Daljeet Kaur, Avinash Kaur Rana, Geetanjli Kalyan, Praveen Kumar

 Abstract : Introduction: Preterm neonates require expressed breast milk feeding as they are not able to coordinate sucking and swallowing reflex. It has been observed that preterm neonates do not get adequate amount of expressed breast milk feed in neonatal unit, tertiary care hospital, North India. Objective: A pilot project was conducted with an objective to assess barriers and suggested facilitators for feeding preterm neonates with expressed breast milk. Methodology: Focus group discussions (FGDs) were conducted with nursing officers till data get saturated. Total 16 FGDs were conducted with nursing officers and in each group 4-5 nursing officers were included. Results: Results of revealed that there are many barriers related to expression of breast milk and feeding of preterm baby with expressed breast milk such as difficulty in tracking the mother of neonates admitted in NICU/ step down nursery, nonexistence of standard operational protocol for feeding preterm neonates with expressed breast milk, lack of knowledge among mothers related to importance of colostrum and breast milk in preterm neonates, lack of standard teaching content for nurses to teach the mothers how to express breast milk and decrease milk output due to increase level of stress and decrease rest period. Some common suggested facilitators include: availability of posters and written protocol, separate area for milk expression, education of mothers on expressed breast milk feeding, counselling of mothers, separate labouring area and so on. Conclusion: The findings of current project concluded that health care professionals should exert efforts to promote expressed breast milk feeding in preterm neonates.

Keywords

Expressed breast milk feeding, preterm neonate, barriers, suggested facilitators

Correspondence at

 Avinash Kaur Rana

Lecturer

National Institute of Nursing Education (NINE), PGIMER, Chandigarh

Introduction

Babies born before 37 weeks of gestation are called preterm neonates. Preterm babies further subdivided in to mild preterm, very preterm and extremely preterm and all preterm babies are also referred as low birth weight babies1. Proper nutrition in neonate is essential as it helps in normal growth, resistance to infection, long term health, optimal neurologic and cognitive development.2,3 Breast feeding is best for neonates as it decreased the risk of sudden infant death,4 cold and flu, asthma, eczema, dental problems, psychological disorder and contribute to increase intelligence of a child. 5,6, A study conducted on 773 premature babies who were born extremely underweight, to demonstrate the importance and benefits of breast feeding. At an age of 30 months, an intelligent test was conducted on all babies. Study concluded that babies who were fed with their mother’s milk had the average mental development as compared to babies fed with infant formula.7

Breast milk produced by mammary gland of human female is a primary source of nutrition for newborns before they are able to eat and digest other foods. Exclusive breast feeding should be given for first six month of life after that it should be supplemented by complementary feeding term milk. Components like non protein nitrogen, volume, solids, total calories, lactose, fat, fatty acid, potassium and calcium are same in both type of milk (preterm and term milk).11,12 Preterm human milk is much suitable than term human milk, for the premature babies.

Preterm babies require to be admitted in neonatal unit for intensive supervion due to complications of prematurity such as respirator y distress, necrotizing enterocolitis, shock, hypoglycemia, hypothermia and infection. Premature babies are not able to coordinate suck and swallow reflex so expressed breast milk is given. In these type of babies breast feeding may not be possible for several weeks or months, depending upon the condition of baby. After the birth of premature baby time is very different to mothers as compared to those with full term. It was observed in routine clinical experience of investigator that preterm neonates are getting very less until 2 years of age.8 If we talk about amount of expressed breast milk feed and composition of human milk it contains 8% to 9% protein, 4.5% fat, 7.1% carbohydrates mainly lactose, 0.2% minerals9 and also IgA which is high from day 10th up to 7.5 month post partum.10 Concentration of nutrients varies with term and preterm milk. Preterm milk contains higher concentration of nitrogen protein, sodium, chloride, magnesium and iron than formula feed is given to fulfil the requirement of babies. Need was felt to assess barriers and facilitators for feeding preterm neonates with expressed breast milk

Objectives

To assess barriers and suggested facilitators for feeding preterm neonates with expressed breast milk.

