NICU human milk logistics portfolio
The following graphic describes the pathway of human milk through the NICU. Medela's human milk logistics portfolio provides solutions to support each of these handling steps.
Expressing human milk
When the infant cannot be fed at the breast or cannot effectively remove milk from the breast, the mother requires assistance to initiate and maintain a sufficient milk supply. The physiological and emotional challenges associated with maternal-infant separation, in addition to inadequate breast stimulation, can interfere with the establishment of breastfeeding and increase the likelihood of complications. As a result, for many mothers of preterm infants the milk pathway begins with expression – rather than breastfeeding – to initiate and maintain lactation. Expressing human milk may pose significant challenges for mothers of preterm infants.
If the initiation of lactation is delayed and the mother does not express consistently from the very beginning, it is difficult to ensure adequate long-term milk production. That is why access to appropriate equipment and timely support is essential. Mothers’ knowledge about the protective properties of their milk is a motivating factor for sustaining lactation while coping with the stress and anxiety they are likely to experience during their infant’s stay in the NICU. It is important to acknowledge that if mothers want to develop their milk supply, they will have to initiate, build and maintain lactation. It is critical to set the right expectations by informing mothers that their milk supply will increase over time. The following interventions are very important for mothers’ ability to produce adequate volumes of milk as the weeks go by:
- Teaching mothers how to use their hands for breast massage
- Removing milk early – pumping in the first hour after birth helps to remove more milk than pumping in the first six hours and it increases milk production in the following weeks
- Initiating lactation using the specifically designed, research-based initiation technology of Symphony PLUS
- Expressing frequently: pump-dependent mothers who express their milk more than six times a day produce more milk than mothers who pump less frequently. Container sizes that reflect the volume of milk the mother will be expressing can help manage expectations in the early days
- Double pumping: it increases milk output as does expressing at the bedside directly after, or even during skin-to-skin contact
Maximising milk volumes: the Symphony breast pump system
The distinctive Symphony breast pump with its Symphony PLUS program card, containing the INITIATE and MAINTAIN programs, is often the starting point for the human milk journey in the hospital. One aim of using a hospital-grade breast pump is to maximise milk output. A second aim is to ensure that the mother achieves an adequate milk supply that can nourish her infant once they return home.
The Symphony breast pump, with its features and accessories, is an excellent partner for supporting a mother and meeting her individual needs throughout the milk production journey.
Supporting the first days of lactation: Medela’s initiation technology
The INITIATE program supports pump-dependent mothers to successfully initiate milk production. The key features of the program are that over a 15 minute session, the frequency of the patterns varies, and pauses are included. This irregular sucking pattern intends to mimic that of a term born infant in the first days after birth, before secretory activation (‘milk coming in’) has occurred. The INITIATE program should therefore be used until the mother pumps 20 mL or more in three consecutive pumping sessions; then the mother can progress to the MAINTAIN program, which is designed to efficiently extract milk after secretory activation.
Research has shown that
- the INITIATE program is effective for mothers of preterm and term infants
- mothers using the INITATE program followed by the MAINTAIN program achieved significantly higher daily milk volumes over the first two weeks
- pump-dependent mothers express enough milk to support an exclusive human milk diet for their infant
Mimicking nature to optimise milk output: The MAINTAIN program with 2-Phase Expression technology
At the beginning of each breastfeed, prior to milk ejection, infants suck rapidly; this changes to a less frequent sucking pattern after milk starts flowing during established lactation. The MAINTAIN program is designed to mimic these two phases of infant sucking. In Symphony, this research-based 2-Phase Expression technology starts with a higher frequency stimulation phase of 120 cycles per minute to elicit milk ejection. When milk begins to flow, the mother can switch to the expression phase, which uses around 60 cycles per minute, to comfortably and efficiently remove milk. The mother should switch from the stimulation to the expression phase as soon as milk flows, and she should adjust the vacuum of the expression phase to the highest possible vacuum that still feels comfortable. When used under these conditions, the Symphony breast pump system has been shown to
- be comfortable
- be efficient
- feel like the baby
- deliver more milk in less time
- help maintain lactation
The Symphony breast pump is designed to support double pumping. While it is clear that pumping both breasts simultaneously saves time, research has also shown that mothers can obtain 18 per cent more milk when they double-pump with 2-Phase Expression technology compared to single pumping. In addition, it was also found that double pumping drained the breasts better as it stimulated an additional milk ejection, and the pumped milk had a higher energy content.
