Topic 3: Breastmilk and Breastfeeding

(NB These three questions have been combined into one recommendation)

Justification

Early expression (<6 hours post birth) is consistently associated with increased breastmilk volume on day 4 and day 14. Double pumping leads to higher yield, improved maternal wellbeing and saves time, but frequent, early expression appears to have the greatest impact when combined. Frequent expression (≥8 times/day) is associated with significantly greater milk yields than <6 times/day. Encouraging early, frequent and overnight expression may help reduce disparities, improve milk supply, and promote long-term breastfeeding.

Subgroup considerations

Moderate to late preterm infants have suboptimal breastfeeding outcomes and should be an area of focus. Whānau Māori may benefit most from prioritised support for early and frequent milk expression to improve equity.

Implementation considerations

Access to skilled lactation support is essential for establishing and maintaining breastfeeding in neonatal settings, particularly for preterm and medically complex infants. Workforce planning, funding, and equitable access to International Board Certified Lactation Consultant-level support are recognised as important implementation considerations.

Equitable access to high-quality breastmilk pumps (especially for mothers at home) and a private space to express is needed. Culturally safe healthcare experience and emotional support for mothers overwhelmed by NICU stress. Early expression within 6 hours can be difficult post-emergency birth, or if mother and infant are separated and rely on support of the midwife post birth. Overnight expressing is physiologically important for establishing and maintaining milk production, particularly in the early postnatal period when prolactin levels are highest overnight. Education about the importance of early, frequent and overnight expression antenatally (wherever feasible) or immediately postpartum.

Education for health professionals should be provided on establishing milk supply, expression management, transition to breastfeeding and protection of lactation during periods of mother-infant separation.

Greater recognition of the practical barriers that some whānau face when establishing and maintaining lactation is needed, including:

• geographical distance from neonatal services;
• separation of māmā and pēpi;
• financial pressures associated with travel and accommodation;
• access to breast pumps and expressing equipment;
• availability of lactation support following discharge.
  

Addressing these barriers through service planning, workforce development and infrastructure investment will be important to achieving equitable outcomes. Consideration should be given to neonatal environments and models of care that enable māmā and pēpi to remain together wherever possible, recognising the importance of parental presence, skin-to-skin care and breastfeeding support for both infant and maternal outcomes.

Monitoring and evaluation

Track and report by ethnicity and gestational age:

• Timing of first breastmilk expression.
• Frequency per 24 hours over first 7–14 days.
• The proportion of preterm infants receiving mother’s own milk only at days 3, 7, 14 and exclusive breastfeeding rates at discharge.
  

Research priorities

• Randomised trials comparing bundled interventions (timing + frequency + method).
• Data on whānau Māori experience and effectiveness of culturally adapted lactation support.
• Impact on clinical outcomes like NEC, sepsis and time to full enteral feeds.
• Evaluation of maternal well-being and acceptability of different expression regimens.
• Whānau Māori experiences of the enablers for early, frequent double pumping to be supported.
  

Justification

While the evidence is of very low certainty and largely observational, consistent findings across multiple studies suggest that providing mother’s own milk as the first feed is associated with higher rates of breastmilk feeding at discharge. Delaying the introduction of alternative milk (formula or donor milk) also appears to improve breastfeeding outcomes. The intervention is aligned with maternal values if they intend to breastfeed, culturally important for whānau Māori, and has the potential to promote equity.

Subgroup considerations

Pēpi Māori and infants from underrepresented ethnic groups are less likely to receive mother’s milk as the first feed. They are also significantly less likely to be exclusively breastfed at discharge. Ensuring mother’s own milk is used for the first feed could improve equity outcomes for these populations.

Implementation considerations

Implement policies that prioritise timely lactation support and access to expressing equipment immediately after birth. Ensure all staff are trained to support mothers with early expression and understand the importance of the first feed. Include clear documentation protocols to record the type of first feed given. Ensure culturally safe communication with whānau Māori and Pacific families about feeding options and implications.

Monitoring and evaluation

Audit rates of first feed type (mother’s EBM vs. donor/formula) by ethnicity, gestational age, and birthweight. Monitor exclusive breastmilk feeding at discharge across all subgroups. Incorporate feedback from families, particularly Māori and Pacific whānau, on their experiences of lactation support and feeding decisions.

