Questions

Speakers' answers to the open questions of the live Q&A sessions

speakers q&a

Dr. Rebecca Powell

We have noticed some mothers who had the Pfizer vaccine experience less milk supply, is it true?

Although this is still being studied, there has been no clear indication so far that there is a supply drop. Some see an increase, some see no change. If anything, it is likely just due to the general inflammation response that one may get due to any vaccine or infection and is temporary.

If you got a J&J vaccine is it possible to get a Moderna vaccine to have a higher immune response?

There is no current official guidance on boosters for J&J recipients. However, getting an mRNA vaccine as a booster would be safe to do and very likely would raise antibody levels significantly.

 

Dr. Dani Dumitriu

Would a mother who has tested positive for COVID-19 still be able to breastfeed?

YES!!! Absolutely!! COVID-19 is not a contraindication for breastfeeding! In fact - mom is likely to protect her infant by breastfeeding!

Is it true that a mother in her late forties shouldn't breastfeed, because her milk maybe isn't as good as it needs to be?

Absolutely not true! All mothers regardless of age should be encouraged and supported to breastfeed. There are VERY few contraindications to breastfeeding. There is no upper age limit for a woman to breastfeed! Women in their 40s can and should breastfeed!

We have had a few mothers on adult ICU on ventilators and while poorly babies have been sectioned and delivered due to mothers health, mothers have got to see their babies at age 20-26 days post discharge, some mothers were so upset on the fact they missed the lactation period, how do we deal with this? can mothers lactate on day 20 and onwards?

While lactation is harder to initiate weeks after delivery, it is not impossible! In fact, a woman can lactate without actually having given birth. Usually it requires a minimum of a few weeks.

Can you clarify whether the mothers after birth were separated from their newborn e.g. admission to NICU? If on NICU was mother still enabled to see her baby or was she in isolation?

Yes, this is an important point! NO separation occurred due to COVID. However, a few of our mothers in the study were separated for standard indications, such as infant prematurity. In those cases, if the mother was COVID positive, she unfortunately couldn't visit NICU for 14 days but was encouraged and supported to pump breast milk which was then given to the infant.

 

Prof. Hans van Goudoever

Is there a recommendation to pasteurize breast milk in NICU to prevent SARS-CoV-2 infection?

No, breast milk does not contain the virus and needs not to be pasteurized. Pasteurization will actually diminish some immunological properties a bit. Only milk from donors needs to be pasteurized.

 

Prof. Donna Geddes

You spoke about the ducts being primarily means of milk removal. Would you say milk storage is fairly uniform or localized in the remaining glandular tissue?
No, I would say based on the anatomic literature of the dissection of lactating human breasts (Russo and Russo) it is shown that the storage of milk throughout the breast is very heterogeneous. The milk in the alveoli vary between alveoli themselves as well as lobules and lobes.

When looking at colostrum composition and different colouring, do you happen to know if "clear" colostrum" is as nutrient dense as bright yellow colostrum is?

Unfortunately, we have not collected clear colostrum so I cannot answer that. I do not know of any literature suggesting otherwise but some suggest the colostrum can be more clear during pregnancy.

Gastric emptying in breastmilk fed NICU babies compared to fortified breastmilk?

Fortifier tends to slow gastric emptying but not to the degree that it is clinically concerning.

Gastric Emptying and Curding of Pasteurized Donor Human Milk: Journal of Pediatric Gastroenterology and Nutrition

You mentioned the first 2 pump cycles remove 70% of the milk. Can you expand on that mechanism? e.g. does that mean 70% of milk is released from lactocytes into ducts, and then removed gradually over time?

We find that the first 2 milk ejections are when we remove the most milk from the breast (this is the milk that is already secreted and stored in the alveoli of the breast). This is likely because the intra-ductal positive pressure is greater during the first 2 milk ejections, mainly due to more milk being in the breast at this time.

 

Dr. Rosalina Barroso

It was mentioned that the nursing load and workflow greatly increased during the pandemic. What did you do to motivate and influence your staff to participate in your auditing and advocating to mothers?

Even though these were hard times due to the pandemic, we schedule team meetings to reinforce the importance of breast milk. These team meetings included the delivery room team, which had a great impact in the first milk expression.

