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care assistants were responsible for cleaning the area and
refreshing the sterilizing units each morning.
Unfortunately, information on how to express was verbal,
and little was said on how to ensure the equipment was safe
for use. I was briefly shown how to use the breast pump on
the first day at the NICU. I have discussed elsewhere how this
experience of trying to express, when transitional breastmilk
had not yet replaced colostrum, was demoralizing (3). With
hindsight, I recognize that I was confused and in shock after
giving birth so prematurely. I found it difficult to take in any
information, so having the information available in multiple
formats, particularly as written and visual information in the
expressing room, would have been beneficial for me.
Some of the hygiene practices that concerned me included
mothers removing equipment from the sterilizing unit and
rinsing it in tap water before using it to express breastmilk.
One mother asked me why I didn't rinse my pumping
equipment after removing it from the sterilizing solution. I
stated that the solution was sterile and that the tap water was
not. She seemed mystified and implied that I too should rinse
the equipment, stating that residue sterilizing solution may
be unsafe for a baby's stomach. Another mother would use
hand towels from the handwashing sink to dry the bottles and
equipment after removing them from the sterilizing solution
and before using them. She would look perplexed as I shook
my sterilized equipment to remove any remaining drips. On
several occasions, I saw expressing equipment handled and
put together with unwashed hands, equipment that had fallen
on the floor being used, and equipment not being left in
sterilizing solution for appropriate duration.
I do not believe any of the mothers had bad hygienic
intentions; however, in my opinion, we were not adequately
informed of how to implement appropriate hygienic practices
when expressing breastmilk. Everyone was trying to do
the best for their child; nevertheless, confusion and mixed
messages were evident regarding appropriate practices to
ensure the safety of expressing equipment. When appropriate
advice and information are not available, it is important to
consider the role social norms may play. People will often
conform or copy behaviors that are common among other
people (9). Without appropriate information, instruction,
and support, it can be difficult for mothers to maintain
appropriate hygienic practices when expressing.
Future considerations for future research and support
To minimize the risk of expressed breastmilk being a
source of infection for susceptible infants, strict hygiene
practices are important during the expression, collection,
transport, storage, and feeding of expressed breastmilk (2).
It is suggested that careful instruction of mothers on the
proper technique for expressing and cleaning the collection
equipment, as well as timely reinforcement of proper
technique, is critically important (7). Indeed, the British
Dietetics Association guidelines for the handling of expressed
breastmilk in neonatal health care settings state that there
is a need to provide written and verbal instructions to each
mother explaining how to express breastmilk, as well as how
to decontaminate the expressing equipment (1). Although I
was shown how to express breastmilk on one occasion, how to
clean and sterilize the equipment was not demonstrated and
no written information was provided. The emphasis was on
using the cold-water sterilizing unit. Displaying step-by-step
information on expressing and sterilizing in the dedicated
expressing room would have been particularly useful.
I believe there is a need to explore the approaches
that different NICUs and special care baby units take to
instruct mothers on how to ensure breastmilk is expressed
hygienically, establish how neonatal nurses are trained to
advise mothers of hygienic practices, assess the adequacy
of the written information provided, and identify potential
barriers that prevent written and verbal instruction from
being provided or followed.
Furthermore, I believe there is a need to explore the
hygiene perceptions and practices of mothers who express
breastmilk for infants in NICUs, establish what information
was provided to them in NICUs, identify the sources of
information they used, and determine their preferences
for information provision and education approaches.
For example, Parker (8) has suggested that there is an
opportunity to provide antenatal education about expressing
breastmilk to mothers delivering infants who require NICU
admission because they are often hospitalized for days before
delivery. This was the case for me, being hospitalized after
going into spontaneous preterm labor and medicated to delay
labor for 4 days before giving birth. This waiting time was
relatively calm and optimistic, which could have been used
to learn the principles of how to express and sterilize the
equipment. In addition to Parker's suggestion (8), I believe
this education could incorporate hygiene principles (3).
CONCLUSIONS
I appreciate that this general interest article is solely based
upon my personal experience, and it may not be reflective
of the experiences of other mothers at different times, or
at different NICUs. Nevertheless, from my experience, a
positive culture pertaining to hand hygiene was evident
at the NICU. This resulted from multiple communication
methods, including verbal prompts, visual information,
written instruction, access and availability of hand hygiene
facilities, and most importantly, the NICU team consistently
demonstrating effective hand hygiene attempts. Hand
hygiene was an integral part of being in the NICU.
However, given that the hygiene practices of mothers
when expressing breastmilk at the NICU were variable
and indicated potential confusion, I feel that there are
opportunities to explore (and enhance) the hygienic
perceptions and practices of mothers when expressing
breastmilk in an NICU. I believe that providing appropriate
July/August Food Protection Trends 359
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