Skip to Content
A home for paediatricians. A voice for children and youth.

Position statement

CPS

Breastfeeding and human milk in the NICU: From birth to discharge

Posted: Jun 6, 2023

The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.

Principal author(s)

Christopher Tomlinson MB ChB, PhD, Laura N. Haiek MD, MSc, Nutrition and Gastroenterology Committee

Paediatr Child Health 28(8):510–517.

Abstract

It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.

Keywords: Breastfeeding; Human milk; NICU; Policies; Preterm; Skin-to-skin care; Very low birth weight

 

The rationale for breastfeeding and providing human milk in the NICU

Breastfeeding, exclusively for the first 6 months of life, and sustained for up to 2 years or longer with appropriate complementary feeding, is the biologically normal and the unequalled method of feeding infants[1].

Human milk is made to meet the needs of human babies, and is superior to other feeding alternatives[2][3]. Breastfeeding and human milk support optimal growth[4]-[7], improve immune function[8][9] and neurodevelopment[6][10], and prevent bowel and septic complications, including necrotizing enterocolitis[11]. Positive outcomes from breastfeeding for both child and maternal health, in the short and longer term, have been well established[12]-[14]. Both the importance of human milk for health outcomes and specific ways and means to support breastfeeding in the neonatal intensive care unit (NICU) have been endorsed in clinical guidelines from the World Health Organizations (WHO), UNICEF, and other leading health organizations and experts[7][15]-[17]. In Canada, the rate of preterm birth hovers at around 8%, with approximately 75% of these infants born late preterm and the remaining 25% born before 34 weeks gestational age (GA)[18]. Most babies admitted to a NICU in Canada are either late preterm (24%) or full term (42%)[19]. While survival rates continue to improve, adverse neurodevelopmental outcomes are still a significant problem for infants born prematurely, their families, and society. Growth in preterm infants is an important determinant of neurodevelopmental outcomes[20], and human milk is key to optimal growth and health for this vulnerable population.

Most women in Canada intend to breastfeed their babies[21], but delivering a preterm or ill infant presents unique challenges to this goal, because many of these women are not able to feed infants at the breast right from birth. However, they often can – with appropriate support – begin to do so when they and their infants become stable[22].

When feeding at the breast is not possible, the first alternative is to feed expressed breast milk from the infant’s own mother. When a mother’s own milk is unavailable, contraindicated, or limited despite appropriate breastfeeding support[7], pasteurized donor human milk (PDHM) from a regulated milk bank is the recommended supplemental or replacement feeding for eligible infants[2]. When PDHM is unavailable, either a regular or preterm commercial milk formula (depending on the infant’s GA and condition), is the next alternative for meeting the infant’s nutritional needs. Commercial milk formula  should only be administered for recognized medical indications. The WHO, UNICEF, the Academy of Breastfeeding Medicine, and the Breastfeeding Committee for Canada each provide a list of such indications[7][23]-[26].

For fast-growing very low birth weight (VLBW) infants, the nutrient content of human milk is insufficient for optimal growth. The use of multi-nutrient fortifiers that contain energy, protein, calcium, phosphorus, and micronutrients can enhance in-hospital growth[27]. Most fortifiers used in Canada are bovine milk-based. One brand of human milk-based fortifier is currently available, but there is insufficient evidence to conclude that it is superior to bovine-based products[28]-[32]. Human milk-based fortifiers have been used as rescue therapy for infants with an extreme feeding intolerance to bovine-based products[33].

Because the ability of late preterm infants to breastfeed efficiently may be overestimated, special attention to avoid complications such as excessive weight loss, hypoglycemia, and hyperbilirubinemia is required[34].

When to initiate feeding at the breast in the NICU

All infants who are able to breastfeed should be fed at the breast within 1 h post-birth or as soon as they are clinically stable, regardless of GA or weight[6][7]. It has been documented that preterm infants have much earlier competence for breastfeeding than previously thought[6][35]-[39]. The first attempts of infants to suckle at the breast vary: some newborns will just sniff, while many others will start by licking, smacking, tasting, rooting, or suckling[35][39]. These behaviours are seen in infants as early as 28 weeks of postmenstrual age (PMA)[36][39], and certainly from 32 weeks PMA onward[35], and can be facilitated with adequate support.

When feeding at the breast is not possible

How infants are fed until feeding at the breast becomes established depends on their maturity and clinical stability (an absence of severe apnea, desaturation, or bradycardia, for example)[7]. More mature infants are usually able to feed at the breast right after birth, whereas less mature or ill infants need to be started with enteral feeding via tube, then transitioned directly to the breast or another oral feeding method[7]. VLBW infants are routinely placed on parenteral nutrition (PN) from birth to promote postnatal growth. Larger infants may also need PN or intravenous (IV) fluids to meet their nutritional or medical needs, depending on the underlying diagnosis and whether their mother’s own milk or PDHM is available for enteral feedings within the first few days post-birth.

How to prioritize feeding methods

Oral feeds

For infants admitted to the NICU whose mothers intend to breastfeed, the first oral feeding should be at the breast. There is no need to systematically empty the breast through expression or to evaluate the infant using a bottle or other method before feeding at the breast[7]. When oral feeding readiness needs to be evaluated, this assessment should be made at the breast, whenever possible. When a mother is producing abundant milk or her milk ejection reflex is especially strong, it can help to express milk before feeding at the breast to avoid overwhelming the infant with the flow, gradually decreasing the amount expressed as the infant’s suck/swallow/breathe pattern matures[7].

