Alăptarea în unitatea de terapie intensivă neonatală: beneficii materne, provocări neonatale și rolul abordării pluridisciplinare

1. Introduction

Breastfeeding is the physiological standard for infant nutrition and one of the most effective public health strategies for improving maternal and child health worldwide⁽¹⁾. Human milk is a dynamic biological system whose composition changes according to maternal physiology, gestational age, lactation stage and the infant’s developmental needs. Breastfeeding provides benefits beyond nutrition, influencing maternal metabolic, endocrine, cardiovascular, psychological and reproductive health. The magnitude of several maternal benefits appears to increase with cumulative duration of lactation, supporting breastfeeding as an important preventive health intervention throughout the maternal lifespan^(1,2). The World Health Organization (WHO) and UNICEF recommend exclusive breastfeeding for the first six months of life, followed by continued breastfeeding with complementary feeding for at least two years⁽³⁾.

Despite these recommendations, breastfeeding rates remain below global targets, particularly among preterm and critically ill infants requiring neonatal intensive care⁽⁴⁾. Human milk is a dynamic biological fluid containing immunoglobulins, cytokines, growth factors, antimicrobial peptides, human milk oligosaccharides (HMOs), extracellular vesicles, stem cells and a diverse microbiome that collectively support neonatal growth and immune development^(5,6). These bioactive factors strengthen intestinal barrier function, promote immune maturation and reduce the susceptibility to infectious and inflammatory diseases during early life^(5,7). Breastfeeding also provides substantial maternal benefits. Early lactation stimulates oxytocin release, promoting uterine involution and reducing the risk of postpartum hemorrhage. Longer breastfeeding duration has been associated with lower risks of breast and ovarian cancer, type 2 diabetes, hypertension and cardiovascular disease⁽²⁾. For infants, breastfeeding reduces neonatal mortality and the incidence of respiratory and gastrointestinal infections, sudden infant death syndrome and necrotizing enterocolitis (NEC), with the greatest benefits observed in preterm infants receiving mother’s own milk^(1,8). Establishing breastfeeding in the neonatal intensive care unit (NICU) remains challenging. Prematurity, immature feeding skills, respiratory support, mother-infant separation, delayed lactogenesis and the need for tube feeding or human milk fortification frequently limit breastfeeding initiation and continuation⁽⁹⁾. Therefore, successful lactation in the NICU requires a multidisciplinary approach, involving neonatologists, nurses, lactation consultants, dietitians, feeding specialists, psychologists and parents. Family-integrated care and structured lactation support have consistently improved breastfeeding rates and parental involvement in neonatal care^(4,10).

2. Materials and methods

This article was conducted as a narrative review of the current literature regarding the benefits of breastfeeding, the role of human milk in hospitalized neonates, challenges associated with breastfeeding in the NICU and the importance of multidisciplinary support strategies. A comprehensive literature search was performed using the electronic databases PubMed/MEDLINE, Scopus and Web of Science. The search included publications available until July 2026. The following keywords and terms were used individually and in combination: breastfeeding, human milk, mother’s own milk, preterm infants, very-low-birth-weight infants, neonatal intensive care unit, NICU, donor human milk, lactation support, family-integrated care and multidisciplinary care. Systematic reviews, meta-analyses, randomized controlled trials, clinical guidelines, consensus statements and relevant observational studies were included. Publications not related to neonatal populations, non-English articles and studies lacking relevant clinical information were excluded.

3. Breastfeeding and maternal benefits

Breastfeeding provides important short- and long-term health benefits for mothers. Early lactation stimulates oxytocin release, promoting uterine contraction, accelerating uterine involution and reducing the risk of postpartum hemorrhage. Oxytocin and prolactin also facilitate maternal-infant bonding during the early postpartum period^(2,11). Breastfeeding also induces lactational amenorrhea through suppression of ovulation, providing a natural contraceptive effect during the early postpartum period⁽¹²⁾. Beyond childbirth, breastfeeding induces favorable metabolic adaptations, including increased energy expenditure, improved glucose homeostasis and enhanced lipid metabolism. These physiological changes contribute to postpartum weight regulation, being associated with a lower long-term risk of type 2 diabetes mellitus, hypertension, metabolic syndrome and cardiovascular disease^(1,2,13). Lactation increases maternal energy expenditure and promotes favorable glucose and lipid metabolism, with particularly important benefits among women with previous gestational diabetes⁽²⁾.

