Hospital-wide breastfeeding rates vs. breastmilk provision for very-low-birth-weight infants

Monitoring the Use of Human Milk, the Ideal Food for Very Low-Birth-Weight Infants-A Narrative Review

Aware of the utmost importance of feeding premature babies-especially those of lower weight-with human milk, as well as the need to monitor this important element of neonatal care, we focused on four aspects in this review. First of all, we reviewed the beneficial effects of feeding premature infants with breast milk in the short and long term. Secondly, we performed a quantitative evaluation of the rates of breastfeeding and feeding with human milk in Very-Low-Birth-Weight infants (VLBWs) during hospitalization in the Neonatal Intensive Care Unit (NICU) and at discharge. Our aim was to take a snapshot of the current status of human milk-feeding care and track its trends over time. Then we analyzed, on the one hand, factors that have been proven to facilitate the use of maternal milk and, on the other hand, the risk factors of not feeding with breast milk. We also considered the spread of human milk banking so as to assess the availability of donated milk for the most vulnerable category of premature babies. Finally, we proposed a protocol designed as a tool for the systematic monitoring of actions that could be planned and implemented in NICUs in order to achieve the goal of feeding even more VLBWs with human milk.

“Breastfeeding at Night Is Awesome” Mothers’ Intentions of Continuation of Breastfeeding Extreme and Very Preterm Babies upon Discharge from a Kangaroo Mother Care Unit of a Tertiary Hospital in South Africa

Kangaroo mother care (KMC) is effective in increasing mothers’ initiation and maintenance of breastfeeding (BF) for extreme and very preterm (VLBW) infants. Although South Africa has implemented KMC for more than two decades, little is known about mothers’ perspectives on KMC. The purpose of this study was to describe the BF intentions and practices of mothers of VLBW infants at home following discharge and assess the role long stay in KMC has on their decision to BF beyond discharge. This qualitative study was conducted at the KMC unit of a tertiary hospital in Pretoria, South Africa. Focus group interviews were conducted with 38 mothers of VLBW infants who had transitioned from neonatal intensive care (NICU) to KMC. We analysed transcripts following the five steps for qualitative thematic data analysis. Mothers were knowledgeable of the importance and value of BF preterm infants and conceded that breast milk has advantages over formula. Mothers had positive feelings toward BF their preterm infants. The stay in KMC increased the direct BF of their preterm infants, mothers’ BF efficacy, and had a positive influence on mothers’ intentions to continue BF following discharge and to exclusively breastfeed for six months. Their BF intentions, efficacy, and practices were influenced by the skilful BF counselling, training, and support they received from the nursing staff. High intention to BF among these mothers is suggestive of their knowledge and confidence in BF for their VLBW infants. It is important that nursing staff in NICU and KMC appreciate the significant role they play in mothers’ readiness and confidence to breastfeed beyond discharge.

A Statewide Evaluation of the Breastfeeding Resource Nurse Model

OBJECTIVE

To evaluate a statewide initiative to increase the provisioning of human milk in NICUs.

DESIGN

A survey of nurses before participation in an educational session, immediately after education, and again 9 months later.

SETTING

Nurses from 22 hospitals throughout Florida.

PARTICIPANTS

We surveyed 121 participants, including some nurses who had prior breastfeeding education or certification as well as those without specialized breastfeeding training.

INTERVENTION

An educational project called the Breastfeeding Resource Nurse Master program was intended to educate NICU nurses to implement the "Ten Steps to Promote and Protect Human Milk and Breastfeeding in Vulnerable Infants."

MEASUREMENT

A quantitative needs assessment survey was administered to participants to determine current hospital practices, policies, and perceived areas for improvement. Pre- and immediate posttraining surveys assessed NICU nurses' knowledge, attitudes, and beliefs about human milk feeding of critical care infants and their self-efficacy for implementing the program in their respective NICUs. A follow-up, open-ended survey was administered at 9 months to yield information on program implementation.

RESULTS

NICU breastfeeding practices varied widely at baseline. Nurses' scores for knowledge, beliefs, and behavioral intentions improved postsession, but the implementation of practice changes related to the Ten Steps for Vulnerable Infants proved difficult. Nurses identified insufficient time and resources as barriers to educating others and changing practice.

CONCLUSIONS

Policies and regulations that make hospitals accountable for increasing human milk provision to vulnerable infants may be necessary to ensure that hospitals devote adequate resources to implementing practice changes in this area.

The Effect of Breast Pump Use on Exclusive Breastfeeding at 2 Months Postpartum in an Inner-City Population

BACKGROUND

Breastfeeding is the optimal form of infant nutrition, yet national rates are below recommendations with persistent disparities. Breast pumps may address the reasons that mothers discontinue breastfeeding.

OBJECTIVES

To determine whether breast pump use increases exclusive breastfeeding at 1.5-3.5 months postpartum.

