by having another
researcher collect data on the same participants following data collection by the principal
investigator and comparing if the variables collected by the two different researchers
were in agreement.
Retrospectively, charts were reviewed and data was analyzed for significant
differences in the proportion of mothers who initiated breast milk feedings, the number of
times per day the mother breastfed after 30 weeks gestation, the proportion of mothers
who provided breast milk at discharge, and the proportion of the hospital stay that breast
milk feedings occurred. Table 2-1 summarizes the dependent variables and null
Table 2-1. Hypothesis testing according to dependent variable
Group Breast milk The Number Breast milk Proportion of the hospital
feedings of Time provided at stay that breast milk was
initiated s the Mother discharge provided
(yes, no) Breastfed Per (yes, no)
Day After 30
Pre- Al B1 Cl Dl
Post A2 B2 C2 D2
The following hypotheses and data analysis plan guided this study.
The rate of breast milk feeding initiation will be higher in the post
intervention group (A2>A1).
Data Analysis Plan: A Pearson's Chi Square was used to test two proportions for
significant differences between the two groups.
The number of times per day that an infant is breastfed after 30 weeks
gestation will be higher in the post-intervention group (B2>B 1).
Data Analysis Plan: A one-way analysis of variance (ANOVA) was not possible
secondary to a violation of the assumption of normality. Therefore, the nonparametric
Mann Whitney was used to test for differences between the 2 groups.
The rate of breast milk feedings at discharge will be higher in the post
intervention group (C2>C1).
Data Analysis Plan: A Pearson's Chi Square was used to test two proportions for
significant differences between the two groups.
The proportion of the hospital stay that breast milk was provided will be
higher in the post intervention group (D2>D1).
Data Analysis Plan: A one-way analysis of variance (ANOVA) was not possible
secondary to a violation of the assumption of normality. Therefore, the nonparametric
Mann Whitney was used to test for differences between the 2 groups.
In this study, the pre-intervention group and post-intervention group were
compared for significant differences in four different variables. For the purposes of this
study, an alpha level of .05 was chosen, which is standard throughout the literature.
Adjusting the Alpha Level
There are no statistical procedures that can simultaneously test multiple outcomes,
some of which are continuous and some of which are dichotomous. Therefore, the
significance levels of the individual tests were adjusted by the ranked Bonferroni
adjustment. There has been criticism of the standard Bonferroni adjustment being too
conservative and that, in theory, if many tests were run, the level of significance would be
so low that no differences could be detected. The ranked Bonferroni adjustment was
preferred over a standard Bonferroni adjustment to enable maximum power in initial
comparisons, by adjusting the alpha level with each additional comparison to prevent
inflation of the type I error rate. This would help to prevent the researcher from rejecting
the null hypothesis inappropriately while minimizing inappropriate stringentp value
constraints (Benjamini & Hochberg, 1995). For this study, the questions were ranked in
order of importance. The first question, whether or not there was a difference in breast
milk feeding initiation, was tested at an alpha of .05. The second question, whether or
not there was a difference in number of times breastfed after 30 weeks gestation, was
tested at an alpha of .025 (.05/2). The third question was tested at an alpha of .017
(.05/3). The fourth question was tested at an alpha of .013.
Each statistical analysis was conducted as a one sided test as it was assumed that
trends would be toward increased rates of breastfeeding with the interventions that were
One hour inservices were conducted 1 to 3 times per week for a total of 10
inservices during the intervention period of March 1, 2005 through April 15, 2005.
General attendance at each inservice was low with approximately 2 to 5 participants at
each one. Self-study modules were also available for check out during this time. Overall
response to complete the self-study modules was also low in the month of March.
Therefore, in April, the researcher started directly asking health care professionals to
complete the modules and offered food prizes for those who did. It appeared that
directly requesting participation was beneficial in promoting participation by the health
care professionals. There were 11 health care professionals who completed the self study
education modules from March 1 through March 31, 2006, and there were 45 health care
professionals who completed the educational module from April 1 through April 15,
The total number of health care professionals who participated in the educational
initiative was 88, which was 63% of health care professionals working in the neonatal
intensive care unit (NICU). The total number of nurses who participated in at least one
of the methods of education was 75, which was 77% of all nurses who care for infants in
the NICU. There were 3 rehabilitation therapists (100%), 1 nurse practitioner (9%), 2
neonatologists (20%), 2 social workers (100%), 1 respiratory therapist (10%), and 5 other
health professionals (83%). All those who participated in the education achieved a
passing score of 80% on a post test.
Nursing managers reported variable levels of compliance with the new strategies
presented in the educational initiative, contained in the educational booklet for mothers,
and on the modified individualized care plan (ICP). Starting on March 1, 2005 the nurses
initiated use of a new, revised individualized care plan (ICP) for documentation. The
revised ICP was supposed to replace the old one. However, in mid April, it was realized
that some old stores of the previous ICP, that did not include the breastfeeding pathway,
had been pulled from the shelf and were being utilized. According to the nursing
manager, this problem was resolved with full use of the new ICP by May 1, 2005.
