Breastfeeding and human milk bank in a neonatal intensive care unit: impact of the COVID-19 pandemic in an Italian cohort of very low birth weight infants

To our knowledge, this is the first study on the impact of the COVID-19 pandemic on the availability of expressed maternal milk in NICU with a further analysis on the role of a donor human milk bank.

One of the most relevant findings of our study is the marked decrease of available expressed maternal milk in our NICU during the pandemic. A recent study by Gunes and co-workers showed that the parent’s breast milk delivery to NICU decreased during the pandemic, even if the exclusive breastfeeding rate at discharge remained unchanged [17]. These findings are consistent with ours. In addition, our results valued the presence of donor human milk bank milk use in the NICU. In our 2020 – 2021 group, in fact, the availability of donated human milk seemed to have highly mitigated the use of infant formula. Donated human milk, accounted for 40.3% of feeds, which is basically the difference between the availability of expressed maternal milk during the pre-pandemic and pandemic period. Although there is evidence that the presence of a donor human milk bank favourably correlates with the breastfeeding rate [18] in NICU, the pandemic period during which it was opened, is likely to have markedly reduced its potential.

An explanation for the lack of significant differences in terms of main clinical outcomes might partly be found in such use of donated human milk. First, no significant differences were found in the time to achieve FEF and in the parenteral nutrition duration, similar to findings of other authors [19]. Then, it is widely known that human milk contains bioactive components and microorganisms that shape the development of the intestinal microbiota contributing to improved clinical outcomes [1, 20]. The population we examined was particularly at risk for complications related to prematurity, which did not increase during the pandemic, despite the reduced use of expressed maternal milk. Given the same level of care provided in our NICU and the same single room NICU setting in the two timeframes analysed, we may speculate that donated human milk contributed to maintaining the clinical outcomes within our previous standards.

Moreover, we showed that the rate of exclusive breastfeeding as well as the rate of formula-fed babies were not statistically different between the two groups at discharge. This might be due to several factors. First, our medical and nursing staff is particularly dedicated to promoting breastfeeding, and this is shown by the high rate of breastfeeding in the 2017 – 2019 group. Moreover, the presence of a donor human milk bank, reducing the initial frustration and stress due to preterm birth and related difficulties, might have promoted the subsequent establishment of breastfeeding [21, 18]. Then, the increasing evidence supporting the practice of breastfeeding during the pandemic has contributed to reassuring mothers regarding the safety and value of their milk. The initial conflicting evidence on the feasibility of breastfeeding at the time of the COVID-19 pandemic, together with uncertainty regarding the viral transmission through maternal milk, has certainly discouraged mothers in the early stage of this emergency [13]. To date, there is indeed convincing evidence from the leading authorities that the use of expressed milk is safe and highly recommended [22].

The significantly lower growth rate between the two groups might be explained by a significantly higher number of intrauterine restricted infants in the 2020 – 2021 group. Also, our findings confirmed what is already known about the different compositions of donated milk and maternal milk and its impact on preterm infants’ growth rates [23, 4].

The daily availability of a dedicated psychologist in NICU allowed us to both provide support to mothers and better interpret our findings. Although the effects of the pandemic on maternal stress are now well known [10], there is little evidence so far that it has impacted the rate of expressed milk in the NICU.

The parental stress related to the pandemic is well documented [12, 10, 11] so far, as well as the stress related to recovery in NICU and its influence on breastfeeding [7,8,9,10]. Our data confirmed that the stress level in mothers was higher than before the pandemic, with a significantly higher need for psychological support and more prolonged follow-up. During the pandemic, restrictive measures have been taken in our hospital regarding access to the NICU. At the onset of the pandemic, only one visitor at a time was admitted, so alternating visits by mothers and fathers were allowed. During the subsequent pandemic waves, further restrictions were introduced and only mothers were admitted to the NICU, with fathers being excluded from visiting their babies. The inability to share the emotional difficulties related to the NICU recovery with their partners, in addition to the fear related to the pandemic period, have reasonably been supposed to have increased the stress of mothers significantly. Consequently, due to the strict interplay between stress and effective breastfeeding [24, 25], maternal expressed milk availability dramatically decreased. Moreover, since the role of fathers in NICU in promoting breastfeeding has been well described [26,27,28], it is reasonable that their absence might have played an additional significant role in reducing maternal milk expression.

The role of counselling and support during breastfeeding in NICU has been widely demonstrated, and this might further explain why the breastfeeding rate at discharge rose again, reaching the previous level [29,30,31].

Our study has some limitations. First, it is a retrospective study involving a single NICU. Also, at the time of the study, the donor human milk bank had just been opened at our NICU, so it might be possible that this “running-in” stage has minimally influenced our data. Then, given the high rate of breastfeeding in our unit out of the pandemic period, we could not perform any comparison with formula-fed babies, which account for a limited number in our cohort. Last, we were not able to make any consideration regarding the effect of the COVID-19 pandemic on donated human milk availability since the opening of our bank coincided with the pandemic onset.

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