Impact of Institutional Breastfeeding Support in Very Low-Birth Weight Infants

Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature

BACKGROUND AND OBJECTIVES

Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes.

METHODS

Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction.

RESULTS

A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias.

CONCLUSIONS

Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.

Lactation support in neonatal intensive care units in Germany from the mothers' perspective - a mixed-method study of the current status and needs

BACKGROUND

Establishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers' perspectives on lactation support in German neonatal intensive care units (NICUs).

METHODS

This paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers' perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs.

RESULTS

The results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information.

CONCLUSION

The overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs.

The Interaction of Early Exclusive Mother's Milk Feeding and Ethnic Background with Ultimate Feeding Outcomes After Very Preterm Birth

Background: Mothers of very preterm infants (born under 32 weeks' gestation) have specific lactation challenges. There is little literature related to the influences on exclusive maternal milk provision. Method: An observational cohort using prospectively entered clinical data in a single tertiary neonatal unit in the United Kingdom over a 2-year period 2019-2021. There were 112 infants born under 32 weeks' gestation who fulfilled inclusion criteria. Results: Average gestation was 27.9 ± 2.6 weeks at birth and 37.3 ± 3.3 at discharge. On day 4 after birth, 29% (31/107) received exclusive maternal milk. At discharge, 54% (60/112) received exclusive maternal milk. Exclusive maternal milk at day 4 was associated with exclusive maternal milk at discharge (adjusted relative risk 2.3, 95% confidence interval 1.5-3.6, p < 0.001). Mothers from "white other," Asian, and mixed/multiple ethnic backgrounds were more likely than white British mothers to give exclusive maternal milk at discharge. This association emerged only after adjustment for exclusive maternal milk at day 4 after birth. Conclusions: The association of minority ethnic background with feeding outcomes that has previously been noted in the United Kingdom general population was also found in this very preterm cohort. The relationship was strengthened after adjustment for exclusive maternal milk at day 4. This may suggest that establishing early milk supply is a universal barrier to later exclusive maternal milk in this population and that once milk supply is established, standard social and cultural experiences come to bear on infant feeding decisions.

Neonatal Intensive Care Unit Interventions to Improve Breastfeeding Rates at Discharge Among Preterm and Low Birth Weight Infants: A Systematic Review and Meta-Analysis

Background: While breast milk is widely accepted as the best source of nutrients for almost all newborns, breastfeeding can be especially challenging for preterm and low birth weight (LBW) infants. With increased risk of admission to neonatal intensive care units (NICUs) and separation from parents, this population experiences significant barriers to successful breastfeeding. Thus, it is crucial to identify interventions that can optimize breastfeeding for preterm and LBW infants that is continued from birth and admission, through to hospital discharge and beyond. Objectives: To identify and analyze evidence-based interventions that promote any and exclusive breastfeeding among preterm and LBW neonates at discharge and/or postdischarge from hospital. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Searches were performed in the following databases: MEDLINE Ovid, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health (CINAHL). Results: From the 42 studies included, 6 groups of intervention types were identified: educational and breastfeeding support programs, early discharge, oral stimulation, artificial teats and cups, kangaroo mother care (KMC), and supportive policies within NICUs. All groupings of interventions were associated with significantly increased rates of any breastfeeding at discharge. All types of interventions except artificial teats/cups and oral stimulation showed statistically significant increases in exclusive breastfeeding at discharge. KMC demonstrated the highest increased odds of breastfeeding at discharge among preterm and LBW infants. Conclusions: A variety of effective interventions exist to promote breastfeeding among hospitalized preterm and LBW infants. Hospital settings hold unique opportunities for successful breastfeeding promotion. PROSPERO registration: CRD42021252610.

Effects of a WeChat Mini-Program on Human Milk Feeding Rates in a Neonatal Intensive Care Unit During the COVID-19 Pandemic

OBJECTIVE

We investigated changes in maternal daily milk pumping frequency and milk volume per expression and their derived lactation indicators, as well as human milk (HM) feeding status with a focus on amount and rates in preterm infants admitted to the neonatal intensive care unit (NICU) after using a WeChat mini-program during the 2019 coronavirus (COVID-19) pandemic.