Although all nurses were expected to follow the established guidelines on the
breastfeeding pathway, during data collection it was observed that the new ICP was not
utilized fully. One example of the lack of full implementation of the new pathway
concerned whether the first oral feeding was at the breast. On the breastfeeding pathway,
all mothers should have been encouraged to have the first feeding at the breast with
documentation accordingly or documentation stating why care deviated from the
pathway. However, the first feeding being at the breast occurred in only 25% of mothers
in the post intervention group, and with full implementation it should have approached
100%. Although it is possible that mothers were encouraged, but declined to participate
in the first feeding at breast, it is more likely that there was lack of full compliance with
the educational key points and the modified individualized care plan.
Starting on March 1, 2005 "A Mother's Gift", the educational booklet for mothers,
was available to be issued to new mothers with infants in the NICU. Initial "Mother's
Gift" educational booklets were tracked to be able to determine if the number of booklets
that were issued matched the number of admissions. Not all mothers were given the
pamphlet over the first few weeks of the intervention. There were reports of running out
of the booklets and not being able to find them. Multiple copies of these were distributed
during and after the educational initiative, but they became impossible to track as they
were frequently misplaced, redirected to the maternity floor rather than remaining in a
central location in the NICU, and others outside of the research initiative made copies of
the booklet for distribution.
Nursing managers reported variable levels of compliance with the new strategies
presented in the educational initiative, contained in the educational booklet for mothers
and on the modified ICP. One nursing administrator, who would function in the role of
bedside nurse approximately once a month and would work directly with mothers and
their babies during this time, reported certain personnel to be implementing strategies
while others, even those who participated in the educational initiative, to be consistently
ignoring the pathway of care contained in the medical chart. The nursing administrator's
occasional role of bedside nurse revealed that there were mothers who never received the
educational materials and that ICPs in the medical chart had inadequate documentation.
The pre-intervention sample data was obtained before the education plan
implementation using quota sampling from the beginning study date of April 15, 2004.
The post-intervention group was obtained after the intervention period implementation
from April 15, 2005 onward. Eighty one participants were obtained for the pre-
intervention group from April 15, 2004 through discharges on December 7, 2004. Data
collection in the pre-intervention group was stopped at 81, because the subsequent 2
admissions crossed into the treatment period. Data from only fifty four participants in the
post-intervention group was collected from April 15, 2005 through discharges on
November 29, 2005. There were no discharges from the NICU of participants who met
inclusion criteria from November 29, 2005 to December 7, 2005.
This sample included all admissions of VLBW infants admitted during the pre-
intervention study dates except for 17 infants who did not meet inclusion criteria.
Among the 17 infants who were excluded, 13 of them were extremely low birth weight
and expired shortly after birth, thus never achieved full gastric feeds. Two of them did
not achieve full gastric feeds before being transferred to another hospital, and 2 of them
had a length of stay that extended into the treatment period. The pre-intervention group
consisted of 83% of all admissions of VLBW infants admitted to the NICU at Shands
during the study dates. The sample included all admissions of VLBW infants admitted
during the post-intervention study dates except for 11 infants. Among those 11 infants
who were excluded were 9 infants who never achieved full gastric feeds and expired
shortly after birth and 2 who had genetic disorders that made eventual oral feeding
contraindicated. The post-intervention group also consisted of 83% of all admissions of
VLBW infants admitted to the NICU at Shands during the study dates.
The data collection period was not extended in order to capture the remaining 17
participants for two reasons: the first is that a long period of time had passed since the
intervention plan, and new interventions were scheduled to be implemented in the NICU.
These would have introduced significant additional confounds into the study. Secondly, a
new power analysis based on actual effect sizes of this partial sample indicated a need for
data from an additional 124 participants in the post-intervention group and 95 in the pre-
intervention group to achieve 80% power because of the already high breast milk
initiation rate (74.1%). Continuing data collection to enroll 82 in each group based on
the original research plan would have increased power from 38.6% to 45.6%, an increase
that was considered to not be feasible given the potential confounders listed above, or
likely to change the statistical outcomes.
To ensure accurate documentation of the research variables, inter-rater agreement
was tested on the chart review procedures. Another researcher conducted data collection
on 3 charts that the principal investigator had already collected data from. There was
100% agreement in 2 out of 3 of the charts. However, one chart revealed agreement of
92%, for a total inter-rater agreement of 97% for this study. The principal investigator
reviewed the chart that did not have complete agreement to find 100% agreement with
her initial findings.
Table 3-1 includes sample demographics andp values for statistical tests to rule out
selection differences. All demographics were collected as continuous or dichotomous
variables, with the exception of race. Race in the medical chart was classified as White,
Black, Asian, Hispanic or Other. Therefore, race is documented with the same
classifications. The pre-intervention group was 4% Hispanic, 42% Black, and 54%
White. The post-intervention group was 2% Asian, 3% Hispanic, 49% Black, 42% White
and 4% with undocumented race in the medical chart. Due to the majority of participants
being Black or White, with minimal representation of other racial backgrounds, and due
to Black being a known predictive factor in the literature, race was dichotomized into
Black and not Black for statistical purposes to rule out selection differences.
Table 3-1. Demographics of the pre-intervention and post-intervention groups with test
statistics for selection differences
Low Race Maternal Marital Transferred Length Birth EGA No.
