Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology.

The majority of new mothers in the United States use breast pumps in the first 4 months postbirth in order to achieve their personal human milk feeding goals. Although these mothers seek guidance from health-care professionals with respect to the type and use of breast pumps, there are few evidence-based guidelines to guide this professional advice. This paper reviews the evidence to facilitate professional individualization of breast pump recommendations using three categories of literature: the infant as the gold standard to which the pump is compared; the degree of maternal breast pump dependency (for example, the extent to which the breast pump replaces the infant for milk removal and mammary gland stimulation); and the stage of lactation for which the pump replaces the infant. This review can also serve to inform public and private payers with respect to individualizing breast pump type to mother-infant dyad characteristics.

Quality indicators for human milk use in very low-birthweight infants: are we measuring what we should be measuring?

OBJECTIVE: The objective of this study was to compare the currently used human milk (HM) quality indicators that measure whether very low-birthweight (VLBW; <1500 g birthweight) infants 'ever' received HM and whether they were still receiving HM at discharge from the neonatal intensive care unit (NICU) to the actual amount and timing of HM received. STUDY DESIGN: This study used data from a large NIH-funded cohort study and calculated whether VLBW infants ever received HM (HM-Ever) and of these infants, the percentage who were still receiving HM at NICU discharge (HM-DC). Then, the HM-DC indicator (exclusive, partial and none) was compared with the amount and timing of HM feedings received by these same infants. RESULT: Of the 291 VLBW infants who met inclusion criteria, 285 received some HM (HM-Ever=98%). At NICU discharge (HM-DC), 24.2, 15.1 and 60.7% were receiving exclusive, partial and no HM, respectively. Of the 60.7% infants with no HM-DC, some had received higher amounts of HM during the NICU hospitalization than infants categorized as exclusive and partial for HM-DC. Of the infants with no HM-DC, 76.8 and 59.7% had received exclusive HM during the days 1-14 and days 1-28 exposure periods, respectively. CONCLUSION: The average daily dose (HM-DD; in ml kg(-1) d(-1)) and cumulative percentage (HM-PCT; as % of cumulative enteral intake) of HM feedings were sufficient to significantly reduce the risk of multiple morbidities, including late-onset sepsis, necrotizing enterocolitis, neurocognitive delay and rehospitalization, in the majority of the VLBW infants who were discharged with no HM-DC. Quality indicators that focus on the amount and timing of HM feedings in the NICU should be added to the HM-Ever and HM-DC measures.

Impact of early human milk on sepsis and health-care costs in very low birth weight infants.

OBJECTIVE: To study the incidence of sepsis and neonatal intensive care unit (NICU) costs as a function of the human milk (HM) dose received during the first 28 days post birth for very low birth weight (VLBW) infants. STUDY DESIGN: Prospective cohort study of 175 VLBW infants. The average daily dose of HM (ADDHM) was calculated from daily nutritional data for the first 28 days post birth (ADDHM-Days 1-28). Other covariates associated with sepsis were used to create a propensity score, combining multiple risk factors into a single metric. RESULT: The mean gestational age and birth weight were 28.1 ± 2.4 weeks and 1087 ± 252 g, respectively. The mean ADDHM-Days 1-28 was 54 ± 39 ml kg(-1) day(-1) (range 0-135). Binary logistic regression analysis controlling for propensity score revealed that increasing ADDHM-Days 1-28 was associated with lower odds of sepsis (odds ratio 0.981, 95% confidence interval 0.967-0.995, P=0.008). Increasing ADDHM-Days 1-28 was associated with significantly lower NICU costs. CONCLUSION: A dose-response relationship was demonstrated between ADDHM-Days 1-28 and a reduction in the odds of sepsis and associated NICU costs after controlling for propensity score. For every HM dose increase of 10 ml kg(-1) day(-1), the odds of sepsis decreased by 19%. NICU costs were lowest in the VLBW infants who received the highest ADDHM-Days 1-28.

Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants.