We are so quick to jump to formula in cases of hypoglycaemia, did you find success in using MOM for this situation?

Since we are quite aware of the benefits of OMM in the first days of life, our procedure is to use OMM in hypoglycemia cases. We never just jump to formula without trying to introduce first the OMM. We have been having success with this protocol.

 

Prof. Shuping Han

We are so quick to jump to formula in cases of hypoglycaemia, did you find success in using MOM for this situation?

The definition of a plasma glucose concentration at which intervention is indicated needs to be tailored to the clinical situation and the particular characteristics of a given infant. If the baby has hypoglycaemia and the own mother’s milk is not enough, we may have to supplement with formula, but we should not unnecessarily disrupt the mother-infant relationship and breastfeeding. We encourage the mother to increase the frequency of feeding and help the mother to produce enough milk for her baby.

Prof. Paula Meier

What is CTV assessing tool? Where can we find this toolkit for coming to volume?

The CTV assessment tool is a simple-to-use tool that tracks progress with establishing an optimal milk supply for breast pump-dependent mothers with infants in the NICU. It is completed by the BPC or NICU nurse daily until the mother achieves at least 350 mL of milk per day for 5 consecutive days.

It has been published in Meier PP et al. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010; 37(1):217–245.

If a mother uses the initiation phase past day 5 does it have a negative impact on supply?

This is a good question, and the answer is that we do not know for sure.  I think that after Day 5, if we still don't see 20 mLs consistently from the 2 breasts combined, we need to be concerned about some underlying pathology that is affecting the milk supply.  In our own studies, we have had mothers continue to use the stimulation pattern because they "like it better", despite our telling them not to.  I will have some published data on this in the next year.  But, always have a "red flag" when there is little milk after day 5, regardless of the pumping pattern.

How often 8 or 12 times a day do you advice mothers to pump is there any difference in the outcome?

There is no one number of times for pumping that works for every mother once secretory activation has occurred.  Some mothers can maintain an established milk volume with 3 pumpings daily, whereas others need to pump 9-10 times.  These differences are likely due to differing milk storage capacities among the women. 

As a general rule, when it is not possible to measure milk storage capacity for each mother, I start off by asking the mother to pump as frequently after birth as possible, just like a full-term healthy baby would do.  This is about 10-11 times each day.  Once the mother has experienced coming to volume (500 mLs/per day within first 14 days), the priority is to maintain that volume, and usually mothers can decrease pumping frequency.  Have the mother start by pumping one time less frequently each day for 4-5 days, and if milk volume does not decrease, try again after that.  Most mothers can maintain ESTABLISHED LACTATION (AFTER ACHIEVING COMING TO VOLUME) with 5-6 pumpings each day.

For a NICU mother, maternal health conditions may affect pumping frequency during first week postpartum.  So, in general, “Let’s pump as frequently as you can, close to 8 times a day, depending upon how you feel.”  Do not set an alarm clock to wake up, but pump if you DO wake up. 

Use the Lactahub resources on pumping to discuss the science and recommendations with NICU families. They are available free of charge from www.lactahub.org/nicu-training.

What about the idea of manually expressing for a few minutes after each feed to provide extra colostrum and help boost supply?

Many people have successfully used pumping combined with hand expression, and this is just fine.  The important thing is not to substitute the pumping for hand expression.  The full term baby sucks at breast in a unique rate and rhythm with greater pressures when milk flow is limited, as it is during colostrum.  This infant suck probably has a role in programming the mammary epithelium to optimize long-term milk synthesis and secretion.  The materials in the FLRF compendium I mentioned have lots of information about this, including explanations for family members. These are available free of charge from www.lactahub.org/nicu-training. There are about 30 videos and 25 education sheets.  Education sheets are available in English and Spanish.

What is the best way to feed the baby the expressed milk?

A baby can be fed expressed milk in many ways, and this will depend upon the baby's condition.  If the baby is too immature or too sick to suck, swallow and breathe safely, the baby should be fed by gavage.  If the baby can be fed orally, the mother should feed at breast.  If the mother is not there, the baby can be fed by bottle, cup or whatever other device the NICU uses.