SES (Black) Age Status Instead of of Weight of
(not DC Home Stay Sibs
Pre- .775 .42 25.46 .56 .432 50 1074 28.57 1.01
Post- .70 .49 25.62 .57 .327 54 1114 28.7 .86
p Value to .339 .256 .899 .860 .225 .534 .368 .762 .297
There was a large percentage of participants of low socioeconomic status (77.5% in
pre-intervention group and 70% in the post-intervention group), Black race (42% in the
pre-intervention group and 48% in the post-intervention group), and unmarried mothers
(56% in the pre-intervention group and 57% in the post-intervention group). Average
maternal age in the pre-intervention group was 25.46 and in the post-intervention group
was 25.62 years. The average birth weight in the pre-intervention group was 1074 grams,
and the average birth weight in the post-intervention group was 1114 grams. The average
gestational age (abbreviated EGA) at birth was 28.57 weeks gestation in the pre-
intervention group and 28.7 weeks in the post-intervention group. The average number of
siblings (abbreviated No. of Sibs) in the pre-intervention group was 1.01 and in the post-
intervention group was .86. Eighty four percent of the pre-intervention group consisted
of single births, and 83.3% of the post-intervention group consisted of single births. In
the pre-intervention group there were 43.2% of participants who were transferred to
another hospital instead of discharge home, and in the post-intervention group there were
32.7% who were transferred to another hospital. Average length of stay in the pre-
intervention group was 50 days and in the post-intervention group was 54 days.
Investigation for Selection Differences
Due to the matching through cohort controls research design, it was important to
first determine if there were selection differences in the two groups being compared.
Socioeconomic status was categorized into Women, Infants and Children (WIC) or
Medicaid eligibility or not WIC/Medicaid eligible. Difference in this variable between
the two groups was investigated by use of a z test for 2 proportions. Hypothesis testing
of two proportions with a z test was used to test for group differences in maternal race,
which was dichotomized as Black or not Black. Group dissimilarity based on maternal
age was investigated through an independent samples t test, while differences in marital
status (married, not married) and sex of the infant were investigated by use of a z test for
two proportions. Gestational age at birth, birth weight and number of siblings was
investigated by use of an independent samples t test. Discharge status was investigated
with a z test of 2 proportions and length of stay with an independent samples t test. By
testing each of the demographic variables at an alpha of .05, none of the demographic
variables were significantly different between the two groups (see table 3-1).
Subsequently, having no selection differences supports the ability to use the matching
through cohort controls design.
Results Per Research Question
The primary aim of this study was to implement a breastfeeding intervention that
would improve breastfeeding practices in the NICU. The results of this study are
provided per research question.
Is there a significant difference in breast milk feeding initiation in very low birth
weight (VLBW) infants admitted to the NICU before and after implementation of
the intervention plan?
Table 3-2 summarizes breast milk feeding initiation results. The breast milk
feeding initiation rate in the pre-intervention group was 74.1%. The breast milk feeding
initiation rate in the post-intervention group was 85.2%. This represents an increase of
11.1%. However, through a Pearson's Chi Square Test of 2 proportions, the p value is
.124, indicating no significant difference between groups when tested at an alpha of .05.
The odds ratio of breast milk feeding initiation is 2.013 with a confidence interval of .818
Table 3-2. Breast milk feeding initiation rates
Was Brest Milk Ever Total Test
Group Pre-Intervention Count 21 60 81
% within 25.9% 74.1% 100.0%
Post- Count 8 46 54
Intervention % within 14.8% 85.2% 100.0%
Total Count 29 106 135
% within 21.5% 78.5% 100.0%
Pearson's Chi-Square .124
Odds Ratio 2.013
Odds Ratio Confidence .818 to
Is there a significant difference in the rate of breastfeeding in the hospital among
women with VLBW infants hospitalized in the NICU before and after the
implementation of the intervention plan?
For the continuous variable of number of times breastfed per day after 30 weeks
estimated gestational age (EGA), see figure 3-1. The graph is clearly skewed toward 0.
Due to the violation of normality, a Mann Whitney nonparametric test was used to test
significance of this variable. Interpretation of this graph and variable is difficult as the
rate of breastfeeding in the NICU is significantly low at .059 in the pre-intervention
group, which is once every 17 days, and .139 in the post-intervention group, which is
once every 7 days (see Table 3-3). This variable proved to be significantly different
between the two groups with ap value of .011.
0.00000 0.20000 0.400O 0 0.60000 0.80000 1.00000 1.20000
Number of Times Breastfed Per Day After 30 Weeks Gestation
Figure 3-1. Number of times breastfed per day after 30 weeks gestation
Table 3-3. Comparison of rates of breastfeeding after 30 weeks gestation
Number of Times
subject Breastfed Per Day
After 30 EGA
Pre-Intervention Men .
Std. Deviation .18818812
Std. Deviation .24433376
Total Mean .0912059
Std. Deviation .21513898
Mann Whitney .011
To enable easier interpretation of this variable, it was dichotomized into whether a
mother ever participated in breastfeeding while in the hospital. In the pre-intervention
group, there were 25.9% of mothers who ever breastfed their infant in the hospital. In the
post-intervention group, there were 44.4% of mothers who ever breastfed their infants in
the hospital (see Table 3-4). This represented an increase of 18.5%, which achieved ap
value of .025 through a chi-square test of 2 proportions. Therefore, there were significant
differences in proportion of women who ever breastfed in the two groups, using an alpha
of .025. The odds ratio of ever breastfed in the hospital was 2.286 with a confidence
interval of 1.1 to 4.750.