OBJECTIVE: The objective of this study was to compare the effectiveness, efficiency, comfort and convenience of newly designed breast pump suction patterns (BPSPs) that mimic sucking patterns of the breastfeeding human infant during the initiation and maintenance of lactation. STUDY DESIGN: In total, 105 mothers of premature infants ≤34 weeks of gestation were randomly assigned to 1 of 3 groups within 24 h post-birth. Each group tested two BPSPs; an initiation BPSP was used until the onset of lactogenesis II (OOL-II) and a maintenance BPSP was used thereafter. RESULT: Mothers who used the experimental initiation and the standard 2.0 maintenance BPSPs (EXP-STD group) demonstrated significantly greater daily and cumulative milk output, and greater milk output per minute spent pumping. CONCLUSION: BPSPs that mimic the unique sucking patterns used by healthy-term breastfeeding infants during the initiation and maintenance of lactation are more effective, efficient, comfortable and convenient than other BPSPs.

Calculating postnatal growth velocity in very low birth weight (VLBW) premature infants.

OBJECTIVE: Currently, there is no standardized approach to the calculation of growth velocity (GV; g kg (-1) day(-1)) in hospitalized very low birth weight (VLBW) infants. Thus, differing methods are used to estimate GV, resulting in different medical centers and studies reporting growth results that are difficult to compare. The objective of this study was to compare actual GV calculated from infant daily weights during hospitalization in a Neonatal Intensive Care Unit (NICU) with estimated GV using two mathematical models that have been shown earlier to provide good estimated GVs in extremely low birth weight (ELBW) infants: an exponential model (EM) and a 2-Point model (2-PM). STUDY DESIGN: Daily weights from 81 infants with birth weights (BWs) of 1000 to 1499 g were used to calculate actual GV in daily increments from two starting points: (1) birth and (2) day of life (DOL) of regaining BW. These daily GV values were then averaged over the NICU stay to yield overall NICU GV from the two starting points. We compared these actual GV with estimated GV calculated using the EM and 2-PM methods. RESULTS: The mean absolute difference between actual and EM estimates of GV showed <1% error for 100% of infants from both starting points. The mean absolute difference between actual and 2-PM estimates showed <1% error for only 38 and 44% of infants from birth and regaining BW, respectively. The EM was unaffected by decreasing BW and increasing length of NICU stay, whereas the accuracy of the 2-PM was diminished significantly (P<0.001) by both factors. CONCLUSION: In contrast to the 2-PM, the EM provides an extremely accurate estimate of GV in larger VLBW infants, and its accuracy is unaffected by common infant factors. The EM has now been validated for use in all VLBW infants to assess growth and provides a simple-to-use and consistent approach.

Mothers' performing creamatocrit measures in the NICU: accuracy, reactions, and cost.

OBJECTIVE: To determine whether mothers of infants in the neonatal intensive-care unit could be taught to perform creamatocrits (CRCTs) accurately on own mothers' milk (OMM). These mothers' reactions to performing CRCTs also were measured. SAMPLE: Twenty-six mothers and four advanced-practice nurses (RNs) participated in this study. DESIGN: For Phase One of this blinded trial, mothers were taught to perform the CRCT by one of the two instructional RNs. For Phase Two, mothers and one of the two validation RNs performed CRCTs simultaneously and independently on the same OMM sample, and the mother completed a Maternal Reactions questionnaire. RESULTS: Mothers' CRCT measures were highly accurate. The mean absolute difference between RNs' and mothers' CRCTs was 0.69%, with 50% and 84.6% of these differences, respectively, < or = 0.5% and < or = 1.0% CRCT. A strong linear correlation was noted between RNs' and mothers' CRCTs. Ninety-six percent of the mothers reported that the CRCT was easy to learn, they felt comfortable performing the procedure, and it made them feel more involved in infant care. A mean of 23.6 minutes was spent teaching the mother to perform CRCT, a figure that reflects the cost-effectiveness of the approach. CONCLUSION: Mothers can be taught to perform CRCTs accurately and easily on their OMM. This practice exemplifies high quality, cost-effective care that maximizes maternal involvement and satisfaction.

Procedures used to prepare and administer intramuscular injections: a study of infertility nurses.