Feeding at the breast is possible even when an infant is receiving nasal continuous positive airway pressure (nCPAP). This emerging practice has been supported by the evidence for safe bottle-feeding while on nCPAP[40][41], and the recognition that premature infants maintain their physiological status better when fed at the breast compared with bottle-feeding[42]. One Danish study demonstrated that in a large cohort of 1488 preterm infants, 21% had their first breastfeeding experience while on nCPAP, with 62% of 60 extremely preterm infants in the same cohort suckling while on nCPAP[35]. Training for NICU personnel and having clear feeding protocols in place are needed to ensure that breastfeeding while on nCPAP is implemented safely[43].

Infants on enteral feeds should be supported to transition directly to feeding at the breast[7]. When this is not possible, the infant may need a transitional phase, where the mother expresses milk directly into her baby’s mouth or uses a spoon, cup, lactation aid, or bottle, depending on the baby’s maturity and anticipated duration of use. Bottle-feeding should be avoided as much as possible because it interferes with learning to breastfeed[7].

Enteral or IV feeds

Infants who are not physiologically stable or who cannot tolerate oral feeds should be started on enteral feeding or IV fluids (which may include PN), depending on their GA and medical condition, and the availability of human milk. For these infants, trophic feedings in the first days post-birth with nutritionally insignificant volumes of enteral substrate, preferably colostrum, stimulates development of the infant’s gastrointestinal (GI) system, supplies nutrients, and prevents GI atrophy[7]. Small amounts of colostrum, applied to the oral mucosae of infants on IV feeds, should also be administered early in the NICU admission to support development of the infant’s microbiota[7] and improve immune function. Fresh breast milk from a preterm infant’s own mother contains probiotics that are uniquely beneficial[44].

How feeding guidelines can support breastfeeding

The goal of feeding strategies for NICU infants of any GA is to achieve optimal growth while minimizing complications related to prematurity, a medical condition, or both. Also, feeding guidelines should support mothers to exclusively breastfeed by the time of discharge, or at least to provide their infants with as much human milk as possible. Despite these shared goals, feeding practices and protocols vary widely among NICUs in Canada. However, general principles tend to apply. For example, for more premature infants requiring parenteral nutrition, the aim is to transition to enteral feeding in the shortest possible time to decrease central IV line-related complications while maintaining optimal growth and nutrition[45]. For these infants, most protocols define an enteral starting volume and adhere to increasing intake at a linear rate. When developing NICU protocols, it is important to consider not only weight and PMA, but also the average increase in both infant physiological intake and maternal milk production[7][24][46]. Considering these factors may help decrease the use of commercial milk formula during feeding progression, provided this is the parents’ goal.

Supplementing human milk with fortifiers is often required to support optimal growth. However, the timing, duration, and level of fortification varies considerably among units, with no clear consensus at present. Most NICUs start when an infant can tolerate an intake of 100 mL/kg/day, but others advocate starting earlier, despite lack of evidence to support the practice[45]. Fortifiers should be weaned as soon as possible to avoid interference with feeding at the breast.

As infants mature, the transitions from enteral feeding to feeding at the breast and from scheduled to infant ‘cue-based’ feeding need to be supported without unjustified restrictions on frequency, intervals between feeds, or duration of feeds at the breast. Test-weights obtained before and after breastfeeding, or by measuring daily weight gain, can be used to assess milk transfer. Remaining intake requirements can then be administered using another feeding method[7][46]. During gavage feeding, it is important to place infants at the breast when they show feeding cues (e.g., licking, smacking, tasting, rooting, or suckling) whether spontaneously or after being stimulated to do so[39].

Feeding guidelines that support early and unrestricted access to the breast regardless of infant GA, PMA, or weight[7], together with a supportive NICU environment, help mothers and babies to attain exclusive breastfeeding (at the breast), which can occur as early as 32 weeks PMA but is more typically achieved between 34 and 39 weeks PMA[35][36][38][39].

How to support mothers to establish and maintain sufficient milk production

Mothers should be supported to express their milk if they are unable to breastfeed or are separated from their infant, or when their infant is unable to feed at the breast or cannot feed efficiently[7][47][48]. The daily volume of expressed milk is the strongest determinant of breastfeeding exclusivity and duration for preterm and ill infants[7]. Establishing milk supply is a time-sensitive process[7][47]. Maternal milk expression needs to start as soon as possible, preferably in the first 1 to 3 h post-birth and certainly within 6 h post-birth[7][49][50]. Expression needs to continue by hand or using a pump at least 7 to 8 times per 24 h, with at least one pumping session during the night[7]. Mothers should aim to establish a milk volume of at least 500 mL/day in the first 14 days post-birth because it is more difficult to increase milk production after it has been low initially[7]. Access to a hospital-grade double pump in care units where mothers and infants are cared for post-birth and for use at home can help reach and maintain milk supply[7].

Skin-to-skin (or ‘kangaroo’) care has been associated with higher volumes of expressed milk and improving breastfeeding exclusivity and duration[51][52]. There is evidence of a dose-response effect for skin-to-skin care on breastfeeding in preterm infants, meaning that positive effects are greater when practiced for longer times per day throughout the hospital stay[35][53][54]. Skin-to-skin care also has an important role when transitioning from enteral feeding to feeding at the breast. Furthermore, skin-to-skin care is used in the non-pharmacological control of pain, and for comforting infants admitted to the NICU[7][55][56].

