Decreased Breast Milk Feedings in the NICU

Decreased Breast Milk Feedings in the NICU

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Decreased Breast Milk Feedings in the NICU

Nursing is an evidence-based profession that is premised on the application of sound theoretical frameworks in clinical settings. The development of nursing practice over the years is attributed to the formulation of various grand, middle-range, and practice-level nursing theories by industrious nursing practitioners and scholars over the years. Many of these theories are being applied in healthcare settings to improve the quality of care by making it more patient-centered and individualized, considering the wide diversity of patient needs and preferences and increased autonomy in deciding their preferred intervention modalities with nurses and other healthcare professionals being decision-making partners.

However, clinical settings are transforming rapidly as populations encounter new health challenges and innovative interventions emerge. Patients have increasingly demanded high-quality healthcare services. Similarly, nurses are operating in transformed workplace settings, while their mandate has expanded over time, as well. The combination of these two eventualities presents very different care scenarios compared to those encountered by the nursing theorists. In this regard, these transformed settings provide an invaluable opportunity for testing existing theories and determining their efficacy in novel situations.

The neonatal care setting has transformed tremendously following the significant advancements in the care of preterm babies. Nowadays, the survival of preterm infants has increased appreciably because the NICU setting is better equipped to provide high-quality care, even in the absence of the mothers and other family members. Therefore, the NICU setting is an appropriate setting for testing the veracity and applicability nursing theories on novel settings, which were inexistent when the theories were first formulated.    

Problem Statement

The phenomenon of interest is breast milk feeding in neonatal intensive care unit (NICU) settings. The NICU setting is particularly challenging because it attends to newborns that are incapable of performing many life-sustaining activities autonomously, including fulfilling their nutritional requirements through feeding. These neonates in the NICU are preterm and therefore, have underdeveloped physiological and neurological capabilities to enable them to undertake the feeding activity autonomously. Besides, the neonates are heavily reliant on breast milk because of its nutritional wholeness and its nutritional suitability for their developmental stage. Specifically, preterm babies that are admitted into the NICU require maternal milk for normal growth and development to achieve the expected milestones prior to being discharged. However, many lactating mothers are unable to physically breastfeed their babies because of the unfavorable settings in the NICU. Similarly, some mothers are unable to produce sufficient milk that can be pumped to feed their preterm infants because of various physiological and psychological experiences, which may be traumatic. Admission of the preterm babies to the neonatal intensive care unit immediately after birth can be highly challenging due to the early mother-child separation. Safari et al. (2018) revealed that mothers without the initial physical contact with their babies do not secrete sufficient oxytocin required to increase breast milk secretion. Also, Saaka and Hammond (2020) and Wang et al (2020) indicated that mothers that had undergone cesarean section rather than virginal birth initiated breastfeeding late and ceased breast feeding early. This delayed initiation of breastfeeding could be a product of policy in some hospitals where NICU settings are not made favorable for mothers to breastfeed their infants regularly. Consequently, such mothers may not have sufficient milk to be pumped for feeding their preterm neonates in NICU.

From another perspective, preterm infants were unable to develop good feeding habits because of the lack of exposure to breastfeeding while in NICU. Li et al. (2020) found from a cross-sectional study that infants that were not breastfed within an hour of birth were unable to respond effectively to feeding cues. Likewise, Gianni, et al. (2018) outlined that the rate of successful breastfeeding is lower in preterm infants compared to babies who have completed the required gestational period. Therefore, while pumped breast milk may be available in NICU from the mothers of the hospitalized neonates, the children may be unable to consume it in sufficient quantities or at all because they have poorly developed responses to feeding cues due to the lack of exposure to breastfeeding immediately after birth. 

Viewed differently, the breastfeeding challenge may be beyond the neonate and its mother, to include the hospital staff and administration. For instance, Safari et al. (2018) noted that some hospital had policies that discouraged breastfeeding in NICU, preferring breast milk pumping instead. Consequently, such hospitals did not have the facilities and conducive environments to facilitate mothers to breastfeed their preterm infants admitted into the NICU. In the same vein, the hospital staff, and particularly nurses, may lack the capacity to promote breastfeeding or breast milk pumping in the NICU setting. More critically, the nurses may not provide proper guidance to lactating mothers on how to use the breast milk pumping devices correctly. Mothers that are unable to draw sufficient quantities of milk from their breasts can be very frustrated, considering that initial lactation after birth is not consistent and may be very erratic. In turn, this post-birth period presents tension and anxiety to many mothers, considering that they are not in continuous physical contact with their preterm babies admitted into the NICU (Rossman et al., 2018). Consequently, these frustrations, along with the dislike of the breast milk pumping devices, can cause the mother to cease lactating, thus not availing sufficient breast milk to their infants.