Table 3-4. Rates of ever breastfed in the neonatal intensive care unit
Frequency Was the Infant Ever Total Test
Breastfed While in the Statistic
Group Pre- Count 60 21 81
Intervention % within 74.1% 25.9% 100.0%
Post- Count 30 24 54
Intervention % within 55.6% 44.4% 100.0%
Total Count 90 45 135
% within 66.7% 33.3% 100.0%
Square Significance .025
Odds Ratio 2.286
Confidence Interval 1.1 to
Is there a significant difference in breast milk feedings at discharge in VLBW
infants admitted to the NICU before and after the implementation of the
There were 35.8% of infants who were provided with breast milk at the time of
discharge in the pre-intervention group. There were 40.7% of infants in the post-
intervention group who were provided with breast milk at discharge. This 4.9% increase
resulted in a p value of .562 through a chi-square test of 2 proportions, indicating no
statistically significant difference among groups. The odds ratio was 1.233 with a
confidence interval of .607 to 2.502.
Table 3-5. Rates of breast milk feedings at discharge
Was Breast Milk Total Test
Provided at Discharge Statistic
Group Pre- Count 52 29 81
Intervention % within 64.2% 35.8% 100.0%
Post- Count 32 22 54
Intervention % within 59.3% 40.7% 100.0%
Total Count 84 51 135
% within 62.2% 37.8% 100.0%
Pearson Chi-Square .344
Odds Ratio 1.233
Odds Ratio Confidence .607 to
Is there a significant difference in the proportion of the hospital stay that breast
milk is provided in VLBW infants admitted to the NICU before and after the
implementation of the intervention plan?
Looking at figure 3-2, both groups have peaks at 0 and 1. However, there is a
larger peak at 0 in the pre-intervention group. The variable, proportion of the hospital
stay that breast milk was provided, did not achieve the assumption of normality as the
graphs are u-shaped. Therefore, an ANOVA could not be run on this variable without
violating assumptions. The nonparametric Mann-Whitney test was used to test for
significant differences. This test indicated that thep value was .108, therefore there were
not significant differences between the two groups in proportion of the hospital stay that
breast milk was provided.
O.0000 0.2000 0.40000 0.60000 0.8000 1.00000
Proportion of Hospital Stay That Breast Milk is Provided
Figure 3-2. Proportion of the stay that breast milk was provided
To look at effect size in a variable that does not have a normal distribution, the
proportion of the hospital stay was dichotomized into breast milk provided for most of
the hospitalization or not. This variable represented whether breast milk feeds were
supplied to the infant more than 50% of the length of stay not. There were 51% of the
pre-intervention group who provided breast milk for most of the hospital stay, and there
were 57% of the post-intervention group who provided breast milk for most of the
hospital stay. This gives an odds ratio 1.219 with a confidence interval of .608 to 2.444
for breast milk feeds being provided for most of the hospital stay.
The Effect of the Interventions on Breastfeeding Practices in the Neonatal Intensive
This research investigated if a three-part intervention plan designed to promote
increased breastfeeding in premature infants would have an effect on breastfeeding
practices in the neonatal intensive care unit (NICU). The three-part intervention
consisted of opportunities for education of health care professionals over a 6 week
educational initiative, an educational booklet for new mothers in the NICU, and
modifications to the individualized care plan (ICP) with a pathway of care for
breastfeeding. This intervention did have an effect on breastfeeding practices in the
NICU, but it did not result in changes across all breastfeeding variables as hypothesized.
Evidence of improved breastfeeding practices was that rates of breastfeeding
(mothers putting their infants directly at the breast) in the NICU improved following
intervention. The number of times infants were breastfed per day after 30 weeks gestation
was significantly greater in the post-intervention group than in the pre-intervention group.
Mothers in the pre-intervention group breastfed their infants after 30 weeks gestation
.059 times per day, and in the post intervention group they breastfed .139 times per day.
This works out to an average of once every 17 days in the pre-intervention group and
once every 7 days in the post intervention group. Although a statistically significant
increase was observed following the intervention, the resultant rate of breastfeeding in
the NICU remained low. After dichotomizing this variable, it was noted that there were
25.9% of mothers who ever breastfed their infant in the hospital in the pre-intervention
group. In contrast, there were 44.4% of mothers who ever breast fed their infants in the
post intervention group. This represented a significant increase of 18.5%. This provides
some support that the program had a positive effect with increased participation in
breastfeeding among mothers in the NICU. However, the overall rate of breastfeeding
participation remains low in the NICU.