We find moms usually don't see any output initially with pumping so we have them hand express after to try and obtain a few drops of colostrum during the early days.

Many people have successfully used pumping combined with hand expression, and this is just fine.  The important thing is not to substitute the pumping for hand expression.  The full term baby sucks at breast in a unique rate and rhythm with greater pressures when milk flow is limited, as it is during colostrum.  This infant suck probably has a role in programming the mammary epithelium to optimize long-term milk synthesis and secretion.  The materials in the FLRF compendium I mentioned have lots of information about this, including explanations for family members. These are available free of charge from www.lactahub.org/nicu-training. There are about 30 videos and 25 education sheets.  Education sheets are available in English and Spanish.

When pumping day 1 day 2, the collection of the minimal EBM volumes can be difficult. Can you give advice for the collection, please.

You can follow the breast pump use with hand expression if you like and mothers are willing.  If the colostrum is on the side of a container or the collection breast shield, it can be mixed with a few drops of sterile water so it is not wasted.  It can be fed to the baby mixed with sterile water.

But sometimes, when mothers use only pump machine they see a little volume and it's make them anxious to. With hand expression, we take her milk and give it immediately to their baby and it's makes her happy. It's help her to feel mother. We always use hand expression with pumping machine.

Using hand expression to encourage a mother is very effective.  My concern about hand expression in the absence of pumping is that expression is "squeezing" the milk out and the infant doesn't do this.  The infant using suction to "pull" the milk out.  The resulting stimulation to the breast is very different.  We need to always think about two priorities in these early days: 1) milk for the infant NOW and 2) protecting the mother's milk supply for later by using best practices early on.  The absence of sucking by the infant (or a pump) during this critical window puts the mother’s future milk supply at risk. The important thing is not to substitute the pumping for hand expression.

While there is likely not a negative effect for combining pumping and hand expression, there is no conclusive evidence about the effectiveness of this practice.  My concern is always trying to “teach” NICU mothers too many things at the same time, especially during the early postpartum days when they are overwhelmed with anxiety and the need to make life-and-death decisions about their babies.  Keep all as simple as possible during this time.  I do not routinely recommend both.  I recommend pumping because of the evidence to do this.  However, I would also argue that my main concern about including hand expression is the mis-direction of focus from using the pump to learning a new skill.  Despite the lack of evidence about supplemental hand expression, I do not think it is negative from a theoretical perspective.

What is the necessity of fortification in your unit that uses a huge amount of MOM. Quite different from the majority of the NICUs.

Fortification is necessary for all babies <1500 grams because they can take such a small volume of the daily pumped milk volume.  Milk is designed to nourish a healthy full-term baby, and a premature baby consumes as little as 1/10 or ¼ of an entire daily milk volume, so the actual amount of calcium, phosphorus, and protein (and other macro and micro nutrients) received by the baby is less.  Add to this the fact that a premature baby has significantly higher growth rates than a full-term baby, so a higher need for calories, and these volume-sensitive milk components.  Fortifier adds these nutrients into a small volume so that lots of extra volume is not necessary.  With the smallest, critically ill infants, it is really important to fit the mothers’ milk (nutrition) into the overall management plan, which most of the time, includes respiratory problems and their management.  This means that extra volume (beyond 180 mLs/kg/d) is not usually an option.  Thus, concentrating the nutrients into a smaller volume is the appropriate strategy.  Once babies are over 1500 g (in general), the fortifier needs can be modified and decreased, on an individual basis.

How long should a mom pump with a baby in the NICU?

Help the mother set her own goals for milk provision.  When a mother asks me this question, I always tell her specific milestones, emphasizing that the most important time is the colostrum, and then that her baby receives only her milk for the first 2 weeks post-birth.  I say, if we can have high amounts of milk all the way through to NICU discharge, we reduce the chances of all of the major complications of prematurity, including NEC, sepsis, BPD, and neurodevelopmental problems.  Then, I say, if we can continue even some mother’s milk after NICU discharge, we reduce the chances and/or severity of infections, including RSV.  I follow all of this by the dose-response of mother’s own milk and neurodevelopmental outcome, sharing the fact that the infant brain grows rapidly through to 2 years after birth, and mother’s own milk is ideally suited to nourish and facilitate optimal development of the human infant brain.