Material and methods

Setting of study was neonatal unit of a tertiary care institute, North India.Neonatal unit consist of CLR nursery, CLR extension nursery, NNN and NICU. Sample was selected by purposive sampling technique. Sample population was nursing officers working in neonatal unit.Tool was consisting of focus group discussion guide which have unstructured open ended questions. All nursing officers were informed about the study. Main focus was problems faced by nursing officers in feeding expressed breast milk in preterm neonates and possible suggested facilitator of those problems. FGDs were conducted till responses get saturated so total 16 FGDs were conducted with nursing officers in group of 4-5 nursing officers per discussion was included. Duration of each FGD was around 30-40 minutes. Audio recording was done for each discussion. After completing all FGDs verbatim were pen down on paper, themes were generated and inferences were drown. Inferences were given to three experts from field of psychiatry for validation. Changes were done according to the suggestions from experts.

Results

Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (CLR extension nursery) Table 1a-b describes the barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers in CLR extension nursery.

Common barriers expressed by nursing officers in CLR extension nursery were : twin pregnancy, no separate area for milk expression, inadequate nurse patient ratio, lack of knowledge among mothers related to colostrum, problem in communication with mothers when she is admitted in other wards, inadequate rest of mothers, no written protocol and AV aids displayed in ward about expressed breast milk feeding Common suggested facilitators in CLR extension nursery were : alternate feeding system for both babies in case of twins, posters related to expression of breast milk should be displayed at different places of ward, separate area for milk expression should be there, lactation counsellors should be available in all three shifts i.e. morning evening and night, education about colostrum should be given, mother should also be admitted in CLR extension nursery if baby is admitted in nursery extension , limited time for attendants, written protocol related to expressed breast milk feeding should be available in wards.

Table 1a: Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers

(CLR extension nursery)

Barriers Verbatim Suggested facilitator
Twin pregnancy In case of twins vxj ,d cPpk NICU esa gSa vkSj nwljk Nursery

esa rks oks T;knk     ;kuNICU okys cPps ij gh nsrs gSa mls gh

EBM nsrs gSa A

blds fy;s dq Alternate Feeding System gksuk pkfg, ftlds rgr ,d ckj Nursery okys cPps dks vkSj ,d ckj NICU

okys cPps dks EBM nsuk pkfg, A

Alternate feedings system for both babies in case of twins
  ( in case of twins if one baby is admitted in NICU and second  
  is in nursery then they will take care of baby who is admitted  
  in NICU and EBM is also given to him only. For that some  
  alternative system should be there according to which once EBM  
  should be given to baby in nursery and once to baby in NICU)  
Inadequacy of posters related to expression of Area esa expression of milk ds ckjs esa dksbZ Hkh Poster ekStwn ugha gS dq rlohjksa okys Poster gksus pkfg,] ftlesa ekrkvksa dks Hkh vklkuh gksxh A Poster related to expression of Breast Milk should
breast milk (There are no posters displayed related to expression of milk in be displayed
  area. There should be some poster with pictures. It will be easy  
  for mothers also.)  
No separate area for milk

expression

Milk expression area ugha gS vkSj dksbZ Screen Hkh ugha gS ftlls ekrkvksa dks Privacy j[kus esa eqf   dy gksrh gS ge Hkhteach

ugha dj ikrs A Milk expression area gksuk pkfg, A

Seperate area for milk expression

should be there

  (Milk expression area is not there and screen is also not  
  available so mothers having difficulty to maintain privacy.  
  We are also not able to teach them. Milk expression area  
  should be there.)  

 

Table 1b: Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (CLR extension)

Themes Verbatim Suggested facilitator
Inadequate nurse patient ratio Nurse patient ratio cgqr de gS bldk dkj.k dbZ ckj teaching

okyk Hkkx jg tkrk gS A ge ekrkvksa dks motivate ugha djikrs A

Lactation counselors rks gSa ij os     kke vkSj jkr esa Hkh gksus pkfg,A

(Nurse patient ratio is less due to which some time teaching is

part left .we are also not able to motivate mothers. Lactation counselors should also be available in night and evening)

Lactation counsellors should be available in evening and night
Lack of knowledge related to colostrum Colostrum ds ckjs esa tkx:drk ugha gS] oks cksyrsa gSa vHkh rks ikuh vk jgk gS rhljs fnu nw/ vk,xk rks ns nsaxs A

Colostrum ds ckjsa esa proper health education gksuh pkfg, A

(No awareness about importance of colostrum, they (mothers)

said that now yellow water is coming, milk will come in third day

then we will give. Proper education about colostrum should be given.)