This preliminary evidence indicates that decreased breast milk feeding in the NICU settings is a real concern because it compromises the health wellbeing of the infants admitted into these settings. This concern is exacerbated by the poor start at life that the preterm neonates are exposed to considering that they are denied the benefit of obtaining the protective factors contained in the colostrum and breast milk. Consequently, the decreased breast milk feeding has serious ramifications for the health of the preterm babies and compromises their future growth and development, while increasing the risk of morbidity and mortality if not addressed urgently.  

Research Question

The research question guiding this inquiry is why is there decreased breast milk feeding in the neonatal intensive care unit (NICU) setting. This question is prompted by the low breast feeding levels by neonates in NICU, considering that the current feeding technologies, including breast milk expression machines and storage equipment have not helped to resolve the nutritional challenge experienced by the hospitalized preterm neonates.

Related Research Studies Review

Various studies have attempted to address the challenge of reduced breast feeding in NICU settings.

Ikonen et al; (2018) investigated why mothers of neonates in the NICU had inadequate breast mild expression practices and why NICU settings did not adhere to the exclusive use of breast milk of the neonates’ mothers. The cross-sectional study revealed that inadequate milk expression practices by mothers and non-exclusive use of breast milk by hospitalized neonates were common in the NICU settings. Many mothers initiated late expression of breast milk because of their harrowing previous NICU experiences, undergoing caesarian section, challenges in psychological wellbeing, and having male infants. However these variables did not include the inadequacy in breast milk expression frequency.

Fewtrell et al. (2016) sought to identify the predictors of breast milk production by mothers of preterm infants admitted to the NICU. The NICU setting sometimes necessitated mothers to avail expressed breast milk for protracted periods when their infants were hospitalized in the NICU, amid the stress and anxiety presented by the separation from their newborns. The study revealed that comfortable breast pumps, early initiation of milk expression, and using the double pumping milk expression approach increased the volume of milk available to neonates in the NICU that could not be breastfed directly.

Leeman et al. (2019) addressed the use of lactation consultants and how they influence breastfeeding and the use of breast milk in NICU settings. Their study revealed that lactation consultants provided vital support to mothers of critically ill infants admitted to the NICU. Specifically, lactation consultations increased the breast of breast milk use in NICU settings. This study revealed the consultation support that mothers of hospitalized neonates needed to improve breast mild feeding in the NICU.

Bartick et al. (2017) quantified the adverse effects on mothers and children associated with the suboptimal breastfeeding rates in the United States. The study revealed that early and regular breastfeeding prevented diseases, such as diabetes, gastrointestinal infections, and respiratory diseases in the children, while the mothers benefited from the reduced risk of maternal high blood pressure, diabetes, and heart complications. The study found that one child was saved from death out of every 597 mothers that initiated breastfeeding at the recommended time immediately after birth. This study presented critical policy implication that could be used to promote optimal breastfeeding as a public health strategy.  

Fleurant et al. (2017)

Osterholm, E. A., & Schleiss, M. R. (2020)

Sigurdson et al. (2020)

Applicable Nursing Theories

The problem of decreased breast milk feeding in the NICU can be addressed using several nursing theories, including the interactive theory of breast feeding, conservation theory, and human care theory. These theories present different perspectives through which the problem of availing breast milk to neonates in the NICU can be understood and resolved.

The interactive theory of breastfeeding suits this problem by directly addressing the breastfeeding issue, which is central to this study. It is a middle-range nursing theory that postulates that there are concepts that influence breastfeeding and control it is a distal manner (Primo and Brandão, 2017). The concepts include the area in which breastfeeding is conducted, the body image of the mother, the maternal role, the biological conditions of the mother and child, the child’s perception, the authority of the family and society, and the organsational system that protects, promotes, and supports breastfeeding (Souza et al., 2018, p. 4). Figure 1 illustrates the conceptual framework of this theory.

Figure 1. The conceptual framework of the Interactive Theory of Breastfeeding

Source: Primo and Brandão (2017)

This theory is premised on the Conceptual System by King using the assumptions advanced by the Open Systems Model. Therefore, it describes breastfeeding as a complex and dynamic interaction between the mother and the child in which social, cultural, and environmental play a mediating role (Primo and Brandão, 2017). Besides, this interaction is primarily influenced by the time of breast feeding and the stress the activity presents. Souza et al. (2018) used this theory to develop a tool for evaluating the dynamic interaction between, child, and the environment of breastfeeding. A five-point Likert scale was using the Pasquali’s model was constructed with its scores ranging from 58 to 290. Souza et al. (2018) concluded that the scale had potential of being used in clinical practice to help healthcare professionals evaluate the factors influencing the dynamic interaction between the mother, child, and environment for breastfeeding. Consequently, nurses could use this tool to formulate interventions that would ensure that the newborn benefits from breast milk feeding early in its life to forestall complications later in life.