OBJECTIVE: To describe the procedures infertility nurses use to prepare and administer intramuscular injections of fertility medications. DESIGN: Descriptive survey. PARTICIPANTS: Nurses listed as members of the Nurses Professional Group of the American Society for Reproductive Medicine (N = 645) were surveyed. Completed questionnaires were returned by 219 of the nurses. MAIN OUTCOME MEASURES: Volume of diluent, needle selection, site selection, internal rotation of the extremity distal to the injection site, and use of the z-track technique. RESULTS: There was wide variation in the gauge and length of needles used to administer the medications, with most nurses using a 22 g, 1-1/2-in needle for all medications. Most nurses changed the needle between preparing and administering medications; however, filter needles were seldom used. There was wide variation in the volume of diluent used to reconstitute medications. Most of the nurses used the dorsogluteal site for injections. Although almost all of the nurses indicated that they routinely rotated injection sites, they infrequently used sites other that the dorsogluteal site. Most nurses did not rotate the extremity distal to the injection site when administering injections and even fewer used the z-track technique. CONCLUSIONS: This study demonstrated wide variation in the procedures used by infertility nurses to prepare and administer intramuscular injections of fertility medications. Many nurses did not use procedures that can reduce the pain and tissue trauma associated with intramuscular injections.

Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding.

This study reports breastfeeding outcomes for 34 preterm infants whose mothers used ultrathin silicone nipple shields to increase milk transfer. Mean milk transfer was compared for 2 consecutive breastfeedings without and with the nipple shield. Total duration of breastfeeding was calculated for a maximum of 365 days. Mean milk transfer was significantly greater for feedings with the nipple shield (18.4 ml vs. 3.9 ml), with all 34 infants consuming more milk with the nipple shield in place. Mean duration of nipple shield use was 32.5 days, and mean duration of breastfeeding was 169.4 days; no association between these variables was noted. The nipple shield was used for 24.3% of the total breastfeeding experience, with no significant association between the percentage of time the shield was used and total duration of breastfeeding. These findings are the first to indicate that nipple shield use increases milk intake without decreasing total duration of breastfeeding for preterm infants.

Reliability of three length measurement techniques in term infants.

PURPOSE: To describe and compare the intra- and interexaminer reliability of three length measurement techniques and to determine if the three measurement techniques yield significantly different measurements. METHOD: Two experienced, mother-baby nurses each obtained length measurements using the supine, paper barrier, and Auto-length measurement techniques twice each from 48 healthy term infants. The nurses were blind to their own and to each other's measurements. The order of the nurses and the order of the measurement techniques were randomized. RESULTS: For intraexaminer reliability, RN-1 had smaller mean absolute differences for the Auto-length measurements. RN-2 had similar mean absolute differences for all three measurement techniques. The percentage of differences < or = 1 cm were smallest for the supine measurements for RN-1 and not remarkably different between the measurement techniques for RN-2. For interexaminer reliability, the mean absolute differences between the pairs of measurements were smallest for the Auto-length measurements for Set-1 and for the paper-barrier measurements for Set-2. The percentage of differences < or = 1 cm between the pairs of measurements for Set-1 were not remarkably different and were lowest for the supine measurements for Set-2. The mean measurements obtained by the supine, paper-barrier, and the Auto-length measurements were respectively: 50.88, 50.33, and 49.67 cm. The differences between the means were statistically significant (X2 = 56.56, p = .0000). CONCLUSIONS: The differences between length measurements by individual examiners and pairs of examiners are relatively large. Clinicians should be aware of the magnitude of error in length measurements and should interpret length measurements with caution. These findings also demonstrate that all clinicians in any setting should use the same technique to obtain length measurements.

Midwifery care of the woman with menorrhagia.

Menorrhagia is characterized by excessive menstrual bleeding and is defined as a menstrual blood loss of greater than 80 mL. Approximately one in ten women in the United States experiences menorrhagia. Although rarely life-threatening, menorrhagia can have a negative impact on women's lives, and its treatment can improve the quality of life for many women with this condition. This article reviews the definition, diagnosis, pathophysiology, assessment, and treatment of menorrhagia as well as the impact of menorrhagia and its treatment on the quality of life for women with this condition. The role of the midwife in the care of the woman with menorrhagia is also reviewed.