The variable of ever breastfed while in the hospital is an important one, as it
requires active participation by the mother and infant. Diminished milk supply is cited as
one of the most significant barriers to breastfeeding in the NICU population. Maternal
stress has been linked to inhibition of oxytocin, which is responsible for the let down
response during pumping and breastfeeding (Lang, 1996). However, physiologically,
oxytocin is facilitated with increased mother-infant contact and environments that foster
breastfeeding ("How breast-feeding postpones ovulation," 1985). Mothers with infants in
the NICU typically experience high levels of stress and anxiety and many are
overwhelmed by the NICU environment (Nyqvist et al., 1994). Many also comment on
the loss of control of their infant to others during stays in the NICU (Lupton & Fenwick,
2001). Close contact, as in skin to skin, as well as breastfeeding, are important in
maintaining bonding in a difficult environment, promoting the milk supply and providing
some control over care for mothers (Kirsten, Bergman, & Hann, 2001). This direct
interaction of the mother and infant can be assumed to be critical to the other
Although positive trends in favor of the post-intervention group were observed
across all variables, the intervention did not have a strong enough impact to result in
significant changes in breast milk feeding initiation rates, breast milk feeding at discharge
rates and proportion of the hospital stay that breast milk was provided. This could be
due to lack of a strong enough impact of the intervention with a need for a more
extensive list of interventions or adjustment of the interventions proposed in this study,
need for consistent compliance with the research interventions to promote change, or a
different time frame for the study to detect changes.
The breast milk feeding initiation rate (was breast milk ever provided) in the pre-
intervention and post-intervention groups appears to be fairly comparable to other
research findings, which have documented rates of breast milk feeding initiation in the
NICU at 64% (Byrne & Hull, 1996), 72.9% (Meier et al., 2004), and 83% (Yip et al.,
1996). Although breast milk feeding initiation failed to reach statistical significance,
there was an increase in breast milk feeding initiation of 11.1%, which was a positive
change in the right direction as more infants received some breast milk following the
intervention. Scientists are beginning to refer to breast milk as medicine and have
initiated discussing breast milk in terms of a dose (Meier et al., 2004). Thus following
the intervention, 11.1% more infants in the post-intervention group received breast milk
at the most critical stage of their recovery. However, this variable did not achieve
statistical significance, which could indicate that the impact of the interventions was not
strong enough or that there was not enough compliance with the interventions to promote
change. It is important to note that breast milk feeding initiation reflected whether breast
milk was ever provided and not if breastfeeding ever occurred or if breast milk continued
to be supplied after the 2nd day of life or at discharge.
Although the rate of breast milk feedings at discharge (was breast milk provided to
the infant at discharge) increased slightly by 4.9%, this difference failed to reach
statistical significance. Succeeding with breast milk feedings until discharge in the NICU
population is a significant challenge for mothers with infants in the NICU. Discharge for
many of these infants did not occur until they were 1 to 4 months old. This supports
other research findings that state that some of the strongest predictors of not
breastfeeding by discharge is being low birth weight, having decreased gestational age
and being admitted into the NICU (Hwang et al., 2006; Li et al., 2005; Powers et al.,
2003; Scott et al., 2006). The findings of this study in both the pre-intervention (35.8%)
and post-intervention (40.7%) groups are comparable to other research findings, which
document breast milk feedings at discharge to be 38% (Yip et al., 1996). The low rate of
breast milk feeding in the NICU at discharge gives some insight into the significant
challenges that women encounter with succeeding with breast milk feedings through a
NICU hospitalization. However, to enable mothers with this process, it is critical that
strategies to promote long term success are implemented. Although lack of full
implementation and compliance with intervention strategies may have factored into this
research study, these results suggest that this 3-pronged intervention was not sufficient to
enable mothers to overcome the barriers to maintaining breastfeeding until the time of
hospital discharge in this complex and challenging environment.
There was no difference between the groups in the proportion of the hospital stay
that breast milk was provided. These results again highlight the importance of
determining strategies for long term success to enable mothers to succeed with the
breastfeeding process for a larger proportion of the hospitalization. Such strategies could
enable breast milk feedings until discharge and beyond.
This study complements conclusions from other studies that attention to and
education about lactation affects health care professional knowledge and support of the
breastfeeding process (Siddell et al., 2003). Many studies cite lack of health care
professional education as a significant barrier to the breastfeeding process in the NICU
(Register et al., 2000). Although improvement in breastfeeding rates in the NICU was
observed in the post education group, there is no way to determine which part of the
intervention plan may have had an effect on this variable. Other studies have concluded
that health care professionals play a significant role in breastfeeding practices in the
NICU (Swanson & Power, 2005) as does increased knowledge about breastfeeding
among mothers in the NICU (Bernaix, 2000). However, because all the interventions
were implemented together as a 3-pronged approach, it is unclear if the educational
materials for mothers, the educational initiative, or the modifications to the
ICP/breastfeeding pathway resulted in the effect on breastfeeding in the NICU.
According to the transtheoretical model of behavior change, change is a process
and sometimes requires multiple approaches that are stage matched in addition to the
passage of time. The real impact of the education perhaps could not be fully observed in
assessing the indirect impact on breastfeeding practices among mothers and infants. By
assessing the indirect impact of the education intervention on breastfeeding strategies
without measuring the knowledge and behavior change of the health care professionals, it
cannot be determined if there was a change in the health care professionals and what the
magnitude of such a change was. This calls into question whether the educational
initiative did what it was intended, which was to change health care professional
behavior. With knowledge of a change in health care professional behavior, the true
impact of education and intervention strategies on breastfeeding outcomes in the NICU
could be assessed. In addition, there were 2 behavior changes that could have been
assessed, the health care professional as well as the mother. Further measuring the
mothers' behavior change, in the presence of education from the health care professional,
would have provided useful information on whether the intervention was strong enough
to elicit positive changes in the mothers.
