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

Double pumping

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

Pumping Log

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.

Pre-printed labels

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.

Cooler Bag

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