Increasing Breastfeeding and Human Milk Use in the NICU

Project Aim

The purpose of this learning collaborative is to increase the number of very low birth weight infants who will receive human milk, preferably their mother’s milk, as their primary source of nutrition to assist with
their immune and gastrointestinal tract development. More specifically, this project is focused on helping participating hospitals identify and overcome barriers to establishing maternal milk supply and barriers to supporting breastfeeding in the NICU.


Intervention by:



Very low birth weight infants (VLBWs), those weighing less than 1500 grams at birth, are approximately 1.5% of the births in Texas. This group of infants is disproportionately impacted by morbidity, mortality, and have the longest hospital stays. VLBW infants are at a risk for developing infection, necrotizing
enterocolitis, respiratory distress and other morbidities during their stay in the NICU.

While preventing VLBW births is difficult, hospitals can take steps to reduce the
morbidity burden on these infants by reducing VLBW infants’ exposure to bovine
proteins. VLBW infants exposed to bovine proteins through formula or nutritional
fortifiers are at higher risk for necrotizing enterocolitis than infants receiving a human milk diet. Further, other benefits of a human milk diet have been documented including lower rates of sepsis and other infections and shorter lengths of stay. The benefits of a human milk diet are well established and human milk feeding for VLBWs is the standard of care endorsed by the AAP.

Learning Collaborative

The human milk learning collaborative began in September of 2016 with 15 participating Level III & Level IV hospitals. Approximately 800 NICU beds are covered by the project.

9 Level III & 6 Level IV, + 2 observing hospitals 800 NICU beds covered by the project

9 Level III & 6 Level IV, + 2 observing hospitals 800 NICU beds covered by the project


This learning collaborative is designed to enable teams to share, test, and implement ideas for improving rates of human milk and breastfeeding among very low birth weight babies. The goal of the learning collaborative calls is to arrive at and spread ideas that will improve outcomes for very low birth weight infants and serve as a model of how to improve care more broadly.

"VLBW infants were 1.4% of the births in Texas in 2013 and 2014, comprising 11,078 births in this two-year period"

Nature of Intervention

The past year, members of the learning
collaborative have worked on: 

  • decreasing the delay between maternal discharge and her receiving a hospital grade breast pump,

  • implementing and using the new Medicaid reimbursement for donor milk use, and

  • increasing the use of mother’s colostrum in their units.

These efforts have resulted in collective improvements among participating hospitals. Hospitals in the learning collaborative have seen increases in the percent of very low birth weight infants that received mother’s own milk, and in the percent of very low birth weight infants receiving donor milk.

The next year, the teams will be collectively working towards increasing the
percent of infants that are discharged still receiving mother’s own milk. The
projects will focus on interventions that assist the mother with increasing her milk
supply or switching their unit to cue-based feeding, which has been found to help
infants transition to direct breastfeeding.


Project Lead
Dorothy Mandell, PhD, UT Health Northeast, Affiliate of The University of Texas System

Charleta Guillory, MD, MPH, Director, Neonatal-Perinatal
Public Health Program, Texas Children’s Hospital
Nancy Hurst, PhD, RN, IBCLC, Director, Women’s Support Services, Texas Children’s Hospital