The Interactive Theory of Breastfeeding addresses the four metaparadigms of nursing; person, health, environment, and nursing. The breastfeeding phenomenon can be used to evaluate the applicability of this theory by assessing how it attends to the four metaparadigms. According to this theory, health is viewed as the positive outcome emanating from the productive interaction between mother and child in the breastfeeding activity.  Similarly, the preterm child or a sick child constitutes the persons with independent perceptions about breastfeeding. The environment is the breastfeeding area while nursing is about the role played by nurses to promote exclusive breastfeeding during the time in NICU and after the child is discharged.  

Other nursing theories include the child health assessment model, by Kathryn E. Barnard, the theory of human caring by Jean Watson, and conservation theory by Levine. 

Conservation theory, which was advanced by Levine has been explored by different researchers for its application in various healthcare environments. For this literature review, the evaluation will be restricted to healthcare settings involving conservation. The literature will help to determine the viability of Levine’s theory and its application to the research question. Missi, Dallaire and Hardy (2022), in a study to determine the connection between status of a discipline and care, and how knowledge contribute to advanced practice, explores the different methods that nurses can use to improve the care provided to preterm babies due based on their structural and physiological vulnerabilities. In the study Missi et al. (2022) refer to Levine’s conservation theory as a model that enabled their study to appreciate the nurse as a change agent who plays a preponderant role in the NICU setting. The theory also provides a fluid interface between the internal and external environments. According to Missi et al. (2022), the model was particularly helpful in the study because of its emphasis on how the environment affects the preterm infant’s biopsychosocial dimension. The study revealed that advanced care founded on an intermediate theory, such as Levine’s conservation theory can reduce structural developmental challenges and mortality. Mefford and Alligood (2011) also tested the theory in a study to evaluate health promotion of infant in NICU. The authors used structural equation modelling in ex post facto research involving 235 pre-term infants. The reliability of care was measured against the mediated effects on physiologic maturity. The model was consistent in improving the infant’s health and its utility was supported in the study.

The effectiveness of Levine’s conservation theory has also been researched by different scholars to determine whether it presents a viable model for health conservation and restoration. In a study to explore role of the theory in restoring the health of children suffering from cancer and with nutritional problems, Saudi, Allenidekania and Agustini (2021) involved five pediatric children and listed the domains that required conservation including energy, structural, personal, and social integrity. Through focused nursing on the listed domains, the general health of the pediatric patients improved. Nutritional disorder affects patients’ response to treatment and adaptation to changes in the external environment (Saudi et al., 2021). The problem explored in the research is lack of maternal breastfeeding and milk pumping in the NICU setting, which affects the infant’s nutrition and adaptation. The outcomes of the study demonstrate that Levine’s conservation theory can be effectively used to conserve the infants’ health by addressing the nutritional problem. The viability of the theory was also explored by Ozcan and Eryilmaz (2021) in randomized controlled study to determine its effectiveness on the post-natal mothers’ quality of life. The study has been integrated into the literature because it focuses on maternal care, which has been outlined in the study as crucial for the health of pre-term infants. Lack of maternal breastfeeding and milk pumping in the NICU may point to wide range of problems including the mother’s disassociation with baby. In the study by Ozcan and Eryilmaz (2021), the mothers who received focused nursing care for conservation demonstrated improved quality of life. The study concludes that Levine’s conservation model provides a reliable framework for integrative care.

Summary of Findings

Literature review matrix

Author(s) and publication titlesTheory/conceptsSubjects/settingsEmpirical indicatorsKey findings

Applicability of the Theories

The Interactive Theory of Breastfeeding, child health assessment model, the theory of human caring, and conservation theory can be used to address the research problem, which is the reduced breast milk feeding in the NICU. This analysis interrogates the applicability of these theories by addressing the four metaparadigms of nursing theory to help formulate wholesome patient-centered interventions.


Bartick, M. C., Schwarz, E. B., Green, B. D., Jegier, B. J., Reinhold, A. G., Colaizy, T. T., … & Stuebe, A. M. (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal & Child Nutrition13(1), e12366.

Bellù, R., & Condò, M. (2017). Breastfeeding promotion: evidence and problems. La Pediatria Medica e Chirurgica39(2).