Compelling evidence from systematic reviews and meta-analyses also demonstrates a dose-dependent reduction in the lifetime risk of breast and ovarian cancers, with longer breastfeeding duration providing greater protection. These effects are attributed to hormonal modulation, reduced lifetime ovulatory cycles and differentiation of breast tissue during lactation^(1,2). The protective effect of breastfeeding against malignancy appears to be duration dependent. Longer cumulative breastfeeding duration is associated with greater reductions in breast cancer risk, and may also decrease the risk of epithelial ovarian and endometrial cancers^(14,15). Breastfeeding may additionally improve maternal psychological well-being. The neuroendocrine effects of oxytocin and prolactin may facilitate maternal-infant bonding, stress regulation and emotional adaptation during the postpartum period⁽⁴⁾. Although the relationship is bidirectional, successful breastfeeding has been associated with lower rates of postpartum depression and anxiety, emphasizing the importance of early lactation support within comprehensive postpartum care⁽⁴⁾. Overall, breastfeeding represents an effective preventive strategy for maternal health, providing immediate obstetric benefits, while reducing the long-term burden of several noncommunicable diseases, as shown in Table 1. Integrating evidence-based breastfeeding support into routine maternal care should therefore remain a public health priority^(2,4).

4. Human milk for the hospitalized infant: neonatal benefits

Human milk is the preferred nutritional therapy for hospitalized neonates, providing essential nutrients together with bioactive components that promote intestinal maturation, immune regulation, microbial homeostasis and organ development. These properties are particularly important for preterm and critically ill infants, who are highly susceptible to infection and inflammatory injury^(6,16). Among very preterm and very-low-birth-weight infants, mother’s own milk (MOM) is associated with lower rates of necrotizing enterocolitis (NEC), late-onset sepsis, bronchopulmonary dysplasia (BPD), severe retinopathy of prematurity (ROP), intraventricular hemorrhage (IVH) and mortality. Greater exposure to human milk is also associated with improved neurodevelopment, demonstrating a dose-dependent protective effect⁽¹⁷⁾. The benefits of human milk are largely mediated by bioactive factors, including secretory immunoglobulin A, lactoferrin, human milk oligosaccharides, cytokines, growth factors and extracellular vesicles, which strengthen intestinal barrier function, modulate inflammation and promote healthy microbial colonization⁽⁶⁾.

Although evidence is strongest for preterm infants, current recommendations support the use of MOM whenever possible for all hospitalized neonates, because of its immunological benefits, improved feeding tolerance and potential reduction in healthcare-associated complications⁽¹⁶⁾. Mothers who deliver prematurely produce preterm human milk, which differs from term milk by containing higher concentrations of proteins, immunoglobulins, lactoferrin, lysozyme, epidermal growth factor and other immune-modulating components adapted to the needs of the premature infant⁽²⁰⁾. When MOM is unavailable, pasteurized donor human milk is the preferred alternative for very-low-birth-weight infants, because it significantly reduces the risk of NEC compared with formula feeding. Since pasteurization reduces protein content and some bioactive components, individualized human milk fortification is recommended to ensure adequate growth and neurodevelopment^(16,18).

Overall, human milk should be considered both nutrition and biological therapy in the neonatal intensive care unit. Early lactation support, standardized NICU protocols, donor milk programs and family-centered care are essential to maximize the use of MOM and improve neonatal outcomes⁽¹⁶⁾.

5. Neonatal challenges to breastfeeding
in the NICU

Despite the proven benefits of human milk, establishing breastfeeding in the NICU remains difficult, particularly for preterm and critically ill infants, as shown in Table 2. Physiological immaturity, medical complexity and organizational factors may delay lactation, reduce maternal milk availability and postpone the transition to direct breastfeeding^(9,20). Prematurity is the main barrier to successful breastfeeding. Immature suck-swallow-breath coordination, poor oral motor function, neurological immaturity and feeding intolerance often require prolonged tube feeding before oral feeding can be safely established. In addition, very preterm infants frequently require human milk fortification to meet their increased nutritional needs and support optimal growth and neurodevelopment^(19,20). Respiratory support, including continuous positive airway pressure (CPAP), high-flow nasal cannula (HFNC) and mechanical ventilation, further delays oral feeding because of impaired feeding-breathing coordination. Consequently, many infants initially depend on expressed MOM administered via enteral feeding^(9,20). Mother-infant separation also compromises breastfeeding success. Prolonged hospitalization, maternal illness, delayed skin-to-skin contact and limited parental involvement may reduce milk production and breastfeeding duration. Early milk expression, frequent pumping and kangaroo mother care improve milk supply and increase breastfeeding rates at discharge⁽²¹⁾.