Education about Colostrum should be given
Problem in communication with mothers when she is admitted in other wards ekrk,a CLR vFkok fdlh nwljh ward esa gksrh gSa rks communication esa eqf   dy vkrh gS] ckj&ckj Qksu djuk iM+rk gS A vxj cPps extension nursery esa gSa rks ekrk Hkh CLR Extension esa gh gksuh pkfg, A

(If mother is admitted in CLR or any other ward then problem is

there in communication, we call again and again. If baby is admitted in extension nursery then mother should also be admitted in CLR extension)

Mother should also be admitted in

CLR extension if baby is admitted to nursery extension

Inadequate rest of mothers ckgj ward ,d fcLrj ij nks ekrk,a gksrh gS A os Bhd rjg ls vkjke Hkh ugha dj ikrh gSa A Attendants dh Hkh HkhM+ gksrh gS A Attendents ds feyus dk le; lhfer gksuk pkfg, A

(In ward two mothers share one bed so they are not able to

take rest properly. Crowd of attendants is also there. Limited time should be there for attendants to meet)

Limited time should be there for attendants to meet
No written protocol About ges kk rktk nw/ nsrs gSa] D;ksafdStorage ds ckjs esa dksbZ Hkh

protocol ugha gS A

(We always give fresh milk, because no protocol is available

related to storage.)

Written protocol should be available

Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (CLR nursery)

Table 2a-b depicts the barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers in CLR nursery.

Barriers by nursing officers in CLR nursery are: Limited time for counselling, lack of knowledge related to colostrum among mothers, no separate area for milk expression, stressful environment of labour room, difficulty to track the mother, entry restricted in nursery at the time of delivery, area of nursery is very less, excessive work load.

Suggested facilitators in CLR nursery as reported by nursing officers are: Lactation counsellors should explain properly about expressed breast milk feeding, health education related to colostrum should be given in antenatal period, separate area for milk expression should be there, labouring area should be separate, post natal staff should inform about shifting area of mother, nursery should be in other wards, CLR nursery should be just to receive the baby after delivery,

Table 2a: Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (CLR nursery)

Themes Verbatim Suggested facilitator
Limited time for counselling Staff   cgqr O;Lr gksrk gS gekjs ikl bruk le; ugha gks rkfd proper couselling   dj ldsa A cl FkksM+s ls steps   crk nsrsa gSa A ijarq T;knk foLrkj esa ugha crk ikrs A

Lactation counsellors   dks properly   le>kuk pkfg,

(Staff is always busy and we don’t have time for proper

counselling. we can only tell few steps but not in detail. Lactation counsellors should explain.

Lactation Counsellers should explain properly
Lack of knowledge related to colostrum yksx cksyrs gSa fd nw/ ugh fudy jgk ;g rks ikuh gSA Colostrum ds ckjs esa irk ugha gSA oks Colostrum nsuk gh ugh pkgrsAAntenatal Period esa Hkh Colostrum ds ckjs esa Health education gksuh pkfg, A (People says that milk is not there. It is water. They don’t

know colostrum. They don’t want to give colostrum. Health education about colostrum should be given in antenatal period.)

Health education related to colostrum should should be done in antenatal period
No separate area for milk expression Feed express djus ds fy, dksbZ Hkh area ugha gS A Feed express

djus ds fy, vyx area gksuk pkfg, A

(No area to express feed. Separate area to express feed should

be available.)

Separate area for milk expression should be there
Stressful environment of labour room Labour Room dks egkSy cgqr stressfull gSA ejht+ labouring ekrkvksa dks ns[kdj ?kcjk tkrs gSa A ;gk ij Delivery room gS A Post

Natal and nursery Hkh gS A Labouring area gh vyx gksuk pkfg, A

(Environment of Labour Room is very stress full. Patient get

anxious by seeing laboring mother. Delivery room is also here,

postnatal and nursery is also here. Laboring area should be separate.)

Labouring area should be separate
Difficulty to track the mother ekrk dgka f   k   V dh xbZ gS gesa irk ugha gksrk A dbZ ckj ge O; gksrs gSa rks <wa< ugha ikrs A Postnatal Staff Nursery esa inform djsa fd ekrk dks dgka f   k   V fd;k x;k gS A

(We don’t know where mothers has been shifted. Most of times we also remain busy and are not able to find out. Postnatal staff should inform in nursery that where mother is being shifted.)