Reliability of length measurements in full-term neonates.

OBJECTIVE: To describe and compare the intra- and interexaminer reliability of four techniques for measuring length in full-term newborns and to determine whether the different techniques yield significantly different measurements. DESIGN: A descriptive study, describing the intra- and interexaminer reliability of four length measurement techniques: crown-heel, supine, paper barrier, and Neo-infantometer. The nurses were blind to their own and to the other nurse's measurements. The order of the nurses and the order in which the measurements were obtained was randomized. SETTING: Mothers' rooms in a university hospital. PARTICIPANTS: Thirty-two healthy full-term newborns. INTERVENTIONS: Length measurements using four different length techniques were obtained twice each by two experienced neonatal nurses. MAIN OUTCOME MEASURES: To measure the intra- and interexaminer reliability, the following statistics were calculated: mean absolute differences, standard deviations, technical error of measurement; percentage less than .5 and 1.0 cm, and percentage of error. RESULTS: Intra- and interexaminer differences were significantly larger when examiners used the crown-heel measurement technique. Although the intra- and interexaminer reliability of length measurements obtained with the supine, paper barrier, and Neo-infantometer techniques did not differ significantly, the amount of error in these measurements was large. CONCLUSIONS: Measurements obtained using the crown-heel technique are significantly less reliable than measurements obtained using the supine, paper barrier, or Neo-infantometer techniques.

Reliability of head circumference measurements in preterm infants.

PURPOSE: To describe and compare the intra- and interexaminer reliability of head circumference measurements obtained with paper and cloth tape measures. METHOD: Two experienced neonatal nurses each obtained head circumference measurements using both paper and cloth tape measures twice each, from 49 clinically stable, preterm infants. The nurses were blind to their own and to each other's measurements. The order in which the measurements were obtained was randomized. The differences within and between examiners for cloth and paper tape measurements were described using mean absolute differences, standard deviation of net differences, technical error of measurement, minimal and maximal differences, percentage of differences 0.25 and 0.5 cm, and percentage of error. RESULTS: Wilcoxon matched-pairs, signed-ranks tests demonstrated significantly greater intraexaminer reliability for measurements obtained with the paper tape for both of the nurses. Wilcoxon matched-pairs, signed-ranks tests also demonstrated significantly greater interexaminer reliability for measurements obtained with the paper tape for both the first and second measurement sets. CONCLUSIONS: Intra- and interexaminer differences were consistently smaller when the examiners used paper tape measures.

Intra- and interexaminer reliability of anthropometric measurements of term infants.

BACKGROUND: The reliability of anthropometric measurements of term infants has not been studied sufficiently to determine if these measurements are reliable enough to be used in clinical practice and research. This study described the intra- and interexaminer reliability of the following anthropometric measurements: weight (WT), head circumference (HC), chest circumference (CC), abdominal circumference (AC), mid-arm circumference (MAC), and length. METHODS: A convenience sample of 50 clinically stable term infants was studied. Two examiners obtained the six measurements twice using blank tape measures. The order of examiners was randomized and the examiners were masked to their own and the other examiners' measurements. RESULTS: The intraexaminer mean absolute differences were as follows: WT = 1.88, 3.28 g; HC = 0.29, 0.29 cm; CC = 0.50, 0.78 cm; AC = 0.71, 0.77 cm; MAC = 0.36, 0.39 cm; length = 0.92, 1.18 cm. The interexaminer mean absolute differences were as follows: WT = 1.94, 1.66 g; HC = 0.37, 0.36 cm; CC = 0.59, 0.72 cm; AC = 0.99, 0.77 cm; MAC = 0.41, 0.57 cm; length = 1.57, 1.47 cm. CONCLUSIONS: These findings indicate that intraexaminer differences tended to be smaller than interexaminer differences for all measures except weight, which remained stable for intra- and interexaminer comparisons. These findings also suggest that weight and head circumference were the most reliable measures, whereas length and mid-arm circumference were the least reliable measures.

