Despite decades of breastfeeding promotion, exclusive breastfeeding rates for the first 6 months of life remain low: around 40% globally. Infants that are admitted to a neonatal ward are even less likely to be exclusively breastfed. Lactogenesis is frequently delayed in mothers that deliver early, with the added burden of separation of the unstable newborn and mother. For such vulnerable infants, donor human milk is recommended by the World Health Organization, UNICEF, and professional organizations as the next best alternative when mother's own milk is unavailable and can serve as a bridge to full feeding with mother's own milk. Hospital support of optimal breastfeeding practices is essential with thoughtful integration of donor human milk policies for those infants that need it most. We propose a decision tree for neonatal wards that are considering the use of donor human milk to ensure donor human milk is used to replace formula, not to replace mothers' own milk. By first evaluating barriers to full feeding with mother's own milk, healthcare workers are encouraged to systematically consider the appropriateness of donor human milk. This tool also seeks to prevent overuse of donor human milk, which has the potential to undermine successful lactation development. In settings where donor human milk supplies are limited, prioritization of infants by medical status is also needed. Readily available and easy-to-use tools are needed to support healthcare staff and mothers in order to improve lactation development and neonatal nutrition.

Background Significant improvements in under-five mortality in Malawi have been demonstrated over the past thirty years; however, Malawian healthcare remains with gaps in availability and access to quality pediatric critical care nursing training and education. To improve expertise of pediatric critical care nurses in Malawi, Kamuzu University of Health Sciences (KUHeS), Queen Elizabeth Central Hospital (QECH), and Mercy James Center (MJC) entered a partnership with Seed Global Health, a US non-governmental organization. A needs assessment was conducted to understand the training needs of nurses currently working in pediatric critical care and in preparation for the development of a specialized Master’s in Child Health pathway in Pediatric Critical Care (PCC) Nursing at KUHeS. Methods The needs assessment was completed using a survey questionnaire formatted using an ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) framework. The questionnaire had Likert scale and yes/no questions. Data was manually entered into excel and was analyzed using descriptive statistics. Results One hundred and fifty-three nurses at QECH and MJC responded to the survey. Most nurses were between the ages of 25 and 35 years (N = 98, 64%), female (N = 105, 69%), and held either a Bachelors (N = 72, 47%) or diploma (N = 70, 46%) in nursing. Nurses had high rates of confidence in certain skills: airway management (N = 120, 99%), breathing assessment & management (N = 153, 100%). However, nurses demonstrated little to no confidence in areas such as: mechanical ventilation (N = 68, 44%), ECG evaluation (N = 74, 48%), and arterial blood gas collection & interpretation (N = 49, 32%). Conclusion It is important to identify priority areas for training and skills development to address in the PCC master’s within the child health pathway at KUHeS. Ideally this partnership will produce practice-ready PCC nurses and will establish a recognized PCC nursing workforce in Malawi.