Collecting human milk
After it has been pumped, human milk must be handled and stored. This comes with risks of nutrient loss and milk contamination. That is why it is essential to apply best practices for the management of human milk.
The procedures for handling human milk can sometimes be complex and time-consuming and should be streamlined for efficiency. Facilities should standardise milk handling procedures with the aim of minimising
- loss of milk through unnecessary transfer between containers
- loss of quality or integrity of components in the milk
- contamination of milk
- risk of mix-ups between patients
Adaptable for all needs and processes: Medela pump sets and bottles
Each hospital is unique and requires a different approach. Medela is able to offer integral product solutions that fit each situation. Pump sets and bottles are available as both reusable and disposable products. For hospitals using sterilisation or disinfection processes, Medela reusable products are autoclavable and designed for use by multiple mothers. Medela disposable consumables have been developed specifically to provide a hygienic solution, while eliminating disinfection or sterilisation processes in the hospital.
Medela disposable products are available as Ready-to-Use or EO sterile. They are intended for single- or one-day-use in hospitals, without the need for cleaning prior to first use.
All Medela products that come into contact with human milk are made from food-grade materials and are BPA free.
Breast shields and containers in various sizes
An essential part of expressing is ensuring that the mother has the right-sized breast shield. An incorrect size can lead to discomfort, friction and may even restrict the flow of milk. Medela’s breast shields are therefore available in a range of different sizes.
Medela collection containers have small and precisely marked volume increments so that users can accurately and easily check and record the quantity of milk that has been expressed. They are available in a range of different sizes, from 35ml to 250ml. Wherever possible, milk should be stored in a container that is appropriate in size. This may be the size that is relevant for the volume the mother is pumping, or for the volume the infant is being fed per day or even per session. Either way, processes should aim to minimise the number of times milk needs to be transferred between containers. This lowers hygienic risks, reduces loss of milk and saves time, storage space and material.
The Medela disposable Colostrum Container has been developed with healthcare professionals and mothers in mind. The curved bottom is designed to minimise the loss of colostrum and human milk when being drawn into a syringe. The small size of the 35ml container is intended to make sure that mothers remain motivated while pumping, by putting their expectations regarding their initial milk production into perspective.
Labelling and tracking containers
Establishing specific protocols to minimise expressed milk feeding errors is essential. Feeding a mother’s expressed milk to the wrong infant may have consequences for the NICU infant. In addition, milk administration errors may cause the affected mother significant stress. For these reasons it is crucial to monitor the supply and track the expressed milk.
Keeping track of, transporting and warming human milk
The Pumping Log is especially designed for pump-dependent mothers. It helps to establish appropriate pumping expectations, explains the benefits of providing human milk and gives tips and hints. Additionally, this log can help healthcare professionals to keep track of and solve potential milk production issues before they become serious.
After pumping, safe storage of milk in the NICU is essential to ensure optimal nutrition for the infant. This includes appropriate labelling, which helps minimise milk mix-ups. Medela’s pre-printed labels help to ensure traceability.
With this in mind, Medela labels request the following data:
- Name of the infant
- Date of expression
- Time of expression
- Quantity of expressed milk
This basic information can ensure that the milk is given to the mother’s own infant. Additionally, if milk is frozen in a container that was not held upright, it can be difficult to assess how much milk the container holds.
Dedicated space in refrigerators and freezers, along with individually labelled trays, can also help to maintain order and avoid mix-ups or confusion.
Maintaining the cold chain
For the mother pumping at home while her infant is still in the NICU, there are some important steps that must be in place to maintain milk quality:
- Milk should be cooled straight after pumping
- The cold chain should not be interrupted
- Whether the milk should be frozen or just cooled depends on criteria such as the distance between home and hospital, the amount of milk the mother has already stored at the NICU and hospital policies.
The transportation of human milk from home to the NICU may be the most problematic part of the cold chain. The bottles of milk should be transported in a secure way that maintains their temperature. For that purpose, Medela has developed the Cooler Bag. The special insulating material of the bag, together with a pre-frozen cooling element, maintains the low temperature necessary for the milk to remain cool or frozen.
Storing human milk
Freezing, while a necessary process in the NICU, alters the integrity of the components of human milk. Though most of these changes are currently considered harmless, the milk still loses some of the value that it has when it is fresh. For example, term infants ingest millions of live cells from their mother’s milk each day. Unfortunately, these cells do not survive the process of freezing.