LrPost natal staff should inform

in nursery

about shifting area of mother

Entry restricted at the time

of delivery

Nursery delivery room esa gS A tc delivery py jgh gksrh gS rks restricted  entry gks tkrh gS A ekrk nursery esa ugha vk ikrhA Wards esa gh nursery gksuh pkfg,] tSls fd Gynae ward.

(Nursery is situated in delivery room. Entry is restricted in delivery room at the time of delivery. Mother can’t come in nursery. Nursery should be in wards eg. In Gynae ward.)

Nursery should be in other wards

not in labour room

Table 2b: Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (CLR nursery)

Themes Verbatim Suggested facilitator
Area of nursery is very less Nursery dk area cgqr de gS A ,d cot esa rhu&rhu cPps Hkh gksrs gSa A ;gha ij LVkQ] MkWDVlZ gksrs gSa A bl otg ls eka ds fy,

txg cgqr de gksrh gS A ;s flQZ receiving nursery gksuh pkfg, A

mlds ckn cPpk nwljh nursery esa shift gksuk pkfg, A

CLR Nursery should be just to receive the baby after delivery
  (Area of nursery is very less. Three babies share one cot. Staff  
  nurses and doctors are also there. So there is very less space for  
  mothers in nursery. Labour Room Nursery should be just to  
  receive the baby. After that baby should be shifted to other nursery.)  
Excessive work load T;knk deliveries gksus ds dkj.k ;gka dkQh HkhM+ gks tkrh gS A vki cPps dks receive dj jgs gks] sick cPPkksa dks Hkh ns[k jgh gks A    ekrk dks le; ugha ns ikrs A EBM ij Hkh focus ugha dj ikrs Nursery gh vyx gksuh pkfg, A ;gka ij dsoy receiving gh gksuh

pkfg, A

CLR Nursery should be just to receive the baby after delivery
  (Rush is there due to number of deliveries. You are receiving the  
  baby and also taking care for sick babies so not able to give time  
  to mother. Due to that we are not able to focus on EBM. Nursery  
  should be separate. This nursery should be for receiving the baby only.)  

 Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (NNN and NICU)

Table 3a-b depicts the barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers in NNN and NICU. Barriers in NNN and NICU as reported by nursing officers are: Difficulty to track the mother, anxious due to prematurity of the baby, lack of knowledge about colostrum among mothers, lack of motivation, breast engorgement, issue of girl child, limited time for counseling, inadequacy of posters related to expression of breast milk,excessive fatigue of mothers, congested milk expression room, boiler is not available.

Suggested facilitators in NNN and NICU as reported by nursing officers are: Lactation counselors should track the mothers, counseling about condition of the baby should be done, health education about colostrum, counselor should be present in wards, health education about breast complications should be given, counseling about gender equality, counseling should be done before first visit in neonatal unit, posters related to expression of breast milk should be displayed, old mothers can also explain to new mothers, time table should be displayed related to activities of mothers, milk expression room should be big, boiler should be available.

Table 3a: Themes of FGD related to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (NNN and NICU)

Themes Verbatim Suggested facilitator
Difficulty to track the mother tc mother nwljs okMZ esa  admit gksrh gS rks communication esa leL;k vkrh gS A gesa irk ugha gksrk fd eka fdl LFkku ij gS A   gesa ;g Qksu djds iw  uk iM+rk gS fd ekrk dgka ij gS A Lactation counsellors dks crkuk pkfg, fd oks nw/ express djas A ekrk,¡ dgka ij gS bldk iwjk fjdkMZ muds ikl gksuk pkfg, A

(When mother is admitted in other wards then there is problem

in communication with mothers. We don’t have knowledge about location of mothers. We use to call in different wards to locate the mothers Lactation counselors should tell about expression of milk to

mothers. They should also have record of location of mothers.)

Lactation counsel- ors should track the mothers
Anxious due to prematurity of the baby Premature cPps dh otg ls ekrk Hkh Mj tkrh gS A Probes dks ns[kdj ?kcjk tkrh gS] os cPps dks    wrh Hkh ugha A cPps dh gkyr ds ckjsa esa crkuk pkfg,] dksbZ counselor gksuk pkfg, tks cPps dh gkyr ds ckjs esa mudh iwjh rjg ls counseling djsa A

(Mothers are afraid due to premature baby. They got anxious by seeing probes, they don’t even touch the baby. Condition of baby

should be explained to mothers, counsellor should be available who can do proper counselling about condition of baby).