Estimating milk intake of hospitalized preterm infants who breastfeed.

This study describes the accuracy of clinical indices to estimate the milk intake of breastfed preterm infants. Twenty-nine mother-infant pairs were studied for a total of 39 breastfeeding sessions. Two NICU nurses (RN1 and RN2) and one certified lactation educator (CLE) collected data, each blind to the others' measures. RN1 and RN2 performed test-weights using the Smart Model 20 electronic scale. The CLE observed the breastfeeding and estimated milk intake, using clinical indices of milk transfer. Clinical indices did not provide an accurate estimate of milk intake (r = .48). The mean absolute difference between the test-weights and clinical estimates was 5.79 ml, with a maximal difference of 20 ml. These differences were random in that clinical indices did not consistently over- or underestimate milk intake. None of 17 clinical indices of milk intake significantly lowered the magnitude of error in the clinical estimate. These data suggest that clinical indices cannot serve as a replacement for test-weighing of preterm infants when an accurate estimate of milk intake is necessary.

Reliability of in-bed weighing procedures for critically ill infants.

The purpose of this study was to describe the intra- and interexaminer reliability of weight measurements obtained from critically ill infants on an in-bed electronic scale. Weight measurements were obtained using the in-bed scale (Smart Model 35, Olympic Medical, Seattle, Washington) for 32 infants; 16 were in an incubator, and 16 were under a radiant warmer. Two nurses each obtained two weight measurements for each infant for three consecutive days, for a total of 96 data collection sessions. The nurses were blinded to their own and to the other nurse's weight measurements. The average mean absolute difference for individual nurses' weight measurements (interexaminer reliability) was 12.58 gm for weights obtained in the incubator and 19.19 gm for weights obtained under the radiant warmer. The average mean absolute difference for pairs of nurses' weight measurements (interexaminer reliability) was 14.29 gm for weights obtained in the incubator and 24.42 gm for weights obtained under the radiant warmer. The average mean absolute differences for weights obtained in the two bed types differed significantly for both intra- (Z = -2.46, p = .0141) and interexaminer (Z = -3.11, p = .0019) reliability. The number of pieces of equipment that had to be held during the weight measurement was weakly correlated with both the intra- (rs = .1878, p = .0091) and interexaminer (rs = .1600, p = .0266) mean absolute differences. These findings suggest that weight measurements of critically ill infants obtained using the Smart Model 35 in-bed electronic scale are sufficiently reliable for calculation of medication, parenteral fluid, blood replacement, and nutritional requirements.(ABSTRACT TRUNCATED AT 250 WORDS)

A new scale for in-home test-weighing for mothers of preterm and high risk infants.

The purposes of this research were to describe the accuracy of test-weighing with the BabyWeigh, a new infant scale suitable for use in the home, and to determine whether mothers and investigators could estimate intake accurately during breastfeeding sessions, using clinical cues that are recommended for this purpose. Within five days of projected NICU discharge, 30 preterm and/or high risk infants and their mothers were studied during a single breastfeeding session. A member of the research team performed test-weights with the Smart Model 20 infant scale, and mothers performed test-weights with the BabyWeigh scale. The mothers and investigators each estimated volume of intake for the breastfeeding session using clinical cues. Mothers and investigators were blind to each others' test-weights and clinical estimates. Results revealed that the BabyWeigh scale provided an accurate estimate of intake during breastfeeding across a large range of infant weights and intake volumes. In contrast, investigator and maternal estimates of intake were not sufficiently accurate.

Fundal height measurement. Part 5--The effect of clinician bias on fundal height measurements.