Multiple guidelines exist for safe practice of skin-to-skin care, with no detrimental effects on physiological stability reported for preterm infants, even if extremely preterm or when they are on assisted ventilation[51]. Due to its documented benefits and safety profile, early skin-to-skin contact, ideally with the infant’s mother, should be facilitated immediately or as soon as possible after delivery. Parents should be allowed, and encouraged, to provide skin-to-skin care every day, for as long and as often as they are able and willing to do so, throughout the NICU stay[6][7].

Rooming-in allows the mothers of preterm infants to recognize feeding cues[57] and promotes breastfeeding[7][35]. Access to single family rooms in the NICU also improves breastfeeding outcomes[7][35][58]-[60]. When a bed in the NICU is not available, parents should be able to rest comfortably at their newborn’s bedside (i.e., in a chair with armrests, or a recliner)[61] and their presence and involvement with infant care should be unrestricted[7] (e.g., at night, during shift changes or medical rounds, or in emergency situations). They should also be accommodated to sleep in a room in or near the NICU for as long as possible, and minimally for the last days before their infant is discharged[22]. When separation is unavoidable, feeds should be coordinated to prevent an infant from being tube- or bottle-fed just before the mother arrives to breastfeed, either from the postpartum unit or from home[7]. The COVID-19 pandemic further underscored the importance of mothers and infants staying together in the neonatal setting, with necessary hygienic precautions[62]. When infection prevention and control measures prevent a mother from being present in the neonatal unit, she should be encouraged to express milk frequently for her infant, with a view to establishing breastfeeding when they are reunited[62][63].

Domperidone may be indicated for off-label use as a galactagogue, to increase milk supply[64], by blocking dopamine D2 receptors in the anterior pituitary and stimulating the release of prolactin[65]. Domperidone use should complement, not replace, a thorough evaluation for medical causes of delayed lactogenesis or low milk supply[23[65][66] and non-pharmacological interventions, such as milk expression, skin-to-skin care, and rooming in, which are known to increase milk production. A 2021 systematic review and meta-analysis showed that domperidone is effective to treat low milk supply in women with preterm infants, without significant side effects[67]. Nevertheless, there remains uncertainty regarding its impact on breastfeeding outcomes[64][65][68] as well as concerns about rare but serious dose-related side-effects, particularly psychiatric manifestations[69] and risk of a prolonged QTc interval[65][66][70]. Due to lack of clear guidelines, a risk-to-benefit approach based on screening for a past medical history and concomitant use of medications, rigorous informed consent, prescription at the lowest effective dose, close follow-up of the dyad and very slow tapering, are essential[66][69][70].

How to create a NICU environment that supports optimal and safe feeding practices

Hospital policies and practices should convey a framework for care in a family-centred, supportive environment for breastfeeding and human milk provision. Care should be delivered in a respectful, coordinated, safe, and consistent manner that accommodates the unrestricted presence of parents. Because provision of human milk is one of the safest and  most effective therapies available[7], parents should be recognized as fully participating partners on the caregiving team[61][71]. When NICUs empower mothers to care for their infants and support them to express milk and breastfeed, they are also promoting relational closeness (“bonding”) and building maternal confidence with infant handling and early parenting behaviours. Supplying milk can also help mothers cope with any stress and trauma related to their infant’s condition[7].

To these ends, each hospital should adopt a clearly written infant feeding policy[6][7][23] that will serve as a framework for developing and implementing breastfeeding and human milk-related procedures and protocols in individual units where mothers and infants are cared for, including the NICU.

Training for NICU staff who provide infant feeding services should include the knowledge, competence, and skills needed to successfully implement breastfeeding practices[6][72]. NICU services should include lactation consultants[73] and nursing staff with expertise in breastfeeding support[7]. Counselling on the importance and management of breastfeeding should be part of routine prenatal care. Women at risk of having an infant admitted to the NICU should be informed in advance regarding how they will be supported to establish milk production and early breastfeeding[7].

Infant feeding is a key NICU activity with multiple challenges, particularly when establishing milk supply and breastfeeding[7][47][48][74]-[77]. Encouragingly, many NICUs in Canada are moving toward the implementation of best practices that support both mothers and infants[47][78]. Hospital managers and care providers should be encouraged to set realistic – but also ambitious – objectives for their NICUs[7].

How to ensure the safe handling of mother’s milk

NICUs should have established procedures for safe and appropriate handling of mothers’ milk, based on those used by milk banks[79]-[81]. Guidance should address hand hygiene, the sterilization and proper handling of pump parts and containers, storage protocols, and the safe transportation of milk to the NICU[79]. Mothers should be counselled and supported to ensure safe handling and storage of expressed milk.

Contraindications to breastfeeding

Breastfeeding is rarely contraindicated[3][5]-[7][17][23][25].

In Canada, mothers with human immunodeficiency virus (HIV) and human T-cell leukemia-lymphoma virus are advised to feed their babies with commercial milk formula rather than mother’s own milk[82]. Maternal cytomegalovirus (CMV) infection remains a concern because unpasteurized breast milk from mothers with positive CMV status (about 55% of mothers in Canada) carries a small but measurable risk of infection for preterm infants[2][83][84]. However, the routine testing of mothers for CMV status is not recommended, and CMV is not considered a contraindication to breastfeeding[17][85].