Although positive changes are evident, the reported compliance with strategies and
follow through of education key points was called into question by the nursing
administration. Other studies have determined that education about breastfeeding has had
an effect on breastfeeding knowledge and supportive behaviors (Ekstrom, Widstrom et
al., 2005). This research study did not measure the behaviors of health care professionals
following education. Therefore, it could be that the 3 part intervention plan was not
strong enough to elicit changes in health care professional behavior, that not enough time
passed post intervention to enable successful change or that the health care professional
change elicited following the intervention was not enough to result in positive outcomes
across all proposed breastfeeding variables. Subsequently, this study provides only
partial support for positive changes in breastfeeding practices in the NICU following the
3 part intervention.
This study is not without limitations. Limitations included inadequate
implementation of all the intervention strategies by the health care professionals, lack of
methods to determine behavior change and implementation by health care professionals,
lack of ability to give ample time for changes to be implemented without introducing
other confounds, lack of participation by key decision makers in the NICU, the inability
to control for other changes in the NICU environment, lack of a more comprehensive
breastfeeding intervention plan, and lack of a randomized sample.
An important limitation of this study was the questionable full implementation of
the strategies learned in the educational initiative as well as inconsistent use of the
modified ICP and inconsistent distribution of"A Mother's Gift". Although there was a
high health care professional participation rate in the education initiative of 63%, health
care professional behavior change and attitudes were not measured. Therefore, there is
no way to know the direct effect of the education and placement of the modified ICP in
the medical chart on health care behavior and attitudes. It can be assumed that although
there was good participation in the educational initiative by bedside nurses and the
breastfeeding pathway on the ICP was added to the medical record, there was a lack of
movement to action among many health care professionals based on the observations by
nursing administration as well as by the first feeding at the breast variable remaining low
in the post-intervention group.
Despite education about promoting breastfeeding in the NICU and how to
introduce such practices, there remained a large percentage of women (56%) who never
breastfed while in the hospital. This demonstrates that although the education may have
occurred, change was not fully embraced and implemented. Health care professionals
care for infants, including caring for nutritional feeds, in the NICU 24 hours a day, and
parents are visitors to the NICU when they come to see their infant. Breastfeeding is
typically something that health care professionals would enable, and thus its low rate
could be attributed to low health care professional support of the breastfeeding process.
This study investigated breastfeeding outcomes in the natural NICU environment in
which health care professionals may have had other priorities, may have had negative
beliefs about breastfeeding in the NICU, may have had control issues that interfered with
promoting a feeding method that they eventually cannot participate in, or may have been
suffering from bum out. However, without the intermediate measure of health care
behavior, it is difficult to determine if the intervention could be effective if health care
professionals demonstrated an appropriate behavior change and were called to action.
According to the trantheoretial model of behavior change (TTM), change is a
process with people moving through different stages of readiness to change (Prochaska et
al., 2001). The intervention plan was designed to provide interventions that are
appropriate for individuals in each stage of readiness to change. However, the
educational initiative and interventions were introduced with data collection occurring in
the post intervention group 6 short weeks later. This may not have been a long enough
period of time to enable individuals to respond to the intervention and move them to
action. According to the TTM, those in the pre-action stages are the precontemplators
(no intention of making a change), the contemplators (intention of making a change in the
next 6 months) and those in the preparation stage (intend on making a change in the next
30 days). Theoretically a six week period may not have been enough to enable
movement through the stages of change to promote action toward increasing
breastfeeding support and implementing strategies learned in the educational initiative.
In contrast, other confounds were being introduced in the NICU in the months following
the conclusion of this study, as more interventions were set to be implemented.
Therefore, this study could not account for the possible inadequate time frame due to the
potential introduction of confounds that could bias the results.
Another limitation was the weak participation in the education modules by
physicians and nurse practitioners, who are key decision makers in the NICU. Prior to
the educational initiative dates, they participated in a short, general inservice about
breastfeeding to facilitate discussion and direction. Due to this recent meeting, it was
difficult to get them to participate in the research educational initiative. Therefore,
participation was low with only 20% of neonatologists and 9% of nurse practitioners
attending an inservice or completing the self study educational module. Although the
researcher did meet with the physician medical director of the unit to discuss key points
of the educational initiative, the initiative may have been much more successful if the
neonatologists and nurse practitioners had higher levels of participation. Nursing staff
and parents look to physicians and neonatal nurse practitioners for direction, and their
lack of participation was a significant limitation to this study.
The NICU is a constantly changing environment that can not be fully controlled in
a study like this, where all infants during a specific time frame are being enrolled. This
study does not account for other changes that may have occurred, such as staff
changeover, other education that health care professionals may be receiving and
implementing, and changes made to the physical NICU environment. Cosmetic changes
were made to the NICU environment during the course of this study, and it was
impossible to determine if this may have had an effect on the results.
