TITLE: Barriers to optimal breast milk provision in the Neonatal Intensive Care Unit (NICU)

Background: In the high risk NICU setting, breast milk use is associated with decreased morbidity and improved neurodevelopmental outcomes.

Objective: This retrospective study aimed to identify patient and systems barriers to optimal breast milk use in infants admitted to a regional NICU in California.
Design/

Methods:
699 babies born at 23-41 weeks of gestation with no congenital anomalies admitted to the NICU within 3 days of birth from 9/2015 to 6/2018 were included. We examined: maternal factors and demographics; neonatal data, need for resuscitation and morbidity; length of stay; frequency of lactation support in first week, during NICU stay, and at discharge; age at first lactation consult; and breastfeeding in the NICU. Bivariate analysis and logistic regression were used to examine patient and lactation consultant service factors associated with breast milk use at discharge.

Results: Breast milk use at discharge for all infants was 89.7%: for extremely preterm (EP) 80.3%, moderate preterm 94.2%, late preterm (LP) 86.3%, and term 92.3%. Low birth weight, morbidities, length of stay, public insurance and lack of lactation support at discharge (OR 0.19 [0.09-0.38]) were associated with significantly no breast milk use at discharge (Table 1). In EP infants, need for resuscitation, morbidities, black race, singleton births, lack of lactation support during NICU stay and at discharge along with lack of breastfeeding in the NICU decreased breast milk use. In term infants, sepsis, home on gavage feeds, lack of lactation support at discharge, and lack of breastfeeding in the NICU significantly decreased breast milk use. In LP infants, inborn, C-section, older maternal age, frequency of lactation support in first week (OR 1.77[1.15-2.74]), and during NICU stay (OR 1.32[1.03-1.68]) increased breast milk use. Older age at first lactation consult (OR 0.88[0.78-1.00]), lack of lactation support at discharge, and lack of breastfeeding in the NICU (OR 0.17[0.04- 0.66]) decreased breast milk use (Table 2). LP infants benefitted from lactation support from admission through discharge. Black race and lack of lactation support at discharge were associated with decreased breast milk use in EP infants.
Conclusion(s): Compared to term infants, LP and EP infants had lower rates of breast milk use at discharge, particularly with decreased use of lactation services. Lactation support should be targeted to increase breast milk use in these high-risk populations.