Albeit rarely, a temporary or permanent avoidance of breast milk may be justified when mothers are using certain medications (e.g., some cancer drugs and nuclear medicine agents)[3][6][23][25]. Information on the compatibility of medications and breastfeeding can be obtained from reputable databases[86]-[88] and professional statements[5][89]-[91].

Ongoing maternal use of illicit drugs (e.g., cocaine, heroin, phencyclidine) and excessive alcohol use can expose the infant to hazardous effects via breast milk[1][23]. In such cases, replacement of mother’s own milk may be necessary. Recreational marijuana and tobacco smoking are not contraindications to breastfeeding or feeding mother’s own milk, but reduced use and cessation should be encouraged[1][5][89][92].

What should be included in the discharge plan

The NICU team, with the infant’s parents, should develop an individualized discharge plan during the hospital stay to support their feeding goals when transitioning to home[64][93]. Specific planning can help mothers to maintain their milk supply and provide infants with as much human milk as possible, or to progress to exclusive breastfeeding if that has not been achieved by discharge[7][93]. Earlier discharge will be facilitated by maximizing skin-to-skin care and supporting mothers and infants with feeding at the breast[7].

Discharge services should be planned for and coordinated, such that parents and their infants have access to ongoing, timely, and skilled breastfeeding support[6]. Parents of multiples, or of infants born very preterm or with complex medical conditions, need special attention and support to optimize breastfeeding.

Recommendations

Hospital and neonatal intensive care unit (NICU) managers and clinicians in Canada should develop and implement policies and protocols to optimize breastfeeding and the provision of human milk for premature and other at-risk infants admitted to the NICU, including the following best practices:

  1. Adopt an evidence-based infant feeding policy that is implemented by a skilled multidisciplinary team, including lactation consultants and nursing staff with expertise in breastfeeding support.
  2. Inform mothers at risk of having an infant admitted to the NICU about in-hospital supports and services to help establish early breastfeeding and optimize breast milk production.
  3. Provide a family-centred environment for breastfeeding and the provision of human milk that ensures parents’ unrestricted presence in the NICU, enables mothers and their infants to remain together, and facilitates their full participation in infant feeding and care.
  4. Support skin-to-skin (or “kangaroo”) care: practiced early, for as long and as often as parents are able and willing to, throughout the NICU stay.
  5. Initiate breastfeeding within 1 h post-birth or as soon as infants and mothers are clinically stable, regardless of gestational age, postmenstrual age, or birth weight, and continue to support unrestricted access to the breast based on infant stability.
  6. Assist mothers with early milk expression when they are unable to breastfeed or are separated from their infants, or when their infants are unable to feed at the breast or cannot feed efficiently.
  7. Aim for all infants admitted to the NICU to achieve exclusive breastfeeding. When a mother’s own milk is unavailable, limited, or contraindicated, provide pasteurized donor human milk from a regulated milk bank to supplement or replace it. Avoid use of commercial milk formulas unless there are medical indications.
  8. As premature infants mature, support transitions from enteral feeding to feeding at the breast and from scheduled to ‘cue-based’ feeds, without unjustified restrictions on frequency, intervals between feeds, or duration of feeds at the breast, making sure to coordinate feeds with the mother as well.
  9. Provide a physical environment that facilitates rooming-in or accommodates parents so they can rest or sleep close to their infants.
  10. With parents, develop an individualized feeding plan before discharge to support the transition to home, including referrals to breastfeeding support services when needed.

Acknowledgements

This position statement has been reviewed by the Canadian Paediatric Society’s Fetus and Newborn Committee. The authors thank Amanda Camacho, nurse clinician and IBCLC and Ghislaine Reid, IBCLC for their contribution in reviewing the manuscript.

CANADIAN PAEDIATRIC SOCIETY NUTRITION AND GASTROENTEROLOGY COMMITTEE (2021-2022)

Members: Belal Alshaikh MD, Linda Casey MD (Past Member), Eddy Lau MD (Board Representative), Ana Sant’Anna MD (Chair), Gina Rempel MD, Pushpa Sathya MD, Rilla Schneider MD (Resident Member), Christopher Tomlinson MB ChB, PhD (Past Member), Catherine M. Pound MD (Past Chair)

Liaisons: Sanjukta Basak MD (Canadian Pediatric Endocrine Group), Mark Corkins MD (American Academy of Pediatrics, Committee on Nutrition), Subhadeep Chakrabarti (Health Canada), Jennifer McCrea (Health Canada), Tanis Fenton (Dietitians of Canada), Laura N. Haiek MD (Breastfeeding Committee for Canada)

