Chest pumping for critically Ill patients: Remaining a breast of best-practices

Chest feeding (CF) is widely recognized as the optimal method of infant feeding, with numerous benefits for both parent and infant.^[1] The terms CF and chest pumping (CP) are used to reflect inclusive language for lactation practices. They refer specifically to the mechanical or manual expression of human milk, aligning with inclusive language practices in perinatal and lactation care.^{[1, 2]} The American Academy of Pediatrics and the World Health Organization recommend exclusive CF for the first six months of life, and support continued CF for two years or beyond.^{[1, 3]} Human milk contains a dynamic and complex composition of antimicrobial, anti-inflammatory, and immunoregulatory components, all of which contribute to the healthy development of an infant’s immune system.^[1] In terms of infant well-being, CF is associated with lower risk of sudden infant death; urinary tract, respiratory, and inner ear infections; and childhood obesity.^{[1, 4,5,6,7]} CF also supports long-term parental benefits, including a reduced risk of type two diabetes mellitus, hypertension, and reproductive cancers.^{[1, 7]} When infants are able to suckle, the release of oxytocin and prolactin not only promotes milk ejection and production, but assists in uterine involution and reduces risk of post-partum hemorrhage—important considerations in the critical care settings.^[8,9,10] Despite these well-established benefits, postpartum patients admitted to intensive care units (ICUs) often face substantial barriers to initiating and maintaining lactation.^[9,11,12]

Establishing lactation in a critically ill postpartum population requires timely assessment, appropriate interventions, and consistent support. However, one commonly encountered challenge is that many ICU nurses report feeling under-trained in managing CF-related care.^[12] Another complicating factor in supporting lactation within the ICU setting is that nurses are tasked with performing frequent and time-sensitive interventions due to patient complexity. This leaves limited opportunity to dedicate the 15-60 minutes required for lactation support every two to three hours.^[9] Time and workload constraints are well-recognized barriers in critical care environments, where competing priorities often limit nurses’ ability to provide sustained lactation-related care.^{[9, 12, 13]} While long-term sustainability of support may benefit from administrative engagement, this educational intervention was intentionally designed to be brief and integrated into clinical workflow within existing staffing structures. Future initiatives may further strengthen implementation through formal leadership support.^{[14, 15]} Additionally, the urgency of critical illness often shifts clinical priorities to physiological stabilization, resulting in omission of lactation during vital windows of milk production.^[9] When lactation support is delayed, complications such as engorgement, mastitis, or breast abscesses can occur, resulting in pain, infection, and in some cases, the need for surgical resection.^[16]

Engorgement typically arises three to seven days postpartum and results from infrequent or ineffective milk removal. It is a major contributor to lactation-related discomfort and early lactation cessation.^[16] ICU nurses should be knowledgeable in order to initiate milk supply, using expression techniques to prevent engorgement, and facilitating CF once the patient’s condition permits.^[9] Mastitis is a bacterial chest infection that affects up to three percent of CF patients. It is often preceded by unresolved engorgement and exacerbated by stress and fatigue – conditions commonly seen in ICU patients.^[16] Without proper support, some patients are unable to establish a milk supply at all, undermining optimal parental and neonatal health outcomes.^{[9, 12]} Given the immunologic and hormonal processes involved in lactation, early intervention is essential. Yet, current practices in critical care lack emphasis on CF support.^[7]

Institutional CF policies can have a significant influence on CF success rates, yet such policies are often underdeveloped or are inconsistently applied in critical care settings.^{[9, 17]} It is well documented that implementing hands-on strategies and improving nursing knowledge can improve CF, in turn reducing risks and improving health benefits for parent and child.^{[7, 9, 18]} The purpose of this quality improvement project was to evaluate the impact of a structured, evidence-based educational intervention on ICU nurses’ knowledge and adherence to best practices for CF in the care of critically ill postpartum patients.

Framework

This project used a pre-post intervention quantitative design and began in January 2025. A series of bedside education sessions occurred over a two-week period, each approximately 15 minutes in length. Participants were ICU registered nurses, recruited based on availability and were provided with information about the project objectives, voluntary nature, and confidentiality safeguards. Pre-education intervention data was collected through an evaluation tool, created based on the facilities ICU pumping protocol, to assess participants’ initial ability to complete the pumping process. The educational intervention was developed collaboratively with ICU nurse educators and lactation consultants and was grounded in current institutional protocols and evidence-based lactation guidelines. Education was delivered at the bedside in brief sessions using a standardized script to ensure consistency. Instruction included hands-on demonstration of setup, initiation, hand expression techniques, and equipment cleaning using a mannequin and visual aids. This approach was intentionally designed for ICU nurses without prior labour and delivery experience and emphasized practical skill acquisition within routine clinical workflows. Following the intervention, post-assessments were conducted and evaluated using the same evaluation tool. Data extraction was conducted by sorting information into a tally sheet using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA, 2024) and analyzed using SPSS software (IBM Corp., Armonk, NY, USA 2021). Pre- and post-intervention scores were compared by t-statistics to evaluate the intervention’s effectiveness. Statistical significance of the improvements was assessed by one-tailed p-values using a significance level (α) of .05. Continuous variables were represented by mean and standard deviation (SD).

Ethical considerations

A total of 60 ICU registered nurses were recruited. The mean age of participants was 37.1 years (SD 10.53 years; range 23-60). The group had a mean of 11.1 years (SD 8.69 years) of clinical experience, reflecting a diverse mix of early-career and seasoned practitioners. Of these participants, 50 (83%) identified as female and 10 (17%) as male. None of participants had previous experience working in a labour and delivery unit. All participants who were approached regarding this project were recruited and there was no attrition.

Following completion of the educational session, adherence to all steps of the chest pumping process improved significantly (p < .001). Table 1 displays a tally of completion and p-values for each step. Figure 1 illustrates success before and after educational sessions.

Figure 1.

Nurses’ success before and after educational session intervention by step

ICU nurses endorse feelings of discomfort, absence of confidence, and lack in competence in meeting the needs of postpartum patients, particularly with CF.^{[9, 12, 13, 20, 21]} Although there is extensive research focusing on the benefits and maintenance of healthy lactation among postpartum patients, there is a paucity of guidance specific to the critical care setting.^{[13, 22]}

4.1Quality improvement uptake

4.2Advanced practice nursing competencies

4.3Limitations

Through alignment with the KTA Framework, this initiative translated current best practices into actionable and sustainable bedside teaching tailored to the realities of critical care. The statistically significant improvements highlight the impact of focused interventions that are often overlooked. Sustaining this new CF initiative will require ongoing education, reinforcement of protocols, and continued prioritization of CF—and postpartum care as a whole—into the usual critical care paradigm. This initiative contributed meaningfully to patient- and family-centered care and reinforces the essential role of ICU nurses in supporting optimal lactation outcomes in postpartum patients with critical illness.

All authors contributed to the study’s conception and writing. The project was completed by T.M.B, and the original manuscript was completed by T.M.B. The project was supervised by C.G., J.S., and B.V-W. D.B and A.W provided figure production. The manuscript was reviewed, edited, and approved by all authors.

This project does not have any funding sources to disclose.

The authors declare that they have no competing interests to declare.

Obtained.

The Publication Ethics Committee of the Association for Health Sciences and Education. The journal’s policies adhere to the Core Practices established by the Committee on Publication Ethics (COPE).

Not commissioned; externally double-blind peer reviewed.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

No additional data are available.