Fewtrell, M. S., Kennedy, K., Ahluwalia, J. S., Nicholl, R., Lucas, A., & Burton, P. (2016). Predictors of expressed breast milk volume in mothers expressing milk for their preterm infant. Archives of Disease in Childhood-Fetal and Neonatal Edition101(6), F502-F506.

Fleurant, E., Schoeny, M., Hoban, R., Asiodu, I. V., Riley, B., Meier, P. P., … & Patel, A. L. (2017). Barriers to human milk feeding at discharge of very-low-birth-weight infants: maternal goal setting as a key social factor. Breastfeeding Medicine12(1), 20-27.

Hoy, S., Harrison, J., Craig, A., & Lafrenière, G. (2021). “The calm in the storm”: A scoping review of hospital-based peer support breastfeeding interventions. Diversity of Research in Health Journal4(1), 22-22.

Ikonen, R., Paavilainen, E., Helminen, M., & Kaunonen, M. (2018). Preterm infants’ mothers’ initiation and frequency of breast milk expression and exclusive use of mother’s breast milk in neonatal intensive care units. Journal of clinical nursing27(3-4), e551-e558.

Leeman, K. T., Barbas, K., Strauss, J., Adams, S., Sussman-Karten, K., Kelly, A., … & Hansen, A. (2019). Improving access to lactation consultation and early breast milk use in an outborn NICU. Pediatric quality & safety4(1).

Li, Z., Mannava, P., Murray, J. C. S., Sobel, H. L., Jatobatu, A., Calibo, A., … & Chhour, Y. M. (2020). Association between early essential newborn care and breastfeeding outcomes in eight countries in Asia and the Pacific: a cross-sectional observational-study. BMJ Global Health5(8), e002581.

Namnabati, M., Zamanzadeh, V., Valizadeh, L. V., & Nyqvist, K. H. (2017). Theory of infants’ transition management from the neonatal intensive care unit to home: a qualitative study. International Journal of Pediatrics5(1), 4151-4162.

Osterholm, E. A., & Schleiss, M. R. (2020). Impact of breast milk‐acquired cytomegalovirus infection in premature infants: Pathogenesis, prevention, and clinical consequences?. Reviews in medical virology30(6), 1-11.

Palmquist, A. E., Holdren, S. M., & Fair, C. D. (2020). “It was all taken away”: Lactation, embodiment, and resistance among mothers caring for their very-low-birth-weight infants in the neonatal intensive care unit. Social Science & Medicine244, 112648.

Primo, C. C., & Brandão, M. A. G. (2017). Interactive Theory of Breastfeeding: creation and application of a middle-range theory. Revista Brasileira de Enfermagem70, 1191-1198.

Saaka, M., & Hammond, A. Y. (2020). Caesarean section delivery and risk of poor childhood growth. Journal of Nutrition and Metabolism2020.

Safari, K., Saeed, A. A., Hasan, S. S., & Moghaddam-Banaem, L. (2018). The effect of mother and newborn early skin-to-skin contact on initiation of breastfeeding, newborn temperature and duration of third stage of labor. International Breastfeeding Journal13(1), 1-8.

Sharp, M., Huber, N., Ward, L. G., & Dolbier, C. (2021). NICU-Specific Stress Following Traumatic Childbirth and Its Relationship With Posttraumatic Stress. The Journal of perinatal & neonatal nursing35(1), 57-67.

Sigurdson, K., Morton, C., Mitchell, B., & Profit, J. (2018). Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of Perinatology38(5), 600-607.

Sigurdson, K., Profit, J., Dhurjati, R., Morton, C., Scala, M., Vernon, L., … & Franck, L. S. (2020). Former NICU families describe gaps in family-centered care. Qualitative health research30(12), 1861-1875.

Souza, C. O. N. D., Ruchdeschel, T., Resende, F. Z., Leite, F. M. C., Brandão, M. A. G., & Primo, C. C. (2018). Interactive breastfeeding scale: proposition based on the middle-range theory of nursing. Escola Anna Nery22.

Wang, Y., Fang, X., Liu, C., Ma, X., Song, Y., & Yan, M. (2020). Impact of intraoperative infusion and postoperative PCIA of dexmedetomidine on early breastfeeding after elective cesarean section: a randomized double-blind controlled trial. Drug Design, Development and Therapy14, 1083.

Xiang, X., Xia, S., Zhu, X., Gao, X., Gao, X., Zhang, A., … & Hei, M. (2020). Attitudes and concerns of neonatologists and nurses to family-integrated-care in neonatal intensive care units in China. Translational Pediatrics9(5), 603.

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