The purpose of this study was to determine whether clinicians' fundal height measurements were influenced by their ability to see the numeric markings on the tape measure during the measurement procedure, and by their knowledge of gestational weeks. Ten certified nurse-midwives and four student nurse-midwives each obtained measurements from 24 women. Each clinician obtained two fundal height measurements with unmarked paper tape measures and two fundal height measurements with marked paper tape measures. The fundal height measurement obtained and recorded on the prenatal chart by the clinician responsible for the woman's routine prenatal visit at the time of data collection was also recorded by the researchers. Comparison of the differences between the clinician's two marked and two unmarked tape measurements demonstrated that the differences between the two marked tape measurements were smaller (mean absolute difference = 0.61 cm) than the differences between the two unmarked tape measurements (mean absolute difference = 0.97 cm). When the gestational weeks were compared with the unmarked and marked tape measurements and with the fundal height measurements recorded on the prenatal record, the smallest differences were between the fundal height measurements recorded on the prenatal record and gestational weeks (mean absolute difference = 1.51 cm); the next smallest differences were between the marked tape measurements and gestational weeks (mean absolute difference = 1.89 cm); and the largest differences were between the unmarked tape measurements and gestational weeks (mean absolute difference = 2.15 cm). These findings demonstrate that clinicians' fundal height measurements are biased by their ability to see the numeric markings on the tape measure and by their knowledge of gestational weeks. These findings suggest that clinicians should blind themselves to their own fundal height measurements and to the number of gestational weeks to avoid the effects of clinician bias on their fundal height measurements.

Nurse-midwifery management of iron-deficiency anemia during pregnancy.

Anemia is a common complication of pregnancy and is associated with preterm birth, low-birth-weight infants, and increased perinatal mortality. Anemia during pregnancy is most commonly caused by iron deficiency. This article reviews the etiology, pathophysiology, diagnosis, and nurse-midwifery management of iron-deficiency anemia during pregnancy.

Fundal height measurement. Part 4--Accuracy of clinicians' identification of the uterine fundus during pregnancy.

The purpose of this study was to determine how accurately clinicians can identify the uppermost border of the uterine fundus when they obtain fundal height measurements. Clinicians were instructed to identify the uppermost border of the uterine fundus in their usual manner and make a small pen mark on the maternal abdomen at that point. Real-time ultrasonography was then used to locate the actual level of the fundus and measure the distance between the clinician's assessment and the actual level of the fundus. Measurements were obtained from 126 women. Six clinicians participated in the study, and the differences between the clinicians' errors were not statistically significant (F = 1.26; d.f. = 5,120; P = .2873). For the entire series, the mean error was -.45 cm (SD = 1.99 cm), the mean absolute error was 1.25 cm, the maximal error was 8.6 cm, the percentage of errors that exceeded 1 cm was 42.1%, and the percentage of errors that exceeded 2 cm was 20.6%. Examiner error was not associated with factors such as maternal height, prepregnancy weight, present weight, prepregnancy body mass index, parity, gestational weeks, the amount of fat on the anterior abdominal wall, or the presence of the placenta or fetal parts in the fundus. Examiner error was influenced by thickness of the uterine wall and fetal presentation. These findings indicate that clinicians make errors in identifying the uterine fundus in a significant number of cases and that the methods used by clinicians to identify the uterine fundus need to be evaluated and improved.

Breastfeeding support services in the neonatal intensive-care unit.

OBJECTIVE: To describe a model for providing breastfeeding support in the neonatal intensive-care unit (NICU). DESIGN: Naturalistic, participant observation. SETTING: Suburban Level III NICU. PATIENTS: One hundred thirty-two mother-infant pairs over 1 year. Infants were hospitalized in the NICU, and mothers had initiated lactation efforts. INTERVENTIONS: Investigators provided breastfeeding interventions for the mother-infant pairs, based on identified problems, the research literature, or both. MAIN OUTCOME MEASURES: Percentage of mothers who were breastfeeding at the time of discharge from the NICU. RESULT: Interventions were classified into five categories: expression and collection of mothers' milk, gavage feeding of expressed mothers' milk, in-hospital breastfeeding sessions, postdischarge breastfeeding management, and additional consultation. CONCLUSIONS: This model was effective in preventing breastfeeding failure for this population. The model can provide the basis for NICU breastfeeding standards of care, protocols, and chart records, or for reimbursement purposes. The model also provides a framework for studying a specific category or breastfeeding intervention.