Establishing refrigeration and freezing guidelines that ensure minimal loss of nutrients, growth factors and many other protective components in milk is crucial.
Storage guidelines for human milk in the NICU
Guidelines for storing and thawing milk will differ according to the environment (home, maternity ward or NICU) and the condition of the infant (NICU, high risk, healthy term infant or older). In all instances, and especially for the NICU, storage times should be as short as possible.
The following recommendations are research-based and cover the human milk pathway in the NICU.
Human milk is a dynamic, living fluid with some unique characteristics that can impact handling and storage processes. One that is quickly observed after expression is that the fat in the milk will rise, usually forming a layer at the top of the collection container. If essential milk components such as fat are not well mixed, any partitioning and transfer of milk between containers may result in an inconsistent nutrient content between containers. To maximise nutritional consistency between feeds and transfers, the following steps should be followed:
- Milk should be swirled gently to redistribute the components before each handling step
- Since fat is the most variable component of human milk, pooling a number of expressions for the day’s feeding requirements may improve nutritional consistency
- To preserve both quantity and quality, transferring milk between containers should be kept to a minimum
Each transfer of milk can lead to loss, which can have a considerable impact when dealing with small volumes, such as colostrum. For infants who are not receiving feeds in the early days after birth, careful handling and use of colostrum is imperative due to its potent properties.
Recording the volume of milk in the container before freezing will help with subsequent milk management steps later on. These include assessing which milk to use for feeds, calculating the required amount of fortifier and ensuring that the container has adequate space available for the fortifier. The following simple steps can reduce the number of times milk needs to be transferred between containers:
- Recording the milk volume on the container label prior to freezing
- Leaving enough space in the container to allow for milk expansion during freezing and for the addition of fortifier, particularly for liquid fortifiers
- Following the manufacturer’s guidelines when adding fortifier; some will suggest adding it at a specific temperature or time prior to feeding
All milk that is expressed should be labelled in the order it was pumped. In general, the order of the milk provided to the infant is:
- Colostrum as early as possible after birth
- Fresh milk prioritised over frozen milk
- Frozen milk pumped in the first weeks prior to frozen milk from a later lactational stage
Warming human milk
Gentle warming is key to keeping the important, living, bioactive and essential components of stored human milk intact so that it remains as similar as possible to fresh human milk.
But temperature does not only have a significant effect on the delicate components of human milk; it also has an impact on fragile preterm infants who are born with very little body fat, thin skin and underdeveloped thermoreceptors and sweat glands, resulting in inefficient thermoregulation. These infants are not able to sense whether milk is too warm or too cool, or respond appropriately to changes in temperature. It has been theorised that milk temperature can influence infant body temperature. For this reason, in many NICUs warming feeds is considered an important step of the milk pathway.
Thawing and warming human milk gently: Calesca
Designed for individual care in the NICU, Calesca is a waterless warming and thawing device that helps optimise and standardise human milk processes. Calesca aims to maintain the integrity of human milk by warming it up to body temperature and not exposing it to high temperatures. Since it is easy to handle, it can be operated by parents, thus supporting family-integrated care and flexible feed preparation times. Calesca is able to warm milk from three different starting temperatures: room, refrigerator or freezer.
In order to maintain flexibility around the milk pathway processes, Calesca keeps milk warm for up to 30 minutes after the completion of a warming cycle.
Feeding human milk
The principal goal for infants who are not feeding at the breast is to receive the benefits of human milk with minimal compromise, while developing natural oral feeding skills to facilitate exclusive breastfeeding upon discharge. With this overall goal of breastfeeding in mind, great attention needs to be paid to the appropriate method of oral feeding. NICUs are increasingly becoming aware of feeding development in order to offer infant and mother the best chance of benefiting from breastfeeding.
Medela supports NICUs with a comprehensive portfolio of feeding solutions tailored to the various challenges and developmental stages of the preterm and hospitalised infant to facilitate direct breastfeeding.
For more information on the World Health Organization’s recommendation on breastfeeding duration visit www.medela.com/who
Lau, C. Effects of stress on lactation. Pediatr Clin North Am 48, 221-234 (2001).
Chatterton, R.T., Jr. et al. Relation of plasma oxytocin and prolactin concentrations to milk production in mothers of preterm infants: Influence of stress. J Clin Endocrinol Metab 85, 3661-3668 (2000).
Meier, P.P. & Engstrom, J.L. Evidence-based practices to promote exclusive feeding of human milk in very low-birthweight infants. NeoReviews 18, c467-c477 (2007).
