A randomized controlled trial of pectoralis major myofascial release massage for breastfeeding mothers: breast pain, engorgement, and newborns’ breast milk intake and sleeping patterns

The importance and benefits of breastmilk for both mothers and infants is well known; yet breastfeeding rates are decreasing over time and continue to decrease further when an infant is 6 months of age.  Factors inhibiting breastfeeding rates include maternal breast pain or engorgement, nipple damage, lack of breast milk, fatigue from frequent feedings, and lack of sleep.  A randomized control trial (RCT) using Myofascial Release Massage (MRM) investigated the effects of using pectoralis major MRM to address these common maternal factors. The study was conducted in Korea and included 58 mother/infant dyads with the infants (7-14 days old) being born between 37-42 weeks GA and weighing >2,000g.

The experimental group (31) received two, 30-minute sessions of pectoralis major (MRM), performed by an IBCLC nurse. MRM I was completed after delivery, with MRM II being completed 48 hours later. The control group (27 ) completed breastfeeding, after which the infant was weighed.  Statistically significant differences were found for:

  • Breast pain: Post-MRM I (<.001), Pre-MRM II, (<.001), and Post-MRM II (<.001)
  • Breast engorgement: Post-MRM I L breast (.037), Pre-MRM II R (.005) and L breast (.075), Post MRM II R (<.001) and L breast (<.001)
  • Newborn breast milk intake: Post MRM I (.003) and Post MRM II (.003)
  • Formula supplementation over 2 days: Post MRM I (.015)

Therefore, myofascial release massage is effective at reducing breast pain and engorgement among breastfeeding mothers. A six-fold reduction in breast engorgement was identified between the experimental and control group. Newborns in the experimental group gained nearly twice as much weight (17g) and consumed less formula (in the 48 hours after MRM I). MRM may help to increase breastfeeding rates in the first year of life. Additional research is needed to generalize these findings and assess if effects last after 6 months of age.

This article supports Day 2 Neonatal Touch & Massage Certification training for therapists and demonstrates the benefits of Myofascial Release with Trigger Point Release for both moms and babies by alleviating breast pain, decreasing breast engorgement, and increasing breastmilk intake by the infant! NTMTCs, what a wonderful opportunity to utilize your manual therapy skills or teach parents how to complete MRM. NTMNCs, if you notice a mom is experiencing these issues at the bedside, partner with your lactation consultant and NTMTC colleagues to get mom some relief!

Choi, W. R., Hur, M. H., Kim, Y. S., & Kim, J. R. (2023). A randomized controlled trial of pectoralis major myofascial release massage for breastfeeding mothers: breast pain, engorgement, and newborns’ breast milk intake and sleeping patterns. Korean journal of women health nursing, 29(1), 66-75. https://doi.org/10.4069/kjwhn.2023.03.15

A Quality Improvement Pilot Project for Noise Reduction in the NICU

Infants cared for in a NICU are exposed to elevated decibel levels and frequent noxious sounds that stimulate activation of the autonomic and hypothalamic-pituitary-adrenal stress systems. Noxious sound has short-term and long-term impacts to infant neuro- and physiological development. The American Academy of Pediatrics (AAP) recommends noise levels should be less than 45 dBA. However, many NICUs do not meet these sound levels which is impacted by ambient noise.

This pilot study used the Plan-Do-Study-Act (PDSA) method to decrease noise levels in a Level IV open-pod NICU from 62.6 dBA (baseline noise levels) to 45 dBA (per AAP’s guidelines) over an 11-week period. Using a Decibel X application noise levels were measured at baseline, two weeks after Phase 1 (parent and staff education) and four weeks after Phase 2 (‘Quiet Time’ implementation).

  • Phase 1: Parent and Staff Education
    • In-person, bedside nursing education and 2 online modules for staff
    • Pamphlets for parents with information on effects of increased noise on development and how to limit exposure
  • Phase 2: ‘Quiet Time’ Implementation
    • 2-hour block, with 1 block per shift (4:00 to 6:00 and 16:00 to 18:00)
      • Staff were notified via a low volume text message on staff phones
      • ‘Noise Champions’ were responsible for posting bedside signage and closing pod doors
      • Weekly emails updated staff on noise levels (measured on random days)

A 13.7% (62.6 dBA to 54 dBA) noise level decrease was accomplished in a 24-hour period. Education for staff and parents, implementation of ‘Quiet Times’, and weekly reminders can be successful in decreasing noise in a level IV open-pod unit. Online modules were most effective in reaching all staff members. Loud speech was identified as the main modifiable noxious noise and increasing staff awareness helped the unit to create a pod that was calmer, quieter, and less stressful.