The lack of optimal resources that may facilitate breastfeeding may also pose a
limitation to this study. During the early stages of planning this research project, funds
were applied for to provide a breast pump loaner closet that would provide a needed
resource for long term maintenance of the milk supply (Meier et al., 2004). These funds
were not achieved, making it impossible to provide this resource to enable long term
success with maintaining the milk supply, and subsequently with addressing the idea of
providing breast milk all the way until the infant was discharged from the NICU.
Providing breast milk or breastfeeding at the time of discharge would be the goal, as this
would indicate that a mother succeeded with providing milk during the hospitalization
and would enable breastfeeding at discharge home. Without the funding, women were
left to find their own resources to access a hospital grade pump for milk expression.
Some may have accessed one for use at home while others may have used store bought
pumps or self expressed.
This study is a cohort study. Due to lack of randomization, there is the possibility
that there are unseen differences in the two groups that lead to differences or similarities
in breastfeeding practices that cannot be attributed to the intervention. Results from this
study can only give conclusions about the population of infants being studied at Shands
Hospital. In addition, the small sample size limited the ability to achieve adequate
power, which can affect being able to detect significant differences, if they exist. Based
on the utilized sample size, 38.6% power was achieved on the primary variable of breast
milk feeding initiation. This indicates that the probability of finding a difference in the
two groups was only 38.6%. The already high breast milk feeding initiation rate in the
pre-intervention group, 74.1%, gave less room for improvement in this variable.
Although comparable with other rates reported in the literature, the rate in this unit was
expected to be lower due to lack of lactation services in the unit and the large population
of Black mothers, mothers with low socioeconomic status and single mothers, which are
all predictive of decreased breastfeeding behaviors (Powers et al., 2003). The nature of
the population may have been a limitation, in that perhaps the effect of the intervention
would be different given a different demographic presence in the NICU. Given the effect
of the current intervention, a larger sample size would be needed to determine if there are
significant differences in the pre-intervention and post-intervention groups. Such sample
size was not feasible during the study period given the number of admissions and
discharges. Prolonging enrollment was not feasible given the risk of introducing
potential bias. To
Recommendations for Further Research
Women with infants in the NICU face unique challenges to the breastfeeding
process. These barriers result in decreased breastfeeding initiation rates and breast milk
feedings at discharge from the hospital. However, these fragile infants are at an increased
need for the benefits of breast milk. Therefore, further studies looking at trends in
breastfeeding and looking at interventions that can assist mothers in overcoming barriers
Future research could investigate the efficacy of educational interventions that
measure the intermediate effects of the intervention on health care professional behavior
as well as the effect on breastfeeding outcomes. With similar findings as this study, this
would make it easier to interpret if the educational interventions did not cause health care
professional behavior change and thus did not affect breastfeeding outcome or if the
educational interventions did affect health care professional behavior but that the
resultant effect of this was not strong enough to result in positive breastfeeding outcomes.
Future studies addressing an educational initiative for health care professionals
with more time to enable change would be appropriate to run in this population. If
change takes time to occur, a longer period between the intervention and the start of data
collection in the post intervention group would help identify change that occurred over a
longer period of time following the interventions. However, such a study would require
close control of the environment to prevent other confounds from being introduced as
time from the education initiative elapses.
Although an intervention with many parts that addresses milk expression and
breastfeeding over the course of hospitalization may be optimal in promoting
breastfeeding practices in the NICU, a look at intervention specific studies could help to
declare which interventions are successful and which are not. Such a study, although it
may require a much larger sample size and perhaps random assignment to groups and a
multi-center trial, could assist with understanding which, if any, and in what combination,
treatments) have an effect on breastfeeding practices in the NICU.
Further research could also investigate the specific results, amount of milk
expression and success with breastfeeding among women who had a nurse who was in an
action oriented stage of behavior change regarding support for lactation compared to
those receiving traditional NICU care. The effects of support and education for the
mother could further be investigated by including success and failure with breastfeeding
among mothers who demonstrated compliance with strategies in "A Mother's Gift"
compared to those who were not fully compliant.
With the paucity of breastfeeding (putting the infant to breast) in the NICU, it is of
great interest to determine the predictive effect of breastfeeding on breast milk feedings
at discharge, milk production, amount of breast milk feedings in the hospital, as well as
the effect on maternal and child health. Likewise, it would be of great interest to
determine if there are any negative effects of not enabling breastfeeding on the ability to
maintain the milk supply, success of breastfeeding at discharge and beyond and the
ability to transition from breast milk feeds to direct breastfeeding.
This study investigated change in breastfeeding practices following implementation
of an intervention plan with 3 parts; an educational booklet for new mothers, an
educational opportunity for health care professionals who serve mother-infant dyads in
the NICU, and changes to the individualized care plan that necessitate breastfeeding
practice documentation by nurses. There were general positive trends across all
variables, which make this type of intervention have some promise for affecting positive
changes in breastfeeding practices in the NICU, given the limitations of this study and the
difficulties that can be expected in the complex NICU environment. There were
statistically significant differences between groups in the rate of breastfeeding, with
infants in the post-intervention group being more than twice as likely to be breastfed in
While health care professionals may play a significant role in the breastfeeding
process, perhaps an educational plan and breastfeeding pathway as well as
complementary educational materials for mothers is not enough to promote full
participation and optimal breastfeeding practices in the NICU. This study demonstrated
limited, but encouraging, support for an intervention plan focused on education to
facilitate change in breastfeeding within the NICU, but perhaps a multifaceted
intervention plan, including hospital grade breast pump allocation may optimize positive
changes in breastfeeding practices. An important limitation of this study was lack of full
implementation of the intervention strategies. Future studies can be designed to better
measure compliance with educational interventions as well as the individual effect of
each intervention and the additive effect of multiple interventions implemented together.