Counseling about condition of the baby should be done
Lack of knowledge about colostrum Colostrum ds ckjs esa mothers dks tkudkjh ugha gksrh A oks cksyrs gSa fd vHkh ihyk nw/ gS] nw/ ugha fudy jgk gS A Colostrum ds ckjs eas iwjh rjg health education gksuh pkfg;s] mlds Qk;ns crkus pkfg, A

(Mothers don’t have knowledge about colostrum. They say that it is yellow milk, pure milk is not coming. Health education about

colostrum should be given, its importance should be explained.)

Health education on about colostrum should be done
Lack of motivation ge ckj ckj Qksu djds cqykrs gSaA Attendant dks Hkh cksyrsa gSa ysfdu tc rd ekrk admit  jgrh gS os vkuk ugha pkgrh A Ward esa gh counselor gksuk pkfg, tks mUgsa le>k lds vkSj motivate dj lds A

(we call them by repeated phone calls. We tell to attendant also but when mother is admitted she don’t want to come. Counsellor should be

present in wards who can explain and motivate them.

Counselor should be present in wards
Breast engorgement dq ekrkvksa dks Breast engorgement gqbZ gksrh gS rks     kq:vkr esa rks oks nw/ express  ugha djrh fQj tc gekjs ikl vkrh gSa rks gkFk ugha yxkus nsrh A       kq:vkr esa ghhealth education  gksuh pkfg, vkSj mudks Breast engorgement ds ckjs esa crkuk pkfg, A

(Some mothers have engorged breast. In starting days they don’t express milk when they come to us, they don’t allow us to touch. Health education should be given in starting days and complications

of breast should be explained.)

Health education on about breast complications should be given
Issue of girl child dbZ ckj Girl Baby gksrk gS rks ekrk,¡ feed fudkyuk ugha pkgrh A oks Girl Child dh care esa Hkh actively participate ugha djrh A

rks bl pht+ ds fy, Hkh counseling gksuh pkfg, A

(In case of girl child mothers don’t want to express milk and they don’t

actively participate in care. Counselling about this should also be done.)

Counseling about gender equality

Table 3b: Themes of FGDrelated to barriers and suggested facilitators for expressed breast milk feeding in preterm neonates reported by nursing officers (NNN and NICU)

Themes Verbatim Suggested facilitator
Limited time for counseling Staff busy gksrk gS rks eqf dy gks tkrh gS ge bruh vP  s ls counseling ugha dj ikrs ftruh vP  h gksuh pkfg, A nwljs dkeksa dh otg ls gekjs ikl Hkh counseling  ds fy, le; de gksrk gSA ekrkvksa dh NICU esa vkus ls igys gh counseling gksuh pkfg, vkSj mudks cPpksa dh gkyr dk Hkh irk gksuk pkfg, A

(There is problem in case staff is busy. We are not able to do counselling as it should be. Due to other works also we don’t have time for counselling. Counselling should be done before visit in NICU and they should have knowledge about condition of baby)

Counseling should be done before first visit in neonatal unit
Inadequacy of posters related to expression of breast milk O;Lr gksrs gSa rks ekrkvksa dks vP  h rjg explain ugha dj ikrs vkSj nwljs dke Hkh gksrs gSa A AV aids are not available. dq AV aids vkSj poster/chart gksus pkfg, vkSj old mothers Hkh new mothers dks explain dj ldrh gSa A

(If we are busy then we are not able to explain properly and we have other work also to do. AV aids are not available. Some AV aids and posters should be available and old mothers can also explain to new mothers.)

Posters related to expression of breast milk should be displayed. Old

mothers can also explain to new mothers

Excessive fatigue of mothers Sometime mothers get exhausted. They are not able to manage properly. They do not take rest and food properly. There should be proper time tables in wards that indicates when she should take rest, express milk and do KMC. Time table should be displayed related to activities of mothers
Congested milk expression room Expression area sufficient ugha gS ,d gh le; lHkh ekrk,a bD~dBh ugha gks ikrh A dq bartkj djuk iM+rk gS A Expression area FkksM+k cM+k gksuk pkfg, rkfd cPpksa dks le; ls feed fey ldsA

(Expression area is not sufficient. All mothers can’t come together. Some mothers need to wait for their turn. Expression area should be big so that all babies can get feed on time.)