References

  1. Health Canada, Canadian Paediatric Society, Dietitians of Canada, Breastfeeding Committee for Canada. Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. Last modified: July 26, 2022: https://www.canada.ca/en/health-canada/services/food-nutrition/healthy-eating/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months.html (Accessed September 26, 2022).
  2. Pound CM, Unger S, Blair B; Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Pasteurized and unpasteurized donor human milk: https://www.cps.ca/en/documents/position/pasteurized-and-unpasteurized-donor-human-milk.
  3. Pound CM, Unger SL; Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Hospital Paediatrics Section. The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding: https://www.cps.ca/en/documents/position/baby-friendly-initiative-breastfeeding.
  4. Edmond K, Bahl R. Optimal Feeding of Low-birth-weight Infants. Technical review. Geneva, Switzerland: WHO; 2006.
  5. Meek JY, Noble L, Section on Breastfeeding. Policy Statement: Breastfeeding and the use of human milk. Pediatrics 2022;150(1)(1):e2022057988. doi: 10.1542/peds.2022-057988.
  6. World Health Organization/UNICEF. Implementation Guidance: Protecting, Promoting, and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services; The Revised Baby-friendly Hospital Initiative. Geneva, Switzerland: WHO; 2018: https://www.who.int/publications/i/item/9789241513807 (Accessed September 26, 2022).
  7. World Health Organization/UNICEF. Protecting, Promoting and Supporting Breastfeeding: The Baby-friendly Hospital Initiative for Small, Sick and Preterm Newborns. Geneva, Switzerland: WHO; 2020: https://www.who.int/publications/i/item/9789240005648 (Accessed September 26, 2022).
  8. Bachrach VR, Schwarz E, Bachrach LR. Breastfeeding and the risk of hospitalization for respiratory disease in infancy: A meta-analysis. Arch Pediatr Adolesc Med 2003;157(3):237-43. doi: 10.1001/archpedi.157.3.237.
  9. Christensen N, Bruun S, Søndergaard J, et al. Breastfeeding and infections in early childhood: A cohort study. Pediatrics 2020;146(5 ):e20191892. doi: 10.1542/peds.2019-1892.
  10. Horta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: A systematic review and meta-analysis. Acta Paediatr 2015;104(467):14-19. doi: 10.1111/apa.13139.
  11. Guthrie SO, Gordon PV, Thomas V, Thorp JA, Peabody J, Clark RH. Necrotizing enterocolitis among neonates in the United States. J Perinatol 2003;23(4):278-85. doi: 10.1038/sj.jp.7210892.
  12. Chowdhury R, Sinha B, Sankar MJ, et al. Breastfeeding and maternal health outcomes: A systematic review and meta-analysis. Acta Paediatr 2015;104:96-113. doi: 10.1111/apa.13102.
  13. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment no. 153. Boston, MA: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2007.
  14. Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet 2016;387(10017):475-90. doi: 10.1016/S0140-6736(15)01024-7.
  15. Nyqvist KH, Maastrup R, Hansen MN, et al. The Neo-BFHI: The Baby-friendly Hospital Initiative for Neonatal Wards. 2015: https://ilca.org/neo-bfhi/ (Accessed September 26, 2022).
  16. O'Brien K, Bracht M, Robson K, et al. Evaluation of the Family Integrated Care model of neonatal intensive care: A cluster randomized controlled trial in Canada and Australia. BMC Pediatr 2015;15:210. doi: 10.1186/s12887-015-0527-0.
  17. Parker MG, Stellwagen LM, Noble L, et al. Promoting human milk and breastfeeding for the very low birth weight infant. Pediatrics 2021;148(5):e2021054272. doi: 10.1542/peds.2021-054272.
  18. Statistics Canada. Table: 13-10-0425-01. Live births, by weeks of gestation (Release date: September 28, 2021. Date modified: September 21, 2022): https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1310042501 (Accessed September 26, 2022).
  19. Canadian Neonatal Network. Annual Report 2020: http://www.canadianneonatalnetwork.org/portal/ (Accessed September 26, 2022).
  20. Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole WK. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics 2006;117(4):1253-61. doi: 10.1542/peds.2005-1368.
  21. Chalmers B, Levitt C, Heaman M, O'Brien B, Sauve R, Kaczorowski J. Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey of women. Birth 2009;36(2):122-32. doi: 10.1111/j.1523-536X.2009.00309.x.
  22. Nyqvist KH, Häggkvist AP, Hansen MN, et al.; Baby-friendly Hospital Initiative Expert Group. Expansion of the Baby-friendly Hospital Initiative ten steps to successful breastfeeding into neonatal intensive care: Expert group recommendations. J Hum Lact 2013;29(3):300-09. doi: 10.1177/0890334413489775.
  23. Hernández-Aguilar MT, Bartick M, Schreck P, Harrel C, Academy of Breastfeeding Medicine. ABM clinical protocol #7: Model maternity policy supportive of breastfeeding. Breastfeed Med 2018;13(9):559-74. doi: 10.1089/bfm.2018.29110.mha.
  24. Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C. ABM clinical protocol #3: Supplementary feedings in the healthy term breastfed neonate, revised 2017. Breastfeed Med 2017;12:188-98. doi: 10.1089/bfm.2017.29038.ajk.