Dewey, K.G. Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr 131, 3012S-3015S (2001).
Newton, M. & Newton, N. The let-down r eflex in human lactation. J Pediatr 33, 698-704 (1948).
Morton, J., Hall, J.Y., Wong, R.J., Benitz, W.E., & Rhine,W.D. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J Perinatol 29, 757-764 (2009).
Jones, E., Dimmock, P.W., & Spencer, S.A. A randomised controlled trial to compare methods of milk expression after preterm delivery. Arch Dis Child Fetal Neonatal Ed 85, F91-F95 (2001).
Morton,J. et al. Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. J Perinatol 32, 791-796 (2012).
Hill, P.D., Aldag, J.C., & Chatterton, R.T. Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants. J Hum Lact 17, 9-13 (2001).
Hopkinson, J., Schanler, R., & Garza, C. Milk production by mothers of premature infants. Pediatrics 81, 815-820 (1988).
Furman, L., Minich, N., & Hack, M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics 109, e57 (2002).
Parker, L.A., Sullivan, S., Krueger, C., & Mueller, M. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med (2015).
Meier, P.P., Engstrom, J.L., Janes, J.E., Jegier, B.J., & Loera, F. Breast pump suction patterns that mimic the human infant during breastfeeding: Greater milk output in less time spent pumping for breast pumpdependent mothers with premature infants. J Perinatol 32, 103-110 (2012).
Hill, P.D., Aldag, J.C., & Chatterton, R.T., Jr. Breastfeeding experience and milk weight in lactating mothers pumping for preterm infants. Birth 26, 233-238 (1999).
Prime, D.K., Garbin, C.P., Hartmann, P.E., & Kent, J.C. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeed Med 7, 442-447 (2012).
Hill, P.D., Aldag, J.C., & Chatterton, R.T. The effect of sequential and simultaneous breast pumping on milk volume and prolactin levels: A pilot study. J Hum Lact 12, 193-199 (1996).
Meier, P.P. Breastfeeding in the special care nursery. Prematures and infants with medical problems. Pediatr Clin North Am 48, 425-442 (2001).
Bier, J.A. et al. Comparison of skin-to-skin contact with standard contact in low-birth-weight infants who are breast-fed. Arch Pediatr Adolesc Med 150, 1265-1269 (1996).
Charpak, N., Ruiz-Pelaez, J.G., Figueroa de, C.Z., & Charpak, Y. A randomized, controlled trial of kangaroo mother care: Results of follow-up at 1 year of corrected age. Pediatrics 108, 1072-1079 (2001).
Hurst, N.M., Valentine, C.J., Renfro, L., Burns, P., & Ferlic, L. Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. J Perinatol 17, 213-217 (1997).
Hill, P.D. & Aldag, J.C. Milk volume on day 4 and income predictive of lactation adequacy at 6 weeks of mothers of nonnursing preterm infants. J Perinat Neonatal Nurs 19, 273-282 (2005).
Wolff,P.H. The serial organization of sucking in the young infant. Pediatrics 42, 943-956 (1968).
Woolridge, M.W. The ‘anatomy’ of infant sucking. Midwifery 2, 164-171 (1986).
Kent, J.C., Ramsay, D.T., Doherty, D., Larsson, M., & Hartmann, P.E. Response of breasts to different stimulation patterns of an electric breast pump. J Hum Lact 19, 179-186 (2003).
Kent, J.C. et al. Importance of vacuum for breastmilk expression. Breastfeed Med 3, 11-19 (2008).
Meier, P.P. et al. A comparison of the efficiency, efficacy, comfort, and convenience of two hospitalgrade electric breast pumps for mothers of very low birthweight infants. Breastfeed Med 3, 141-150 (2008).
Burton, P. et al. Randomized trial comparing the effectiveness of 2 electric breast pumps in the NICU. J Hum Lact 29, 412-419 (2013).
Mitoulas, L., Lai, C.T., Gurrin, L.C., Larsson, M., & Hartmann, P.E. Effect of vacuum profile on breast milk expression using an electric breast pump. J Hum Lact 18, 353-360 (2002).
Mitoulas, L., Lai, C.T., Gurrin, L.C., Larsson, M., & Hartmann, P.E. Efficacy of breast milk expression using an electric breast pump. J Hum Lact 18, 344-352 (2002).
Kent, J.C. et al. Volume and frequency of breastfeeds and fat content of breastmilk throughout the day. Pediatrics 117, e387-e395 (2006).
