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Length of stay in the NICU and association with breastfeeding rates | LATCH


Article Review: Length of Stay in a Neonatal Intensive Care Unit and Its Association With Low Rates of Exclusive Breastfeeding in Very-Low-Birth-Weight Infants


Author: Pam Middleton, RN, BSN, MPA

Numerous articles promote the use and benefit of feeding mother’s own milk (MOM) and/or donor human milk (DM) to preterm infants. These benefits have included lowering rates of infection and necrotizing enterocolitis, and a positive long-term impact on intellectual and neuropsychomotor development.1

Investigators Maia and colleagues examined the effect of length of stay (LOS) on the use of MOM and DM at a Brazilian hospital in 2011, and the results were published in The Journal of Maternal-Fetal & Neonatal Medicine.2

The aim of the study was to determine the rate of exclusive breastfeeding (EB, defined as MOM with/without DM or fortification) following discharge in very-low-birth-weight (VLBW) infants and to identify the inpatient maternal and neonatal factors associated with EB after discharge. This study was performed at a referral center for high-risk pregnancies in northeast Brazil over a 13-month period. The hospital is Baby Friendly certified and adheres to the 10 steps to successful breastfeeding as recommended by the World Health Organization. The facility used the Kangaroo Method for all VLBW infants, which allows mothers to remain in the institution for the entire neonatal intensive care unit (NICU) hospitalization of her child.

The cohort study included 119 VLBW (<1500 g) babies. The infants were followed during the entire hospital stay and through their first post-discharge visit. At the one-week post-discharge visit, patients were classified as “exclusive breastfeeding” or “weaning,” defined as receiving formula partially or exclusively. During the study period, 119 patients met the criteria of being discharged from the NICU using mother’s milk with no formula prescribed. Of the 119 patients, 88 returned for a follow-up visit within one week of discharge. Only 22 (25%) received EB at one week post discharge, and 66 (75%) were given formula. The factors of maternal age, number of prenatal visits, type of delivery, residing with the father, location of residence, education, and family income did not differ between the groups. No association was observed regarding the neonatal factors of gestational age, AGA and SGA status, respiratory depression, CNS impairment, or Apgar scores.

The study identified that longer length of stay for VLBW infants was the determinate factor for low EB rates (P = 0.013).  Lower birth weight and a longer time to regain birth weight without fortification were associated with a shorter period of EB and earlier addition of formula to the diet. Prolonged mother-child separation, prolonged enteral feeding time, extended duration of enteral feeding, longer stay in the NICU, and a longer period of hospitalization were also associated with an earlier weaning to formula. In 2012, the American Academy of Pediatrics issued its recommendation that “all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg.”1

Yet, to this day we continue to experience difficulty maintaining MOM throughout the NICU stay and following discharge. There are opportunities to improve this situation. Healthcare providers must initiate and successfully implement clinical models that support the initiation and maintenance of MOM production as well as successful breastfeeding when possible. We invite you to review a  paper by Meier and colleagues, published in Clinics in Perinatology (2017), that provides an extensive review of evidence-based methods that promote human milk feeding of preterm infants in the NICU.3


  1. American Academy of Pediatrics. Breastfeeding and the use of human milk. Section on breastfeeding. 2012;129(3):e827-e841. doi:10.1542/peds.2011-3552
  2. Maia C, Brandao R, Roncalli A, Maranhao H. Length of stay in a neonatal intensive care unit and its association with low rates of exclusive breastfeeding in very low birth weight infants. J Matern Fetal Neonatal Med. 2011;24(6):774-777. doi:10.3109/14767058.2010.520046
  3. Meier P, Johnson TJ, Patel AL, Rossman B. Evidence-based methods that promote human milk feeding of preterm infants: an expert review. Clin Perinatol. 2017;44:1-22. doi:10.1016/j.clp.2016.11.005