Could you send us the form/table to quantify quantity and number of extractions?

This is the My Mom Pumps for Me! milk log.  It is published in the review paper Meier PP et al. Supporting breastfeeding in the Neonatal Intensive Care Unit: Rush Mother's Milk Club as a case study of evidence-based care. Pediatr Clin North Am. 2013; 60(1):209–226.

I learnt that colostrum can be expressed from the breast after 16 weeks of pregnancy, is it possible for it to drop or pour on its own during pregnancy, say from second trimester, even without expression? And why please?

The breast begins the processes of secretory differentiation during pregnancy.  While it is normal to have some leaking/dripping occasionally during the last trimester of pregnancy, I would want to investigate a “pouring” phenomenon.  It is always important to weigh “normal” from “abnormal”, and while, rare, I would want to make sure there was not a prolactinoma or other medical condition that requires directed care.  An occasional drop is normal.  Pouring of milk would be a reason to seek medical attention.

You mentioned that manual expression alone is not enough to stimulate milk production in the early time after delivery. However I have read that utilizing both manual expression and the pump are more advantageous than either alone. In my own practice I have seen mothers become discouraged when no drops are seen with early pumping but very encouraged by the drops procured from manual expression. Do you recommend both or only pumping?

Using hand expression to encourage a mother is very effective.  My concern about hand expression in the absence of pumping is that expression is "squeezing" the milk out and the infant doesn't do this.  The infant using suction to "pull" the milk out.  The resulting stimulation to the breast is very different.  We need to always think about two priorities in these early days: 1) milk for the infant NOW and 2) protecting the mother's milk supply for later by using best practices early on.  The absence of sucking by the infant (or a pump) during this critical window puts the mother’s future milk supply at risk. The important thing is not to substitute the pumping for hand expression.

Can you share where the CTV and FLRF toolkits are available?

The CTV assessing tool has been published in Meier PP et al. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010; 37(1):217–245.

These FLRF toolkit is available free of charge from www.lactahub.org/nicu-training. There are about 30 videos and 25 education sheets.  Education sheets are available in English and Spanish.

Has anyone taken care of intubated mothers? How do we protect their milk supply to eventually help them breastfeed?

These mothers can and do pump routinely in many institutions.  They may need assistance from the nurse or a family member, and the extent to which consent for assisted pumping can be acquired prior to delivery is an asset.

 

Kimberly Seals Allers

Thank you for your very interesting presentation. I'm a pediatric nurse and breastfeeding consultant, too. My school's memory was about less breastfeeding in black people in France. And my conclusion was that African women prefer to give some baby formula because they want to be free to find a job, for example. It is not because they don't know the importance of mother's milk. 

Yes, I agree 100% --people are not struggling to know if mothers milk is better, people are challenged by HOW to make it work within the context of their lives. If you think formula means work freedom--then we have failed to properly educate on pumping and work. We have failed to properly engage all employers to have a breastfeeding policy... Agree! it is the HOW of breastfeeding that creates barriers.

 

Prof. Diane Spatz

How can we access the second to last flyer you shared from AWHONN?

AWHONN EBG is available at this link:

The Use of Human Milk During Parent–Newborn Separation (jognn.org)

Could you send us the form/table to quantify quantity and number of extractions?

Click here to download the table

How long should a mom pump with a baby in the NICU?

For an individual pumping session:

If parent is using hospital grade pump with Initiation Technology™ -they would pump for the full 15 minute pattern.

Once they switch to the 2 phase pattern, they should pump until they don’t see any more jets of milk and then an extra 2 minutes to ensure the breast is as empty as possible.

For the duration of time as a whole - entire NICU stay and beyond ideally!

Has anyone taken care of intubated infants? How do we protect their milk supply to eventually help them breastfeed?

Of course, all of my infants start out intubated!

The most important thing is the early and frequent breast stimulation!

  • Use of a breast pump
  • Within 1st hour after birth
  • Then every 2-3 hours for 8 times per 24-hour period.
  • First 2 weeks are critical for milk supply!