Table 2. Critical Periods for Protecting Maternal Milk Volume in Breast Pump.

Dependent Mothers of Preterm Infants

Critical Period	Problem	Impact	Best Practice(s)	References
Initiation	Lack of understanding about the mechanisms that trigger secretory differentiation and regulate lactation Multiple risk factors for delayed or impaired initiation of lactation Use of ideology versus evidence about method and timing of milk removal/mammary gland stimulation Early administration of hormonal contraceptives Economic barriers for access to equipment and NICU-specific lactation care	Interference with rapid post-birth decline in progesterone Lack of timely mammary gland stimulation to complete secretory differentiation (lactogenesis II) Impaired or delayed secretory differentiation segues into permanent low milk volume	Assure that mothers are taught about the potential impact of hormonal contraception during the maternity hospitalization on the initiation of lactation so they can make an informed decision about its timing Screen mothers for risk factors for delayed or impaired onset of lactation (e.g. hypertension, obesity, Cesarean delivery) and share this information (and a plan for monitoring) with them Do not use exclusive hand expression in the absence of breast pump stimulation. Initiate pumping within the first hour post-birth Use a breast pump suction pattern that mimics the human infant during the initiation of lactation and has been shown to increase HM volume compared to standard breast pump suction patterns Assure mothers have access to NICU lactation care providers with expertise in breast pump dependency	35,41–43, 45,51–54,81–86
Coming to Volume	Lack of understanding about change from endocrine to autocrine regulation of lactation Unclear messaging for mothers about necessity of frequent and complete HM removal to effect this transition. Lack of proactive lactation care strategies that prevent and or detect early problems with HM volume	Mothers who fail to come to volume by 14 days post-birth are statistically unlikely to provide sufficient HM through to NICU discharge. Overlooking common pitfalls during coming to volume can translate into long-term HM volume problems	Educate mothers about the critical nature of coming to volume, emphasizing that most HM volume problems present during this time, and must be managed quickly and correctly. Share HM targets (≥ 500 mL/day) for post-birth day 14 or before. Explain and use Coming to Volume Assessment tool to detect and manage modifiable HM volume problems Explain and use My Mom Pumps for Me! maternal HM volume log Assess pumping technique by watching mothers use the pump daily during coming to volume. Check for correct breast shield sizing, pumping pressures and thorough breast emptying	18,35,81
Maintenance of Established Lactation	Lack of proactive strategies to monitor changes in mothers’ personal goals for providing HM through to NICU discharge Inadequate proactive counseling/teaching about common problems/scenarios that reduce HM volume during the later NICU hospitalization Lack of support for long-term pumping	As the duration of the NICU hospitalization increases, mothers do not achieve their personal HM feeding goals. Infants do not receive the highest possible NICU dose of HM, reducing protection from potentially preventable morbidities	Meet with each mother weekly to review and update personal HM feeding goals (Use “My Feeding Plans” tool) Proactively review common scenarios that reduce HM volume during the late NICU hospitalization. Substituting a feeding at breast for breast pump use (Need to pump after breastfeeding) Returning to employment and reducing total daily pumping time or using less effective (portable) breast pump Incorporate NICU-based breastfeeding peer counselors and mother-to-mother support for long-term pumping	14,26,27,33, 77,81,87