METHODS

The study was conducted with 482 mothers and their 544 babies. We prospectively enrolled mothers and infants with birth weight <1,500 g or gestational age <32 weeks born in 2020, and retrospectively included the same population in 2019. All study subjects were classified into three subgroups: pre-pandemic (PP, 2019), early pandemic (EP, January to April 2020), and late pandemic (LP, May to December 2020). From 1 January 2020, mothers recorded in an online pumping diary using the WeChat mini-program. We obtained the infants' feeding information from an online database for analysis.

RESULTS

Maternal lactation indicators did not change significantly. However, 56.7% (139/245) of mothers achieved milk volume ≥500 ml/day (CTV) in PP, 58.9% (33/156) in EP, and a slight increase to 60.7% (91/150) in LP. Maternal pumping frequency remained about eight times/day. In LP, daily milk volume was higher than the other two periods from day 4, and mothers achieved CTV by day 12, which was achieved in the other two groups by 13-14 days. There were several statistical differences in the amount and rates of feeding between the groups, particularly about HM and donor milk feeding, with the vast majority being decreased during EP, while during LP they returned to PP levels. Pleasingly, the median average daily dose of HM at 1-28 days was highest in LP (LP, 87.8 vs. PP, 75.5 or EP, 52.6 ml/kg/day, P _corrected < 0.001). In addition, most categorical feeding indicators decreased in EP and recovered in LP.

CONCLUSION

An education model based on the WeChat program could aid lactation education and management in mothers of preterm infants to maintain healthy lactation. The model, together with optimized management strategies, can ensure that the HM feeding rate is not compromised in vulnerable high-risk infants during NICU hospitalization in a public health emergency, like the COVID-19 pandemic.

Quality Improvement to Increase Breastfeeding in Preterm Infants: Systematic Review and Meta-Analysis

Background and Objective: Due to its numerous health benefits, breast milk (BM) is recommended for preterm infants. Despite such recommendations, the rates of breastfeeding in preterm infants are lower than that in term infants. Quality improvement (QI) bundles increase breastfeeding in preterm infants, but their replication in neonatal intensive care units has had inconsistent outcomes. Methods: We used the Population or Problem, Intervention, Comparison, and Outcomes (PICO) framework to develop our search strategy, and searched MEDLINE, Embase, and the Cochrane Library from inception through January 15, 2021. Studies describing any active QI intervention to increase BM use in preterm infants were included. The primary outcome measure was the rate of any breastfeeding or exclusive mother's own milk (MOM) at discharge or during hospitalization. Results: Sixteen studies were eligible for inclusion and showed an acceptable risk of bias, and included 1 interrupted time series, study 3 controlled before-and-after studies, and 12 uncontrolled before-and-after studies; of these, 3 studies were excluded due to insufficient dichotomous data, 13 were included in the meta-analysis. In the meta-analysis, the rate of any breastfeeding was significantly improved at discharge and during hospitalization after QI [risk ratio (RR) = 1.23, 95% confidence interval (CI): 1.14-1.32, P < 0.00001 and RR = 1.89, 95% CI: 1.09-3.29, P = 0.02, respectively]. The rate of exclusive MOM after QI was also significantly increased at discharge (RR = 1.51, 95% CI: 1.04-2.18, P = 0.03), but not during hospitalization (RR = 1.53, 95% CI: 0.78-2.98, P = 0.22). However, after sensitivity analysis, the comprehensive results still suggested that QI could significantly improve the rate of exclusive MOM during hospitalization (RR = 1.21, 95% CI: 1.08-1.35, P = 0.001). Funnel plots and Egger's test indicated publication bias in the rate of any BF at discharge. We corrected publication bias by trim and fill analysis, and corrected RR to 1.272, 95% CI: (1.175, 1.369), which was consistent with the results of the initial model. Conclusions: A QI bundle appears to be effective for promoting BM use in preterm infants at discharge or during hospitalization.