Research priorities

• High-quality prospective studies examining the impact of first feed type on long-term breastfeeding outcomes.
• Implementation studies evaluating structured first-feed protocols on equity and breastfeeding continuation.
• Qualitative research on maternal experiences and decision-making related to early feeding, with an equity lens.

Justification

While the overall certainty of evidence is very low, the direction of effect favours the intervention, with likely benefits across a range of important outcomes such as earlier provision of breastmilk, increased any breastmilk use during hospital stay and reduced time to full enteral feeds. There is no evidence of harm, and the equity implications may be significant for whānau Māori, Pacific families and underserved groups. Lactation consultants offer critical, targeted support for parents navigating the complex challenges of establishing and maintaining lactation while their infant is in neonatal care. The intervention is likely acceptable to parents and clinicians. While there are cost implications, these could be offset by reduced NICU stay and improved long-term health outcomes. Increasing breastmilk supply and the ability for mothers to breastfeed is an important outcome and the evidence indicates lactation consultants do this.

Subgroup considerations

No specific subgroup analyses were available for extremely preterm or low birthweight infants, but these groups may stand to benefit the most from targeted lactation support. Target and prioritised lactation support is also likely to benefit whānau Māori, Pacific families and underrepresented groups who experience structural barriers to breastfeeding and are more likely to be affected by preterm birth.

Implementation considerations

Preterm and medically complex infants frequently experience feeding challenges that require advanced assessment and support. International Board Certified Lactation Consultants play a critical role in supporting milk production, feeding assessment, transition to breastfeeding, complex feeding plans and post-discharge follow-up. Lactation support is a fundamental component of neonatal and preterm care and should be resourced accordingly. Access to embedded skilled lactation support should therefore be considered an essential component of care rather than an optional adjunct service. Lactation consultants should be prioritised for units with the highest rates of preterm births and inequities in breastfeeding outcomes and be available 7 days a week. Services need to be culturally appropriate and delivered in ways that are responsive to the needs of Māori, Pacific and other priority populations. Consider shared care models (e.g. trained lactation nurses, peer supporters) where specialist lactation consultant FTE is limited. Training, protocols and collaboration with midwifery and neonatal teams will be important in the implementation. Workforce planning and ongoing resourcing (e.g. breast pumps, education tools) are essential to sustainability.

Monitoring and evaluation

Track lactation consultant services and breastfeeding outcomes by neonatal unit. Audit time to first breastmilk expression, duration of expression support, and engagement with lactation services. Evaluate impact on time to full enteral feeds, NICU stay and parent-reported experience measures. Collect data by ethnicity and gestational age to evaluate equity impacts

Research priorities

• Research into the cost-effectiveness of lactation consultant services in reducing length of stay and improving breastfeeding rates.
• Explore different models of lactation support delivery (e.g. videos, apps, pamphlets).
• Investigate barriers to access, uptake and impact on long-term breastfeeding continuation and infant outcomes.
• Investigate all of the above by ethnicity.

Justification

Skin-to-skin care should be used routinely as it is beneficial and free with known benefits for infants and whānau. Moderate to high certainty evidence shows skin-to-skin care increases the likelihood of exclusive breastfeeding at discharge by 50% and improves breastmilk supply. High-certainty evidence shows skin-to-skin care reduces mortality by 30%, particularly when initiated early. Moderate to low certainty evidence shows large reductions in both hypothermia and hypoglycaemia. Moderate certainty evidence indicates reduced nosocomial infection risk. Low-certainty evidence supports improved weight gain, length, and head circumference. Skin-to-skin care is associated with reduced length of hospital stay and lower healthcare costs. Overall, strong evidence of benefit, no convincing evidence of harm and potential cost savings.

Subgroup considerations

While the evidence includes a range of gestational ages and birthweights, most studies involved low- and very-low birthweight infants. There is less data specific to extremely preterm infants (<28 weeks); however, early initiation of skin-to-skin care is likely to be safe and beneficial with clinical oversight.