  25. World Health Organization/UNICEF. Baby-friendly Hospital Initiative Training Course for Maternity Staff. Geneva, Switzerland: WHO; 2020: https://www.who.int/publications/i/item/9789240008915 (Accessed September 26, 2022).
  26. Breastfeeding Committee for Canada. Baby-Friendly Implementation Guideline, Medical Indications for Supplementation. 2021: https://breastfeedingcanada.ca/wp-content/uploads/2021/04/Medical-Indications-for-Supplementation-April-14.pdf (Accessed September 26, 2022).
  27. Brown JV, Lin L, Embleton ND, Harding JE, McGuire W. Multi-nutrient fortification of human milk for preterm infants. Cochrane Database Syst Rev 2020;6(6):CD000343. doi: 10.1002/14651858.CD000343.pub4.
  28. Cristofalo EA, Schanler RJ, Blanco CL, et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr 2013;163(6):1592-95.e1. doi: 10.1016/j.jpeds.2013.07.011.
  29. O'Connor DL, Kiss A, Tomlinson C, et al. Nutrient enrichment of human milk with human and bovine milk-based fortifiers for infants born weighing <1250 g: A randomized clinical trial. Am J Clin Nutr 2018;108(1):108-16. doi: 10.1093/ajcn/nqy067.
  30. Premkumar MH, Pammi M, Suresh G. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Cochrane Database Syst Rev 2019;2019(11):CD013145. doi: 10.1002/14651858.CD013145.pub2.
  31. Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeed Med 2014;9(6):281-85. doi: 10.1089/bfm.2014.0024.
  32. Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr 2010;156(4):562-67.e1. doi: 10.1016/j.jpeds.2009.10.040.
  33. Sandhu A, Fast S, Bonnar K, Baier RJ, Narvey M. Human-based human milk fortifier as rescue therapy in very low birth weight infants demonstrating intolerance to bovine-based human milk fortifier. Breastfeed Med 2017;12(9):570-73. doi: 10.1089/bfm.2017.0017.
  34. Boies EG, Vaucher YE. ABM clinical protocol #10: Breastfeeding the Late Preterm (34-36 6/7 weeks of gestation) and early term infants (37-38 6/7 weeks of gestation), second revision 2016. Breastfeed Med 2016;11:494-500. doi: 10.1089/bfm.2016.29031.egb.
  35. Maastrup R, Hansen BM, Kronborg H, et al. Breastfeeding progression in preterm infants is influenced by factors in infants, mothers and clinical practice: The results of a national cohort study with high breastfeeding initiation rates. PLoS One 2014;9(9):e108208. doi: 10.1371/journal.pone.0108208.
  36. Nyqvist KH. Early attainment of breastfeeding competence in very preterm infants. Acta Paediatr 2008;97(6):776-81. doi: 10.1111/j.1651-2227.2008.00810.x.
  37. Nyqvist KH. Lack of knowledge persists about early breastfeeding competence in preterm infants. J Hum Lact 2013;29(3):296-99. doi: 10.1177/0890334413489774.
  38. Nyqvist KH, Färnstrand C, Eeg-Olofsson KE, Ewald U. Early oral behaviour in preterm infants during breastfeeding: An electromyographic study. Acta Paediatr 2001;90(6):658-63. doi: 10.1080/080352501750258739.
  39. Nyqvist KH, Sjödén PO, Ewald U. The development of preterm infants' breastfeeding behavior. Early Hum Dev 1999;55(3):247-64. doi: 10.1016/s0378-3782(99)00025-0.
  40. Hanin M, Nuthakki S, Malkar MB, Jadcherla SR. Safety and efficacy of oral feeding in Infants with BPD on nasal CPAP. Dysphagia 2015;30(2):121-27. doi: 10.1007/s00455-014-9586-x.
  41. Shetty S, Hunt K, Douthwaite A, Athanasiou M, Hickey A, Greenough A. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Arch Dis Child Fetal Neonatal Ed 2016;101(5):F408-11. doi: 10.1136/archdischild-2015-309683.
  42. Lucas RF, Smith RL. When is it safe to initiate breastfeeding for preterm infants? Adv Neonatal Care 2015;15(2):134-41. doi: 10.1097/ANC.0000000000000167.
  43. SickKids Hospital. Non-Invasive CPAP Respiratory Support and Establishing Safe Nipple Feeding for Preterm and High Risk Infants (Breastfeeding, bottle feeding and non-nutritive sucking at the breast while on non-invasive CPAP). April 26, 2018: https://torontocentreforneonatalhealth.com/wp-content/uploads/2019/09/Non-Invasive-CPAP-Respiratory-Support-and-Establishing-Safe-Nipple-Feeding-for-Preterm-and-High-Risk-Infants.pdf (Accessed September 26, 2022).
  44. Marchand V; Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Using probiotics in the paediatric population. Updated June 18, 2019: https://www.cps.ca/en/documents/position/probiotics-in-the-paediatric-population.
  45. Dutta S, Singh B, Chessell L, et al. Guidelines for feeding very low birth weight infants. Nutrients 2015;7(1):423-42. doi: 10.3390/nu7010423.
  46. Nyquist KH, Hetzel Campbell S, Haiek LN. Breastfeeding and the preterm Infant. In: Lactation Education Accreditation and Approval Review Committee (LEAARC); Hetzel Campbell S, Lauwers J, Mannel R, Spencer B, eds.. Core Curriculum for Interdisciplinary Lactation Care. Burlington, MA: Jones & Bartlett Learning; 2018.
  47. Dharel D, Singhal N, Wood C, et al.; Canadian Neonatal Network, Canadian Preterm Birth Network Investigators. Rates and determinants of mother's own milk feeding in infants born very preterm. J Pediatr 2021;236:21-27.e4. doi: 10.1016/j.jpeds.2021.04.037.
