Background
Breastfeeding has numerous advantages to the baby and mother including reduced infections and higher intelligence in the breastfed children and reduced breast cancer with lower risk of diabetes for the mothers [
1]. Showing all mothers how to ‘.. . maintain lactation even if they should be separated from their infants’ is one of the ten steps to successful breastfeeding, identified under the Baby Friendly Hospital Initiative (BFHI) [
2].
A considerable number of babies who are in neonatal units either due to prematurity or other illness are unable to breastfeed directly as they are receiving invasive ventilatory support or are too premature to have coordinated, safe, sucking and swallowing reflexes [
3]. These babies need to be provided with expressed breast milk, which can be given to the baby via several different methods including nasogastric or orogastric tubes, cup feeds, and syringe or dropper feeds [
4]. The numbers of babies using these different methods have not been published in Sri Lanka or elsewhere. The monthly statistics of the unit that the first author is attached to, reveal that there were 3382 births in 2017, with 744 admissions to the neonatal unit including 61 babies born in other hospitals. This unit is a referral centre for fetal medicine. The number of babies less than 36 weeks gestation who were admitted to the neonatal unit, who would certainly have been given expressed breast milk at some point, was 272, that is 36% of the admitted babies. Some of the other babies more than 36 weeks who were on the ventilator or double phototherapy would also have received expressed breast milk.
In most developed countries like Australia, the United Kingdom and the United States of America, mothers are discharged from hospital even if their infants remain in the neonatal unit. Therefore, if they are providing breast milk for their babies they have to express breast milk at home and bring it to the hospital. In Sri Lanka, most mothers spend the entire time their baby is in the neonatal unit in hospital, and they provide fresh expressed breast milk for each feed. However, with increasingly lower gestation babies surviving in the neonatal units in Sri Lanka, mothers have to spend many weeks in the hospital, which becomes difficult in practice for some mothers. Mothers whose babies are in the neonatal unit do not even get a bed of their own at times due to overcrowding in the postnatal ward; there are situations where several mothers whose babies are in the neonatal unit have had to share a single bed. Meals are provided by the hospital, but most mothers wish to have their meals brought from home by relatives in the belief that lactating mothers should be provided with special home-made meals. A restricted number of relatives are allowed to visit the mother during the three visiting hours per day, but children are not allowed to come to the postnatal ward.
As there are concerns about the safety of using breast milk expressed at home and brought into hospital, this is currently not encouraged, especially from long distances; a safe method of expressing, storing and transporting breast milk for sick newborns in Sri Lanka therefore needs to be established. Currently there is no written feeding guideline for the unit at which the principal author works in Sri Lanka, but the hospital strives to adhere to the 10 steps of BFHI [
2] in taking decisions regarding the feeding plan for individual babies. The different modes of feeding have not been formally evaluated or described in a study yet, in Sri Lanka.
A written guidance is used in the unit in assessing fitness for discharge, with the minimum criterion being that the baby is fully breast milk fed, using a combination of breastfeeding and cup-feeding (without use of bottles and teats) and being 1.2 kg by weight (around 34 weeks). The mothers receive intensive support in lactation management during hospital stay and the babies are closely followed-up for weight gain after discharge.
Having access to a refrigerator is essential for breast milk storage if it is to be expressed at home, stored and transported to the hospital later. National Sri Lankan data from 2009/10 which is the latest available, show that 60% of urban households and 38% of rural households have a refrigerator [
5]. This number is certainly higher now although no more recent data are available, either for the country or for any particular hospital.
The bacteriological contamination of stored human milk and fresh milk has shown varied results in studies conducted under different conditions leading to differences in recommendations made by different institutes [
6‐
10]. Studies have also examined the biochemical properties of stored milk [
11,
12]. As there is currently no gold standard in best practice for expressing, storing and transporting human milk from home to hospital specifically for sick and preterm infants, we set out to review recommendations from a number of sources.
Methods
In order to establish safe standards for transporting expressed breast milk in Sri Lanka we initially identified information sources from Melbourne, Australia, where the researchers had access to the detailed protocols and guidelines of the Level 3 neonatal units, and other countries where transportation of expressed breast milk is common practice. The information sources we used are given in Table
1. The resources written for hospital staff were evaluated using the Appraisal of Guidelines for Research & Evaluation – II (AGREE-II) instrument [
13] to assess the quality of guidelines. The information sources for which the AGREE II instrument was used has been indicated in Table
1. Guidance given by the Level 3 neonatal units in Melbourne, Australia and recognized health authorities in UK, USA, and Sri Lanka as well as the World Health Organization (WHO) recommendations were used. The documents from Australia, UK and USA are meant for neonatal intensive care unit hospital staff and mothers. The Sri Lankan fact sheet is mostly used in the community, but is given to some mothers with babies in the neonatal unit as a written guidance to the method of expressing breast milk by hand. The WHO recommendations, which are meant for global usage including resource limited settings, are used by the Family Health Bureau of the Ministry of Health, Sri Lanka, for training of all health care personnel in the country on breastfeeding issues.