Randomized multi-institutional studies will enable larger intervention trials as well as
generalization of findings.
OUTLINE OF THE EDUCATION MODULE
Breastfeeding in the Neonatal Intensive Care Unit
An Educational Module for Health Care Professionals
Benefits of Breastfeeding for the Full Term Infant
Benefits for Preterm or High Risk Infants
Benefits for the Mother
Barriers to Breastfeeding
Transition to Mature Milk
The Breast and Lactogenesis
General Interventions for Supporting Breastfeeding
Appropriate Timing of Interventions
Interventions in the NICU
Interventions Prior to Active Breastfeeding
Maintaining a milk supply
Early initiation of direct breastfeeding
Monitoring Physiologic Responses
Transition to Direct Breastfeeding
Interventions for Supporting Breastfeeding
Determining Adequacy of Intake
For further information, contact the authors:
Roberta Gittens Pineda: firstname.lastname@example.org
Cammy Pane: email@example.com
OUTLINE OF ITEMS ADDED TO THE INDIVIDUALIZED CARE PLAN
Within 6 hours of delivery: Mom is given "A Mother's Gift"
Within 24 hours: Ensure proper pumping (with hospital grade pump) and storage
3 to 5 days of life: Assess Mom's milk production. Address problems
10 days of life: Mom's milk supply should be at least 350 ml per 24 hours
With each parent contact: Offer support and discuss any problems
Kangaroo care is encouraged as soon as possible
First oral feeing is at breast
Mom is encouraged to breastfeed at each visit with supplementation only when
At discharge: Encourage transition to full breastfeeding while monitoring weight
OUTLINE OF THE EDUCATIONAL BOOKLET FOR MOTHERS
A Mother's Gift
Breastfeeding and Pumping for Your Baby in the NICU
Breast milk is the best food for your baby's start in life
Each mother's milk is prefect for her baby
Babies who drink breast milk are healthier and smarter
This makes breast milk even more important for premature babies
Breastfeeding is healthy for the mother too!
Providing breast milk for your baby is something very special you can do to help your
It is important to begin expressing your milk as soon after delivery as possible,
and to keep pumping
Pumping may seem complicated at first, but it is worth it for your baby
During pumping, relax and enjoy gentle thoughts about your baby
At first, you may not get any milk, or only a few drops
Here is how to store your milk
Every mother wants to know-"Am I making enough milk"
In order to maintain a good milk supply...
Most mothers really want to hold their babies
Kangaroo care is good for your baby
Kangaroo care is good for parents too
Privacy is more important to some than others...
Suckling at the breast is the best way to nourish your baby... and it takes practice
Positioning during breastfeeding will become easier with practice...
Is my baby really, really, really getting enough milk
Please take extra care of yourself too!
If you are taking medications
Making milk for twins or more...
Please ask if you have questions or need help
How to obtain a pump for home use...
Chart for tracking milk production
For more information, contact:
Roberta Gittens Pineda: firstname.lastname@example.org
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Dr. Roberta Gittens Pineda received her doctor of philosophy degree at the
University of Florida. She received her Bachelor of Science in occupational therapy at
the Florida Agricultural and Mechanical University in 1992 and achieved her Master of
Health Science degree at the University of Florida in 1994. She has worked as an
occupational therapist, primarily in the inpatient pediatric setting, and has been a lecturer
at University of Florida as well as Washington University.
Dr. Pineda's primary clinical setting is the neonatal intensive care unit, where she
most recently has specialized in treatment of feeding and swallowing problems in these
complex, medically fragile infants. In addition, she suffered premature labor with her 3
pregnancies and learned, first hand, the difficulties associated with being a mother of an
infant hospitalized in the neonatal intensive care unit.
Dr. Pineda decided on her dissertation topic following an invitation by the chief of
neonatology at Shands Hospital to be part of a March of Dimes Advisory Committee.
The University of Florida at Shands Hospital had decided to participate in a program
sponsored by the March of Dimes aimed at making the unit more developmentally
supportive and family centered. Through this project, she joined efforts with a
pediatrician to design a plan aimed at making the neonatal intensive care unit (NICU)
more breastfeeding friendly. As she had frequently assisted mothers with breastfeeding
in the unit as part of occupational therapy intervention and had struggled with the issues
of nursing in the NICU when her own son was born at 29 weeks gestation, she found
herself very passionate about fostering changes and quickly decided to focus her research
around the changes that were set to be made. Dr. Pineda's dissertation topic is entitled
"Breastfeeding Practices in the Neonatal Intensive Care Unit before and after an
Intervention Plan". Dr. Pineda has thoroughly enjoyed the research process and looks
forward to a career in research and teaching.