For mothers separated from their infants or unable to initiate direct breastfeeding, early milk expression is essential. Initiation of milk expression within the first hours after birth and frequent breast stimulation are associated with improved milk volume and earlier establishment of lactogenesis II, particularly among mothers of very-low-birth-weight infants⁽²²⁾. Maternal factors such as caesarean delivery, hypertensive disorders, diabetes, obesity, postpartum hemorrhage and psychological stress may delay lactogenesis and reduce milk volume, increasing the need for donor milk or formula supplementation⁽²¹⁾.

Addressing these challenges requires a multidisciplinary approach involving neonatologists, nurses, lactation consultants, dietitians, feeding specialists, psychologists and families. Standardized breastfeeding protocols, donor human milk programs and family-integrated care are key strategies to increase the use of MOM in this vulnerable population^(9,10).

6. Multidisciplinary approach

Optimizing breastfeeding in the NICU requires coordinated multidisciplinary care, as lactation is influenced by neonatal condition, maternal health, nutritional needs and psychosocial factors. Early identification of breastfeeding barriers and individualized support should begin soon after birth, particularly for preterm and critically ill infants, to maximize the availability of mother’s own milk⁽¹⁶⁾. Neonatologists promote human milk as the first-line nutritional therapy, while neonatal nurses support early milk expression, skin-to-skin contact, kangaroo care and parental education. Early and frequent milk expression is associated with greater milk production and higher breastfeeding rates at discharge⁽¹⁶⁾.

Lactation consultants provide specialized support for establishing and maintaining lactation, addressing breastfeeding difficulties and improving maternal confidence. Structured lactation programs in the NICU have been shown to increase the use of MOM and breastfeeding at discharge⁽²³⁾. Effective lactation support includes the assessment of breastfeeding technique, education regarding milk expression, management of breast-related complications and continued psychological support. Kangaroo mother care, prolonged skin-to-skin contact and hands-on pumping techniques may improve milk removal and support lactation maintenance, particularly in mothers of preterm infants^(22,24).

Dietitians optimize individualized nutritional management, including human milk fortification for very preterm infants, whereas speech and occupational therapists facilitate the transition from tube feeding to oral feeding through feeding readiness assessment and cue-based strategies. Psychological support is equally important, as parental stress and anxiety may adversely affect lactation and breastfeeding continuation⁽¹⁶⁾. Family-Integrated Care (FICare) actively involves parents in neonatal care and has been associated with higher breastfeeding rates, improved parental confidence and better infant outcomes. Integrating families into routine NICU care is therefore considered a key component of modern neonatal practice⁽¹⁰⁾.

7. Future perspectives

Future advances in neonatal nutrition are moving toward precision-based human milk management. Human milk analysis and individualized fortification may optimize nutrient intake and improve growth and neurodevelopment in preterm infants⁽¹⁸⁾. Expanding donor human milk banking, implementing standardized breastfeeding protocols and improving access to lactation consultants may further increase the availability of human milk for hospitalized neonates. Broader adoption of FICare is also expected to enhance breastfeeding continuation after NICU discharge^(10,23). Emerging research on the human milk microbiome, extracellular vesicles, metabolomics and other bioactive components is improving our understanding of the mechanisms underlying the protective effects of human milk and may support future personalized nutritional strategies⁽⁶⁾. Digital health tools, including telelactation and remote breastfeeding support, offer new opportunities to extend lactation care beyond hospitalization. Further multicenter studies are needed to evaluate their effectiveness and integration into routine neonatal practice^(4,23). Overall, combining precision nutrition, evidence-based lactation support and family-centered care may further improve the availability of MOM and long-term outcomes for hospitalized neonates^(4,10,18).

8. Conclusions

Breastfeeding is more than a source of nutrition; it is a biological therapy that provides significant health benefits for both mothers and infants. Its protective effects are particularly relevant for preterm and critically ill neonates, in whom MOM reduces major morbidities and supports optimal growth and neurodevelopment. Supporting maternal lactation from the first hours after birth is essential, particularly when direct breastfeeding is delayed because of prematurity or neonatal illness. Despite these benefits, breastfeeding in the NICU remains challenged by neonatal immaturity, maternal factors and organizational barriers. A multidisciplinary approach, combining early lactation support, individualized nutritional management, donor human milk programs and family-integrated care, is essential to maximize the use of mother’s own milk and improve both short- and long-term outcomes in this vulnerable population^(1,10).

Corresponding author: Adriana-Mihaela Dan E-mail: adriana.dan@umfcd.ro

Conflict of interests: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.