Table 1
List of information sources reviewed
MHW | 2013 | 1. Breastfeeding guide [ 17] | Mothers | Not used |
2012 | 2. Breast Milk Expression Procedure [ 18] | Staff | Used |
2014 | 3. Breast Milk Expressing Equipment Management Procedure [ 19] | Staff | Used |
2015 | 4. Expressed Breast Milk (EBM): Storage and Management in Neonatal Services Procedure [ 20] | Staff | Used |
2014 | 5. Expressing breast milk [ 34] | Mothers | Not used |
6. Cleaning your breast pump equipment [ 36] | Mothers | Not used |
RWH | 2015 | 1. Expressing breast milk for sick or preterm babies [ 21] | Mothers | Not used |
2013 | 2. Expressing breast milk [ 22] | Mothers | Not used |
2011 | 3. Infant Feeding: Expressed Breast Milk: Management in Newborn Services [ 37] | Staff | Used |
2008 | 4. Using a breast pump [ 35] | Mothers | Not used |
Monash | 2014 | 1. Expressed breast milk (EBM) safe management and storage [ 23] | Mothers | Not used |
2011 | 2. Expressing breast milk [ 24] | Mothers | Not used |
RCH | 2013 | 1. Breastfeeding a baby in hospital [ 25] | Mothers | Not used |
2013 | 2. Breastfeeding at The Royal Children’s Hospital [ 26] | Mothers | Not used |
NHS (UK) | 2016 | 1. Expressing and storing breast milk [ 27] | Mothers | Not used |
2014 | 2.Breastfeeding your premature baby [ 28] | Mothers | Not used |
HMBANA | 2011 | 1. Best Practice for Expressing, Storing and Handling Human Milk in Hospitals, Homes, and Child Care Settings.© HMBANA. 3rd Edition [ 30] | Staff | Used |
WHO/UNICEF/ Wellstart | 2009 | 1. Baby-Friendly Hospital Initiative - revised, updated and expanded for integrated care. Section “ Results” Breastfeeding Promotion and Support in a Baby-Friendly Hospital. A 20-h course for maternity staff [ 31] | Staff | Used |
SL | | How to express breast milk [ 32] | Mothers | Not used |
The guidelines of the National Health and Medical Research Council, Australia and the Academy of Breastfeeding Medicine, USA protocol were not used as these guidelines focus on expressing and storing human milk for healthy term babies when mothers are separated from this infants, e.g. for paid employment [
14,
15]. A recent review by Peters et al. provides one of the most comprehensive systematic literature reviews on the safe management of expressed breast milk [
16]. However that review did not make a clear distinction between expressing milk for sick preterm babies in hospital and healthy term infants at home [
16].
The guidelines for hospital staff and fact sheets for parents provided to mothers from the four hospitals in Melbourne, Australia which have level 3 neonatal units, namely Mercy Hospital for Women (MHW) [
17‐
20], the Royal Women’s Hospital (RWH) [
21,
22], Monash Health (MH) [
23,
24] and the Royal Children’s Hospital (RCH) [
25,
26]; the National Health Service (NHS) website from the United Kingdom [
27,
28]; the guideline of the Human Milk Banking Association of North America [
29,
30]; information provided in the World Health Organization training course for maternity staff on breastfeeding promotion and support in a baby friendly hospital [
31]; and the fact sheet for mothers on breast milk expression published by the Ministry of Health, Sri Lanka [
32] were used to identify the recommendations made regarding storage and transport of expressed breast milk for sick babies in hospital. If these information sources provided advice separately for both categories of babies – those in neonatal units and those at home, only those relevant to the hospitalized infants was used. Two of the institutes whose recommendations were reviewed (Mercy Hospital for Women, Melbourne and HMBANA) also provided advice regarding milk being brought in for human milk banking and milk donation, but this information was not considered in the review.
The RCH and RWH recommendations are available online for access by the general public, while the MHW and Monash guidelines are available only on the intranet of each hospital for internal use only. The NHS, UK has a web page accessible by the general public with useful attractive illustrations regarding expression of breast milk, and advises to contact hospital staff regarding storage of milk for sick newborns.
Guideline quality assessment by the AGREE II instrument
The guidelines written for hospital staff were appraised by two assessors using the AGREE-II instrument. The assessment is done based on 23 items classified into six domains – namely scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability and editorial independence [
13]. Each item is scored on a 7-point scale. The scores given by the assessors are presented as percentages based on the maximum possible score for each domain. The maximum possible score depends on the number of assessors and number of items in a particular domain that were assessed. In our assessments all 23 items were scored and none were left out. In some of the documents from Mercy Hospital for Women, stakeholder involvement was unclear and clarifications were made by contacting the staff of the Department of Paediatrics and Human Milk Bank at the hospital.
Review of the recommendations provided by the information sources
The recommendations provided by the chosen information sources were categorized under the following topics and tabulated.
1.
