The TIG Blog invites any interested trainees to write a guest post about a topic that interests them. These blogs can be about a current issue in human milk and lactation research, a description of their own research, or simply a question of interest. This guest post was written by ISRHML trainee Laura Galante, who is currently in her first year as a doctoral student in biomedical science at the Liggins Institute, part of the University of Auckland in New Zealand.
Collecting breastmilk in neonatal intensive care units (NICU) is not an easy job.
When I began my doctoral research in human lactation, I naïvely believed that collecting breastmilk must not be that hard. However, this line of thinking changed as soon as I started collecting samples. Since I am collecting human milk for a study designed to assess the effect of different nutritional strategies used in the NICU on preterm neonates, the first environment I had to face was not a familiar or easy one. Collecting breastmilk in New Zealand, especially in delicate settings such as NICUs in the first few days after birth, can be indeed very challenging.
Over the past fifteen years, New Zealand’s Ministry of Health has been promoting breastfeeding to achieve a substantial increase in rates, given the dramatic drop that had been observed in the past after the first 6 weeks postpartum. In response, the country has embraced a strong policy for the promotion of breastfeeding that is especially supported in neonatal units. This constitutes valuable support for new mothers, whose babies often have to stay in hospital for a while. Despite the fact that our study infants are not early-preterm, there are still concerns regarding their health and feeding, such as weight loss, delays in reaching full enteral feeds, and inadequate growth. This is all in addition to the milk supply issues that mothers of premature infants often face. As such, most of the concerns around collecting breastmilk samples were not coming from mothers, but instead from midwives, nurses, and lactation consultants, whose primary thought was ensuring the babies’ nutrition was appropriate and supporting mothers to begin breastfeeding or expressing milk. This reluctance was something that I did not foresee, and at first was quite surprising to me.
However, as I became acquainted with the NICU environment, I began to understand the intense feelings surrounding the topic. As I mentioned before, the main apprehensions regarded the infants, in particular, and whether or not they needed those few extra millilitres that we were collecting for our research. Another concern was that we might add further stress to mothers, who already are often quite stressed by the situation. Indeed, research has shown that mothers of babies categorized as very low-risk and are just as stressed out as those of infants that doctors are really worried about.
In addition, the presence in NICU of students, unknown to the clinical staff, was a further issue that needed to be addressed. In addition to the emotional dimension – related to the concerns for the NICU babies and their mothers – operational considerations regarding the quality of the samples were also an issue. Our original protocol, designed to standardize milk collection, was quite strict and after we had collected only a few samples, it was determined that the protocol as written was very hard to follow in a NICU setting. For instance, we learned that collecting milk at times just after birth (day 3) is difficult. In addition, specific timing of collection is hard to stick to because research staff and/or mothers are often not available at that specific time for every collection day.
To address these issues that came up with the study, we made some adjustments. For example, at every collection, we gave the mother the option to give a milk sample or to opt out. This was done in an attempt to decrease stress and any feelings of obligation. If the mother agreed on that day, we made sure to check that the milk could be collected without impacting the baby’s nutritional needs. The toughest issue to address was the protocol, where we had to be physically present to collect the samples, especially since the clinical staff in NICU rotates frequently. We decided one way to improve our success was to introduce ourselves appropriately to the relevant personnel before approaching a mother for a sample. With regard to our protocol, I had to learn the virtue of sample collection flexibility, which I had never considered in my previous research experience, when I collected blood samples strictly every hour for seven hours during a study visit. Our new operational protocol (which we like to think is mostly optimized now) was constantly amended for months in order to primarily accommodate the necessities of babies and mothers, while still maintaining sample integrity and consistency.
Nonetheless, at the end of the first few months of collection it became clear that better communication should have been promoted between research staff and practitioners. In order to dispel the misconceptions that it seemed had arisen from our study amongst the clinical staff, we set about distributing a “frequently-asked questions” document addressing common concerns along with some important explanations on the rationale for the study design, the purpose of collecting the breastmilk samples, why we need them to be collected in that specific way and at that specific time, what were the outcomes that we were targeting by undertaking the study.
At present, I cannot say that the atmosphere when I collect a sample in NICU is completely relaxed. There will always be some concern around the fact that we are “taking” milk from mothers of babies that need all the nutrients they can get. Some of these concerns may even be ingrained in the culture of the country or in the specific policy the government has lately adopted. Nevertheless, better communication with the clinical staff resulted in fewer objections by making clear that by studying mothers’ milk we are trying to help future NICU babies. After all, research in clinical settings must strike a balance between current patient care and quality of the samples collected, which will ultimately determine the quality of knowledge for the care of future patients. Researchers or practitioners may often only see one of these two aspects, the one that is more relevant to them, and for this reason it is always important to consistently work on communication between the two sides.
When you think that what you are doing will hopefully help somebody, it is objectively hard to realize that somebody else thinks you are doing harm. As a new and probably naïve researcher, I found myself thinking that the importance of my research would be immediately evident to anybody. The reality, however, is that there will always be someone, maybe also in the specific field in which we are working, who may be discordant or who might not have fully understood the aim of our research and to whom it will always be worth explaining it. At the end of the day, I like to think that it is our responsibility to do so (but in the nicest and most engaging way possible)!
Thank you Laura for sharing these challenges and your solutions with us! If you’d like to contact Laura to further discuss her research or these challenges she’s navigated, you can email her at email@example.com
Laura Galante is a doctoral candidate at the Liggins Institute, University of Auckland under the supervision of Professor Mark Vickers, Dr. Amber Milan, and Dr. Clare Reynolds. She graduated with a bachelor’s degree in biology from University of Trieste in Italy, and a master’s degree in nutrition from the University of Milan, also in Italy. Laura decided to go back into tertiary education after a year working as a pharmacovigilance and medical information specialist for IQVIA (formerly Quintiles Ltd) in Ireland. Science aside, Laura spends her free time drawing, practicing ballet, and reading classic literature. Her newest challenge is to become a decent piano player starting from scratch at the venerable age of 26. Greatest unrealistic dream: receiving a Nobel Prize. Greatest realistic dream: becoming a writer and illustrator of science books for children and adults.
Laura’s research is focused on how the infant sex and maternal conditions affect breastmilk composition and what is the role of these factors in infant growth. If you’d like to learn more about her and other Liggins Institute’s research, you can do so here.