Implementation considerations

Barriers may include a lack of private spaces (this has been reported in our interviews), staffing to support parents, or clinician hesitation in unstable infants or with umbilical catheters. Facilitators are education, whānau-centred NICU design, peer support and clear policies promoting skin-to-skin early and often. Ensure that whānau Māori have culturally safe support to participate in skin-to-skin care. Early initiation is critical: within 24 hours where feasible. Pēpi Māori and Pacific families: Implementation should be prioritised due to the potential to increase equity in breastfeeding and health outcomes. Skin-to-skin care may help redress these inequities by promoting bonding, milk supply, and cultural connection. We suggest exploring whānau perspectives and tikanga expert opinion on how it might be framed as traditional practice.

Monitoring and evaluation

Collect and report data on (by ethnicity): rates of skin-to-skin care initiation (add as a Key Performance Indicator for Australian and New Zealand Neonatal Network), duration per day, timing (early vs. late) and breastfeeding outcomes at discharge, whānau experience and satisfaction.

Research priorities

• Acceptability and cultural preferences of skin-to-skin care for whānau Māori, Pacific families and underrepresented groups.
• Implementation strategies in resource-limited or high-acuity settings.
• Use of skin-to-skin care with extremely preterm or medically fragile infants.
  

Justification

Although most of the evidence is of low certainty, the direction consistently favours improved breastfeeding outcomes, particularly early expression, milk supply, and exclusive breastfeeding at discharge. Qualitative evidence strongly reinforces that dedicated staff support is essential, valued by whānau, and likely to improve breastfeeding success. Undesirable effects are uncertain and probably small.

Subgroup considerations

Whānau Māori and those with lower access to lactation/breastfeeding support may experience the greatest benefit, given known inequities in breastfeeding outcomes. Effects may differ by gestational age, with parents of extremely preterm or long-stay infants requiring more sustained support. Tailoring to cultural needs and communication preferences is important.

Implementation considerations

Implementation depends on staffing capacity, training, and the design of services. Additional staff time, lactation expertise, or structured programmes may be required. Services will need to ensure culturally safe, skilled, consistent, whānau-centred approaches and consider partnering with Māori to co-design support. Costs and workforce pressures may be barriers.

Monitoring and evaluation

If implemented, services should monitor breastfeeding outcomes (e.g., early expression, exclusive breastfeeding at discharge, breastfeeding after discharge), whānau experience measures, cultural safety, and any unintended impacts on workload or service flow. Equity impacts, particularly for Māori whānau, should be routinely reviewed.

Research priorities

• Further high-quality research is needed to evaluate specific staff-related support models in NICU, including culturally grounded approaches.
• Priority areas include effectiveness on breastfeeding outcomes, long-term infant health, cost-effectiveness, and the impact on equity for Māori and other underserved groups.

Justification

Evidence (mainly qualitative and from broader Māori populations) suggests tikanga-aligned practices support breastfeeding, strengthen whānau involvement and improve cultural safety. No major harms were identified, but the effectiveness in preterm infants is uncertain. Despite low certainty within the preterm population, the likely benefits and alignment with Te Tiriti support a conditional recommendation. Enacting this will contribute to increasing health equity for Māori.

Subgroup considerations

Interventions may be easier to implement for moderate–late preterm infants than for extremely preterm or medically complex pēpi. First-time mothers and whānau with fewer supports may need tailored approaches. Regional resourcing, urban/rural differences and deprivation may influence feasibility and effectiveness.

Implementation considerations

Implementation should be Māori-led and co-designed, with staff training in tikanga, support for whānau involvement, and strengthened lactation support both in NICU and post-discharge. Ensure policies enable skin-to-skin, minimise separation where safe and provide adequate resources for equipment and specialist support.

Monitoring and evaluation

Track breastmilk feeding during admission and breastfeeding rates at discharge and post-discharge, monitor equity gaps between Māori and non-Māori, gather whānau feedback, and review staff training uptake.

Research priorities

• Further research into which aspect is the most effective in supporting wāhine Māori to achieve exclusive breastfeeding. 
• Prioritise NICU-specific, Māori-led implementation studies, trials evaluating breastfeeding outcomes in preterm infants, equity-focused research, and work assessing which components of tikanga-aligned breastfeeding support are most effective.