General information on expression of breast milk and preparation for expression (Additional file
1: Table S1)
2.
Container for collection and storage of expressed breast milk (Additional file
2: Table S2)
3.
Hand expression of breast milk (Additional file
3: Table S3)
4.
Using a pump for expression of breast milk (Additional file
4: Table S4)
5.
Storage of expressed breast milk (Additional file
5: Table S5)
6.
Thawing and warming of stored expressed breast milk (Additional file
6: Table S6)
7.
Transport of expressed breast milk (Additional file
7: Table S7)
A detailed section on developing the healthcare workers’ communication skills to counsel and build the self-confidence of mothers is available only in the WHO guidance [
31].
Discussion
The purpose of this paper was to review selected guidelines and factsheets on expression and storage of breast milk, both at home and in the neonatal unit, and on transport of expressed breast milk from home to hospital, in order to assist in establishing safe standards for transporting expressed breast milk in Sri Lanka from home to neonatal units in the hospital for mothers who are unable to stay in hospital with their sick newborns. In reviewing the selected guidelines and fact sheets we noted that most recommendations on general aspects of breast milk expression, how to hand-express and freezer storage guidelines were similar in the different guidelines. However, when taking each information source individually there were gaps, wide variations and unclear areas with regard to the method of transport. There is therefore a need for a written single guideline, for each unit which contains recommendations on all aspects of expressing, storing and transporting breast milk which has the same basic information for mothers and the healthcare staff and further technical details for staff if required. The Sri Lankan fact sheet strongly discourages the use of pumps, even going to the extent of stating that it is more painful. Concerns about cleanliness have also contributed to the discouragement [
32]. In Sri Lanka – especially for hospital based use, only fresh expressed breast milk is generally used. Therefore, currently there is no necessity for expressing large volumes for storage in Sri Lanka. This may be the reason for discouragement of pump use along with concerns about the cost of pumps as well – although hand pumps are now available for very reasonable prices. The available guidelines have been written nearly a decade ago and neonatal care, especially in terms of survival of preterm infants has improved greatly since then. Therefore, the Sri Lankan information sheet needs to be updated with more evidence-based recommendations that are relevant to the current situation of sick newborns in the country. There is an urgent need to identify safe modes of storage and transport of expressed breast milk in Sri Lanka, taking into consideration available modes of storage and transport along with weather conditions. Sri Lanka is an island situated within the tropics where the mean annual temperature varies between 27 °C in the coastal lowlands to 16 °C in the central highlands. Even in the highlands the maximum daytime temperatures are more than 18.5 °C [
38]. The average relative humidity is > 65% in all parts of the country and above 75%, up to 95%, in the wet zone [
39].
The Sri Lankan fact sheet does not mention the use of photographs of the baby to stimulate hormonal responses in the mother because it is currently not relevant as mothers will be doing most of the expression of breast milk in the neonatal unit itself [
32]. However, it would be very useful for the mothers who are unwell in intensive care unit themselves and therefore may not even have seen the baby yet. There are hospital regulations in Sri Lanka which prohibit photography of patients which would need to be addressed. Other methods of stimulating a hormonal response which enhance milk secretion, that could be mentioned in a guideline or fact sheet for mothers include kangaroo mother care and back massage for the mothers [
31].
With regard to containers, the Sri Lankan recommendation is the use of wide-mouthed containers as they can then be used directly for cup-feeding of the baby. In Sri Lanka, in keeping with the ten steps of the Baby Friendly Hospital Initiative, the recommended method of feeding expressed breast milk even at home is by cup or rarely spoon; mothers are advised to avoid teats and bottles for feeding the expressed breast milk; it is always cups or spoons that are used for feeding of supplementary expressed breast milk even after the babies are discharged home. This recommendation should be considered by other institutes worldwide as well, if they are hoping to achieve baby-friendly hospital status.
This paper is the first component of a series of studies to establish the necessity and safety of an economical method of expressing, storing and transporting breast milk in Sri Lanka from home to hospital, for mothers who are unable to stay in hospital for a prolonged period with their sick newborns. A Hazard Analysis and Critical Control Points is a system designed to ensure food safety by preventing hazards due to microbiological contamination, biochemical and physical changes that occur in food items from the stage of raw material to the finished product that would be consumed and a previous study in Belgium has studied this in 2011 for expressed breast milk on a neonatal unit [
8]. When the final version of the recommendations for Sri Lanka are prepared, the points that need to be addressed e.g. method of hand expression including cleaning of hands before expression of milk, type of container used for storage, cleansing of the container for storage, methods of storage and transportation of the expressed breast milk that will maintain desired temperatures and acceptable microbiological status, will be identified using the guidelines and protocols that have been studied in this paper, taking economical and sociocultural aspects of Sri Lanka into consideration. The availability of a refrigerator or freezer at home and transport modes that will be used by mothers or the person bringing in milk from home to hospital will be studied prior to making any recommendations. The guideline we prepare will include a section on breastfeeding counselling and supporting a mother to build her self-confidence.