Prime, D.K., Geddes, D.T., Hepworth, A.R., Trengove, N.J., & Hartmann, P.E. Comparison of the patterns of milk ejection during repeated breast expression sessions in women. Breastfeed Med 6, 183 (2011).
Cossey, V., Jeurissen, A., Thelissen, M.J., Vanhole, C., & Schuermans, A. Expressed breast milk on a neonatal unit: A hazard analysis and critical control points approach. Am J Infect Control 39, 832-838 (2011).
Cossey, V., Johansson, A.B., de, H., V, & Vanhole, C. The use of human milk in the neonatal intensive care unit: practices in Belgium and Luxembourg. Breastfeed Med 7, 302-306 (2012).
Human Milk Banking Association of North America 2011 Best practice for expressing, storing and handling human milk in hospitals, homes, and child care settings (HMBANA, Fort Worth, 2011).
Jones, E. Initiating and establishing lactation in the mother of a preterm infant. Neonatal Nursing 15, 56-59 (2009).
Drenckpohl, D., Bowers, L., & Cooper, H. Use of the six sigma methodology to reduce incidence of breast milk administration errors in the NICU. Neonatal Netw 26, 161-166 (2007).
Dougherty, D. & Nash, A. Bar coding from breast to baby: A comprehensive breast milk management system for the NICU. Neonatal Netw 28, 321-328 (2009).
Hassiotou, F. et al. Breastmilk cell and fat contents respond similarly to removal of breastmilk by the infant. PLoS. One. 8, e78232 (2013).
Lawrence, R. Storage of human milk and the influence of procedures on immunological components of human milk. Acta Paediatr Suppl 88, 14-18 (1999).
Stellwagen, L.M., Vaucher, Y.E., Chan, C.S., Montminy, T.D., & Kim, J.H. Pooling expressed breastmilk to provide a consistent feeding composition for premature infants. Breast Med 8, 205-209 (2013).
Mathur, N.B., Dwarkadas, A.M., Sharma, V.K., Saha, K., & Jain, N. Anti-infective factors in preterm human colostrum. Acta Paediatr Scand 79, 1039-1044 (1990).
Rodriguez, N.A. et al. A pilot study to determine the safety and feasibility of oropharyngeal administration of own mother’s colostrum to extremely low-birthweight infants. Adv Neonatal Care 10, 206-212(2010).
Narayanan, I., Prakash, K., Verma, R.K., & Gujral, V.V. Administration of colostrum for the prevention of infection in the low birth weight infant in a developing country. J Trop Pediatr 29, 197-200 (1983).
Hanna, N. et al. Effect of storage on breast milk antioxidant activity. Arch Dis Child Fetal Neonatal Ed 89, 518-520 (2004).
Anderson, G.H., Atkinson, S.A., & Bryan, M.H. Energy and macronutrient content of human milk during early lactation from mothers giving birth prematurely and at term. Am. J. Clin. Nutr. 34, 258-265 (1981).
Eckburg, J.J., Bell, E.F., Rios, G.R., & Wilmoth, P.K. Effects of formula temperature on postprandial thermogenesis and body temperature of premature infants. J Pediatr 111, 588-592 (1987).
Gonzales, I., Durvea, E.J., Vasquez, E., & Geraghty, N. Effect of enteral feeding temperature on feeding tolerance in preterm infants. Neonatal Netw 14, 39-43 (1995).
Knobel, R. & Holditch-Davis, D. Thermoregulation and heat loss prevention after birth and during neonatal intensive-care unit stabilisation of extremely low-birthweight infants. J Obstet Gynecol Neonatal Nurs 36, 280-287 (2007).
Meier, P. Bottle- and breast-feeding: Effects on transcutaneous oxygen pressure and temperature in preterm infants. Nurs Res 37, 36-41 (1998).
Nilsson, K. Maintenance and monitoring of body temperature in infants and children. Paediatr Anaesth 1, 13-20 (1991).
Beauchamp, G.K. & Mennella, J.A. Early flavor learning and its impact on later feeding behavior. J Pediatr Gastroenterol Nutr 48, S25-S30 (2009).
Cruz, A. & Green, B.G. Thermal stimulation of taste. Nature 403, 889-892 (2000).
Meier, P.P., Engstrom, J.L., Patel, J.L., Jegier, B.J., & Bruns, N.E. Improving the use of human milk during and after the NICU stay. Clin Perinatol 37, 217-245 (2010).