  48. Parker LA, Hoffman J, Darcy-Mahoney A. Facilitating early breast milk expression in mothers of very low birth weight infants. MCN Am J Matern Child Nurs 2018;43(2):105-10. doi: 10.1097/NMC.0000000000000408.
  49. Parker LA, 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;10(2):84-91. doi: 10.1089/bfm.2014.0089.
  50. Parker LA, Sullivan S, Kruger C, Mueller M. Timing of milk expression following delivery in mothers delivering preterm very low birth weight infants: A randomized trial. J Perinatol 2020;40(8):1236-45. doi: 10.1038/s41372-020-0688-z.
  51. Jefferies AL; Canadian Paediatric Society, Fetus and Newborn Committee. Kangaroo care for the preterm infant and family. Paediatr Child Health 2012;17(3): 141-43: https://cps.ca/en/documents/position/kangaroo-care-for-preterm-infant.
  52. Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2016(8):CD002771. doi: 10.1002/14651858.CD002771.pub4.
  53. Flacking R, Ewald U, Wallin L. Positive effect of kangaroo mother care on long-term breastfeeding in very preterm infants. J Obstet Gynecol Neonatal Nurs 2011;40(2):190-97. doi: 10.1111/j.1552-6909.2011.01226.x.
  54. Oras P, Thernström Blomqvist Y, Nyqvist KH, et al. Skin-to-skin contact is associated with earlier breastfeeding attainment in preterm infants. Acta Paediatr 2016;105(7):783-89. doi: 10.1111/apa.13431.
  55. Barrington KJ, Batton DG, Finley GA, Wallman C; Canadian Paediatric Society, Fetus and Newborn Committee. Prevention and management of pain in the neonate: An update: https://www.cps.ca/en/documents/position/prevention-management-pain-neonate.
  56. Trottier ED, Doré-Bergeron MJ, Chauvin-Kimoff L, Baerg K, Ali S; Canadian Paediatric Society, Acute Care Committee, Hospital Paediatrics Section, Community Paediatrics Section, Paediatric Emergency Medicine Section. Managing pain and distress in children undergoing brief diagnostic and therapeutic procedures. Paediatr Child Health 2019;24(8)509-21: https://www.cps.ca/en/documents/position/managing-pain-and-distress.
  57. Flacking R, Dykes F. 'Being in a womb' or 'playing musical chairs': The impact of place and space on infant feeding in NICUs. BMC Preg Childbirth 2013;13:179. doi: 10.1186/1471-2393-13-179.
  58. Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: Comparative patient progress in open-ward and single family room units. J Perinatol 2011;31(4):281-88. doi: 10.1038/jp.2010.120.
  59. Jones R, Jones L, Feary AM. The effects of single-family rooms on parenting behavior and maternal psychological factors. J Obstet Gynecol Neonatal Nurs 2016;45(3):359-70. doi: 10.1016/j.jogn.2015.12.015.
  60. Wataker H, Meberg A, Nestaas E. Neonatal family care for 24 hours per day: Effects on maternal confidence and breast-feeding. J Perinat Neonatal Nurs 2012;26(4):336-42. doi: 10.1097/JPN.0b013e31826d928b.
  61. Nyqvist KH, Häggkvist AP, Hansen MN, et al. Expansion of the ten steps to successful breastfeeding into neonatal intensive care: Expert group recommendations for three guiding principles. J Hum Lact 2012;28(3):289-96. doi: 10.1177/0890334412441862
  62. Haiek LN, LeDrew M, Charette C, Bartick M. Shared decision-making for infant feeding and care during the coronavirus disease 2019 pandemic. Matern Child Nutr 2021;17(2):e13129. doi: 10.1111/mcn.13129.
  63. Narvey M, Finan E; CPS Fetus and Newborn Committee. Care considerations for infants born to mothers with suspected or confirmed SARS-CoV-2 infection. February 2023: https://cps.ca/en/documents/position/infants-born-to-mothers-with-COVID
  64. Anderson N, Narvey M; Canadian Paediatric Society, Fetus and Newborn Committee. Discharge planning of the preterm infant. Paediatr Child Health 2022;27(2): https://cps.ca/en/documents/position/discharge-planning-of-the-preterm-infant.
  65. Asztalos EV. Supporting mothers of very preterm infants and breast milk production: A review of the role of galactogogues. Nutrients 2018;10(5):600. doi: 10.3390/nu10050600.
  66. Brodribb W. ABM clinical protocol #9: Use of galactogogues in initiating or augmenting maternal milk production, second revision 2018. Breastfeed Med 2018;13(5):307-14. doi: 10.1089/bfm.2018.29092.wjb.
  67. Shen Q, Khan KS, Du MC, Du WW, Ouyang YQ. Efficacy and safety of domperidone and metoclopramide in breastfeeding: A systematic review and meta-analysis. Breastfeed Med 2021;16(7):516-29. doi: 10.1089/bfm.2020.0360.
  68. Foong SC, Tan ML, Foong WC, Marasco LA, Ho JJ, Ong JH. Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants. Cochrane Database Syst Rev 2020;5(5):CD011505. doi: 10.1002/14651858.CD011505.pub2.
  69. Majdinasab E, Haque S, Stark A, Krutsch K, Hale TW. Psychiatric manifestations of withdrawal following domperidone used as a galactagogue. Breastfeed Med 2022;17(12):1018-24. doi: 10.1089/bfm.2022.0190.
  70. McBride GM, Stevenson R, Zizzo G, et al. Women's experiences with using domperidone as a galactagogue to increase breast milk supply: An Australian cross-sectional survey. Int Breastfeed J 2023;18(1):11. doi: 10.1186/s13006-023-00541-9.