This pilot study highlights that staff education and designated ‘Quiet Times’ can be successful at reducing noxious noise in the NICU.  As a NTMC professional,  the importance of neuroprotective, family centered care is foundational.  We also know that our units can be filled with a lot of noise.  Protect infants on your unit by creating a task force to actively monitor and decrease noise levels! 

Hull, W., & Wright, K. (2023). A quality improvement pilot project for noise reduction in the NICU. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses, 00(0), 1-8. https://doi.org/10.1097/ANC.0000000000001074

Standards for Level of Neonatal Care: II, III, and IV

The American Academy of Pediatrics (AAP) has recently published an updated policy statement and complementary tool to assure all infants receive risk-appropriate neonatal care.  The update is based on existing AAP policy, evidence-based literature, standards of professional practice from national organizations, and expert opinion. The 31-page document identifies new minimum required standards for facilities and the professionals working in a level II, III, or IV NICU.  Below are highlights of the new standards addressing areas we found highly relevant to NTMC professionals.

Family-Centered Care: Recommended for all levels of care, including skin-to-skin care, appropriate developmental positioning based on gestational age, lactation and breastfeeding support, and engagement of families in their infant’s care.

  • The facility will:
    • Allow all parents to have reasonable access to their infants, at all times
    • Have access to the services personnel, and equipment needed to provide the appropriate level of care for all infants
    • Support the physiologic, developmental, and psychosocial needs of infants and their families
    • Have a process to screen every family for social determinants, depression, and cultural needs
    • Refer patients and families to appropriate resources as needed
  • Professional staff roles to support family-centered care will include:
    • Clinical Nurse Staff
    • Neonatal Therapists
    • Child Life Services (Level IV)

Nursing Education: Annual nursing education must be completed and documented by the facility at all levels of care to address needs assessment and complete skill-based simulations for the safe care of the infants at each level of care.

  • The Clinical Nurse Specialists role in Level III and IV NICUs is to develop and educate staff to provide evidence-based nursing care
  • The Clinical Nurse Educator in a Level II, III, and IV NICU is to collaborate with neonatal nurse leader and facility leadership to improve the quality of care and patient care outcomes and have experience and expertise to evaluate the education needs of the clinical staff, develop didactic and skill-based education tools, oversee education, skills verification, and evaluate retention of content, critical thinking skills, and competency relevant to level II, III, or IV neonatal care

Neonatal Therapists: Level III and IV facilities are required to provide on-site consultative services. Level II facilities must have a formal process to provide access to neonatal therapy expertise. On-site consultative services should be provided by:

  • An occupational or physical therapist with neonatal expertise (neonatal therapy certification preferred)
  • At least 1 individual skilled in the evaluation and management of neonatal feeding and swallowing concerns (SLP with neonatal expertise, neonatal therapy certification preferred, is recommended for a Level III and IV NICU)
    • Annual review of neonatal therapist personnel to maintain adequate multidisciplinary neonatal therapist coverage, based on the need and volume of the neonatal population served.

It is amazing to see more standardization for neonatal practice! As family-centered care, clinical nurse specialists, and qualified neonatal therapists become the minimum requirements for NICUs across the country, we are thrilled to continue to provide the growing NTMC family with ongoing mentoring, education, hands-on trainings, and up-to-date literature. Utilize these new AAP Standards to advocate for continuing education for your entire NICU team, and changes to your unit’s policies!

Stark, A. R., Pursley, D. M., Papile, L. A., Eichenwald, E. C., Hankins, C. T., Buck, R. K., Wallace, T. J., Bondurant, P. G., & Faster, N. E. (2023). Standards for levels of neonatal care: II, III, and IV. Pediatrics, 151(6), e2023061957. https://doi.org/10.1542/peds.2023-061957

All of these articles support the principles of NTMC through neuroprotective care and therapeutic interventions. Thank you for improving the lives of babies and families worldwide!