Milk expression room should be big
Boiler is not available gekjs ikl boiler ugha gS ,d irhyk gS lid ds lkFk] mlh esa boil djrs gSa tks ,d boiler  Fkk ysfdu vc oks [kjkc gS A ,d boiler gks rks Bhd jgsxk A

(We don’t have boiler. We have one vessel with lid to boil. One boiler is there which is out of order. It will be good if we have one boiler.)

Boiler should be available

Discussion

Expressed breast milk is very important for preterm neonates. Breast feeding is very challenging in case of preterm neonates, despite of the fact that these babies have even greater need for human milk. There can be many factors that may affect the feeding preterm neonates with expressed breast milk. Maternal factors also affect feeding in preterm neonates who are admitted in NICU. Sucking by baby helps in production and ejection of milk so mother separated from baby is not able to produce and express milk properly and maternal psychological factors also affect. Separation from baby hindered the letdown reflex. In neonatal unit, number of babies are getting formula feed because expressed breast milk is not sufficient to fulfill the requirement of babies. Henceforth present project was taken up to assess the barriers and suggested facilitators for feeding preterm neonates with exclusive expressed breast milk.

Focus group discussions were conducted with nursing officers and number of focus group discussions depends upon the saturation of data. Neonatal units consisted of different areas such as CLR nursery, CLR extension nursery, NNN and NICU. There were different barriers and suggested facilitators for each area. Therefore number of discussions were required and data got saturated after 16 FGDs. The result of present study highlighted the main barriers and suggested facilitators to expressed breast milk feeding in preterm neonates according to nursing officers. According to Black & Hylander, 2000 one of the barrier feed in preterm is prematurity and related admission in NICU, the mother get separated from her baby13. In present study staff reported that baby remain in CLR nursery, NNN/NICU and mother is admitted in different wards. Few studies mentioned that let down reflex is hindered by the inability to relax in stressful environment14-16. Similarly in present study also nursing officers reported that stressful environment of labour room result in inadequate milk supply to premature babies

Gianni explained some barriers such as occurrence of comorbidities, presence of medical devices, separation from infant and having twins17. Consistent with this, in current study, nursing officers also reported that mothers are anxious due to prematurity of the baby and have fear to handle the baby. They are also afraid of medical devices. Having twins was also reported by the staff one of the barrier to expressed breast milk feeding.

Barrier varies area to area for example separate milk expression area is not available in CLR nursery, LR extension nursery and wards whereas in NICU milk expression area is there but it is very congested. Environment of labour room is very stressful and no attendant is allowed with mothers however attendant is allowed in mother’s room although it is also very congested. Some common barriers in all areas are unavailability of written guidelines and A.V aids, limited time of nursing officers for health education to mothers, anxiety of mothers etc.

Regarding facilitators most of staff stressed the importance of counseling of mothers about expressed breast milk feeding. Maria Lorella Giannì also reported the importance of expert lactation support, including education by health care professionals17. Studies by Bernaix, 2000; Siddell, Marinelli, Froman, & Burke, 2003; Swanson & Power, 2005 .have identified that attitude and knowledge about breast feeding can be effected by education and training.18-20 Similarly in current study nursing officers also reported the importance of education of mothers related to expressed breast milk feeding. Many studies have recommended the guidelines for mothers to instruct and promote breastfeeding.21-23 In present study also nursing officers suggested for written protocol and AV aids related to expressed breast milk feeding. AV aids displayed in wards will help to remind nursing officers about expressed breast milk feeding and mothers of preterm neonates can also learn about expressed breast milk feeding.

Many of suggested facilitators reported by nursing officers can be implemented on administrative level such as separate area for milk expression, separate labouring area, big mother’s room, adequate nurse patient ratio etc but health care professional also should make effort at their own level to promote expressed breast milk feeding in preterm neonates. Nursing officers should give proper health education and psychological support to mothers. In service education programs for nursing officers related to expressed breast milk feeding should be arranged. So that they can make efforts to promote exclusive expressed breast milk feeding to all preterm neonates in their area.

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