  71. Craig JW, Glick C, Phillips R, Hall SL, Smith J, Browne J. Recommendations for involving the family in developmental care of the NICU baby. J Perinatol 2015;35(Suppl 1):S5-8. doi: 10.1038/jp.2015.142.
  72. World Health Organization/UNICEF. Competency Verification Toolkit: Ensuring Competency of Direct Care Providers to Implement the Baby-friendly Hospital Initiative. Geneva, Switzerland: WHO; 2020: https://www.who.int/publications/i/item/9789240008854 (Accessed September 26, 2022).
  73. Mercado K, Vittner D, McGrath J. What is the impact of NICU-dedicated lactation consultants? An evidence-based practice brief. Adv Neonatal Care 2019;19(5):383-93. doi: 10.1097/ANC.0000000000000602.
  74. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: A key to "becoming a mother" and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med 2006;62(1):70-80. doi: 10.1016/j.socscimed.2005.05.026.
  75. Flacking R, Ewald U, Starrin B. "I wanted to do a good job": Experiences of 'becoming a mother' and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci Med 2007;64(12):2405-16. doi: 10.1016/j.socscimed.2007.03.008.
  76. Flacking R, Lehtonen L, Thomson G, et al. Closeness and separation in neonatal intensive care. Acta Paediatr 2012;101(10):1032-37. doi: 10.1111/j.1651-2227.2012.02787.x.
  77. Sweet L. Breastfeeding a preterm infant and the objectification of breastmilk. Breastfeed Rev 2006;14(1):5-13.
  78. Maastrup R, Haiek LN, Neo-BFHI Survey Group. Compliance with the "Baby-friendly Hospital Initiative for Neonatal Wards" in 36 countries. Matern Child Nutr 2019;15(2):e12690. doi: 10.1111/mcn.12690.
  79. Human Milk Banking Association of North America. HMBANA Standards for Donor Human Milk Banking. Fort Worth, TX: Human Milk Banking Association of North America; 2020: https://www.hmbana.org/about-us/our-work/publications.html (Accessed September 26, 2022).
  80. Jones F. Best Practises for Expressing, Storing and Handling Human Milk in Hospitals, Homes and Child Care Settings, 3rd edn. Fort Worth, TX Human Milk Banking Association of North America; 2011.
  81. Omarsdottir S, Casper C, Akerman A, Polberger S, Vanpée M. Breastmilk handling routines for preterm infants in Sweden: A national cross-sectional study. Breastfeed Med 2008;3(3):165-70. doi: 10.1089/bfm.2007.0033.
  82. Canadian Paediatric Society. Information for pregnant women who have HIV. Updated: August 2022: https://caringforkids.cps.ca/handouts/pregnancy-and-babies/pregnant_women_who_have_hiv.
  83. Miron D, Brosilow S, Felszer K, et al. Incidence and clinical manifestations of breast milk-acquired cytomegalovirus infection in low birth weight infants. J Perinatol 2005;25(5):299-303. doi: 10.1038/sj.jp.7211255.
  84. Lawrence RM. Cytomegalovirus in human breast milk: Risk to the premature infant. Breastfeed Med 2006;1(2):99-107. doi: 10.1089/bfm.2006.1.99.
  85. Garofoli F, Civardi E, Zanette S, et al. Literature review and an Italian hospital experience about post-natal CMV infection acquired by breast-feeding in very low and/or extremely low birth weight infants. Nutrients 2021;13(2):660. doi: 10.3390/nu13020660.
  86. Association for Promotion of and Cultural and Scientific Research into Breastfeeding: http://e-lactancia.org/ (Accessed September 26, 2022).
  87. CHU Sainte-Justine. Centre IMAGe. Info-Médicaments en Allaitement et Grossesse: https://www.chusj.org/fr/soins-services/P/Pharmacie/Centre-IMAGe (Accessed September 26, 2022).
  88. National Library of Health (US). Drugs and Lactation Database (LactMed): https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed September 26, 2022).
  89. Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: Guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med 2015;10(3):135-41. doi: 10.1089/bfm.2015.9992.
  90. Lacaze-Masmonteil T, O’Flaherty P; Canadian Paediatric Society, Fetus and Newborn Committee. Managing infants born to mothers who have used opioids during pregnancy. Paediatr Child Health 2020;23(3):220-26: https://cps.ca/en/documents/position/opioids-during-pregnancy.
  91. Hendson L, Shah V, Trkulja S; Canadian Paediatric Society, Fetus and Newborn Committee. Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors in pregnancy: Infant and childhood outcomes. Paediatr Child Health 2021;26(5):321: https://cps.ca/en/documents/position/selective-serotonin.
  92. Government of Canada. Is Cannabis Safe during Preconception, Pregnancy and Breastfeeding? Cannabis resource series. Ottawa, Ont.: Health Canada; October 17, 2018: https://www.canada.ca/en/health-canada/services/publications/drugs-health-products/is-cannabis-safe-during-preconception-pregnancy-breastfeeding.html (Accessed September 26, 2022).
  93. Noble LM, Okogbule-Wonodi AC, Young MA. ABM clinical protocol #12: Transitioning the breastfeeding preterm infant from the neonatal intensive care unit to home, revised 2018. Breastfeed Med 2018;13(4):230-36.

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.

Last updated: Apr 23, 2024

In this section

Related information

statements and practice points

Paediatrics & Child Health