MATERIALS AND METHODS

We reviewed charts for maternal-infant descriptors and feeding type for infants born between November 2013 and June 2014 who received any breast milk at a visit <14 days of age in our inner-city pediatric practice. We compared feeding at 1.5-3.5 months between those with breast pump and those without breast pump.

RESULTS

Of the 905 infants with feeding type recorded, 487 (54%) received any breast milk, of whom 355 (72.9%) had a visit at 1.5-3.5 months [95.4% African American (AA)]. Rates of any breastfeeding (93.8% vs. 38.9%) and exclusive breastfeeding (50.0% vs. 17.8%) were significantly higher in non-AAs than in AAs. Due to small numbers of non-AAs, further analyses were conducted for AAs only. The rate of exclusive breastfeeding at 1.5-3.5 months (19.4% vs. 16.3%) was similar between those with a breast pump and those without a breast pump, whereas rates of any breastfeeding were higher among those with no breast pump (46.9% vs. 31.4%, p = 0.004). Also, among AA mothers, rates of feeding at the breast were lower (21.5% vs. 44.4%, p < 0.0001) and rates of feeding expressed breast milk were higher (16.6% vs. 8.2%, p = 0.02) among those with a breast pump versus those without a breast pump.

CONCLUSIONS

Although breast pumps were free, breast pump use among predominantly AA WIC-eligible mothers was not associated with increased rates of exclusive breastfeeding at 1.5-3.5 months postpartum.

Using quality improvement to increase human milk use for preterm infants

This review will provide an overview of quality improvement methods that have been used to improve human milk use (mother's own milk and donor milk) for very low-birth-weight infants in the hospital setting in the last decade. We will review the following: (1) evidence-based practices known to increase mother's own milk for very low-birth-weight infants; (2) individual hospitals with exemplary lactation programs and past and current US-based statewide quality improvement collaboratives focused on increasing mother's own milk; and (3) existing quality metrics for human milk and gaps in metrics. Finally, we will provide practical examples of key driver diagrams and change concepts that may be used to inform quality improvement for mother's own milk for very low-birth-weight infants.

Factors associated with infant feeding of human milk at discharge from neonatal intensive care: Cross-sectional analysis of nurse survey and infant outcomes data

CONTEXT

Nurses are principal caregivers in the neonatal intensive care unit and support mothers to establish and sustain a supply of human milk for their infants. Whether an infant receives essential nutrition and immunological protection provided in human milk at discharge is an issue of health care quality in this setting.

OBJECTIVES

To examine the association of the neonatal intensive care unit work environment, staffing levels, level of nurse education, lactation consultant availability, and nurse-reported breastfeeding support with very low birth weight infant receipt of human milk at discharge.

DESIGN AND SETTING

Cross sectional analysis combining nurse survey data with infant discharge data.

PARTICIPANTS

A national sample of neonatal intensive care units (N=97), nurses (N=5614) and very low birth weight infants (N=6997).

METHODS

Sequential multivariate linear regression models were estimated at the unit level between the dependent variable (rate of very low birth weight infants discharged on "any human milk") and the independent variables (nurse work environment, nurse staffing, nursing staff education and experience, lactation consultant availability, and nurse-reported breastfeeding support).

RESULTS

The majority of very low birth weight infants (52%) were discharged on formula only. Fewer infants (42%) received human milk mixed with fortifier or formula. Only 6% of infants were discharged on exclusive human milk. A 1 SD increase (0.25) in the Practice Environment Scale of the Nursing Work Index composite score was associated with a four percentage point increase in the fraction of infants discharged on human milk (p<0.05). A 1 SD increase (0.15) in the fraction of nurses with a bachelor's degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p<0.05). The acuity-adjusted staffing ratio was marginally associated with the rate of human milk at discharge (p=.056). A 1 SD increase (7%) in the fraction of infants who received breastfeeding support was associated with an eight percentage point increase in the fraction of infants discharged on human milk (p<0.001).

CONCLUSIONS

Neonatal intensive care units with better work environments, better educated nurses, and more infants who receive breastfeeding support by nurses have higher rates of very low birth weight infants discharged home on human milk. Investments by nurse administrators to improve work environments and support educational preparation of nursing staff may ensure that the most vulnerable infants have the best nutrition at the point of discharge.

A multipronged approach is associated with improved breast milk feeding rates in very low birth weight infants of an inner-city hospital

Breast milk feeding has advantages over formula feeding in premature infants, but its use in them is low. We initiated measures in our inner-city hospital such as starting a dedicated lactation service, counseling the mothers prenatally and postnatally, educating hospital staff, and advocating with our state's Medicaid insurance to provide free home breast pumps. These measures were associated with improvement in our breast milk feeding rates in very low birth weight infants from 22% to 88% over 5 years. This article describes our multipronged approach and can help encourage and guide other units with similar demographics to improve their breast milk feeding rates.