Improving Exclusive Breastfeeding Rates of Preterm Neonates.

Abstract This study is a single center quality improve- ment (QI) initiative in a tertiary care neonatal intensive care unit which was done with an objective to increase the proportion of neonates receiving mother’s own milk (at postnatal age of 7 d) from the current rate of 12.5% to 30% over a period of six weeks. Additional objec- tives were to evaluate the proportion of mothers’ ex- pressing breast milk within 3 h of birth, on day one and three and the amount of expressed breast milk (EBM) on day one and day seven. A team was formu- lated to evaluate the reasons for inadequate breast milk expression and to plan the steps for promoting the same. Comprehensive postnatal breast feeding counsel- ing (CPNC) to promote early breast milk expression was initiated soon after the birth of a preterm neonate. CPNC was done for next fifteen mothers and their breast feeding support was streamlined. The effect of CPNC and teamwork was discussed amongst the team members every day and adjustments incorporated (Plan- Do-Study-Act cycle). The proportion of neonates receiv- ing mother’s only milk (MOM) on day 7 increased to 80% (12/15) after 4 wk of QI. Thus, a simple and feasible CPNC package lead to improved breast milk output in mothers.

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Keywords Breast milk . Neonate . Quality improvement

Introduction

Exclusive breastfeeding for six months is the most effective preventive strategy for under-five mortality [1]. Host resis- tance factors are abundant in fresh breast milk and when prop- erly collected and stored, it provides the highest quality of anti-infective properties. [2, 3] However, for various reasons, mothers of these neonates face multiple challenges in estab- lishing and maintaining an adequate supply of milk, this phe- nomenon being more common in preterm neonates [4, 5]. The gap in current evidence based implementation is the strategy to reduce the time to first milk expression and to increase frequency of expression and night time expression of milk in these mothers. It is also known that mothers of extremely preterm neonates should be taught early and effective milk expression techniques [6].

The authors identified problem of delayed breast milk ex- pression by mothers of preterm neonates whose babies were admitted in the neonatal intensive care unit (NICU). The fre- quency of milk expression in these mothers was limited to two to three times in the entire day leading to most neonates re- ceiving predominant formula feed for the first one week.

In view of the existing evidence and the identified problem, the authors formulated an aim to increase the proportion of breast milk intake in the admitted preterm neonates on day 7 from a current baseline rate of 12.5% to 30% over a period of six weeks by comprehensive postnatal breast feeding counsel- ing (CPNC) of mothers soon after the birth of the preterm neonate.

Material and Methods

This quality improvement initiative was conducted in a Level- 3 NICU of a tertiary care hospital from 15th August through

* Ashok Kumar Deorari ashokdeorari_56@hotmail.com

1 Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi 110029, India

Indian J Pediatr (April 2017) 84(4):322–325 DOI 10.1007/s12098-017-2306-4

 

 

30th September 2015 to improve the exclusive breastfeeding rates in preterm neonates.

Mother-newborn dyads who were likely to stay for more than 7 d in the unit were included. Critically sick mothers admitted in obstetrics intensive care unit, retro-positive mothers who declined breastfeeding and mothers with neonates having major congenital malformations requir- ing surgical intervention and hence, non establishment of exclusive breast feeding in the initial one week were excluded from the study.

A team comprising of one faculty incharge, two resident physicians, one nurse educator and two senior staff nurses was formulated to evaluate the reasons for poor breast milk expres- sion and to plan the subsequent steps for promoting the same.

Baseline data [including time of first expression of breast milk (EBM); daily amount of EBM from day one to seven; exact amount and type of milk provided to the baby and time of postnatal counseling related to breast feeding issues (if any) given to these mothers] was collected among eight postnatal mothers and newborn dyads over 7 d.

A fish bone analysis was done to identify the possible fac- tors limiting breast milk expression in these mothers. Lack of sensitization of health care providers and lack of knowledge among mothers and family members were identified as the Bvital few^ causes limiting breast milk expression in these mothers.

After baseline data collection and problem analysis, a com- prehensive postnatal counseling (CPNC) package was planned which consisted of two main elements; one was edu- cation and sensitization of health care providers and the sec- ond was education and sensitization of the family members (Table 1). These changes were tested as a part of Plan-Do- Study-Act (PDSA) cycle (Fig. 1).

Proportion of mothers’ expressing breast milk within 3 h of birth, on day one and three and the amount of expressed breast milk (EBM) on day one and seven and the proportion of neonates fed on mother’s own milk (MOM) on day 7 of life were evaluated. One of the balancing outcomes which the team intended to measure was an anticipated reduced sleep time for the mothers because of frequent milk expression.

The data was entered in excel datasheet. The data was coded and analysed statistically using STATA version 11.1 (Stata Corp, College station, Texas, US).

The nurse-educator and team of nurses met the on-duty NICU nursing staff every third day to apprise them of the situation and share the results that they were getting from the intervention. This allowed for continuous feedback to staff and resident doctors involved in the clinical care.

The continuous data with normal distribution was analysed by ‘t’ test and non-normally distributed data byWilcoxon rank sum test (Mann-Whitney). Categorical data was analysed using Chi-square test or fisher’s exact test. A ‘p’ value of <0.05 was taken as significant.

Results

In the observation phase, the time to first milk expression was 24 to 48 h. Total amount of EBMwas minimal (Table 2). Only one out of eight mothers expressed milk on day one (12.5%). Out of 8 neonates only one of the eligible neonates was on exclusive MOM on day 7 of life (Table 2).

Intervention phase: CPNC was done for next fifteen mothers and their postnatal support was streamlined (Table 1). All these mothers expressed milk within three hours. The proportion of mothers expressing milk on day 1 increased to 86.6%. Total amount of EBM on day 7 and pro- portion of neonates on exclusive MOM also increased.

Sustenance phase: The authors evaluated the proportion of mothers expressing milk on day 1 and proportion of neonates on full EBM on day 7 after 1 y of initiating this QI project in two epochs (Epoch 1: 15th August through 30th August 2016 and Epoch 2: 20th September 2016 through 5th October 2016) and this was 100% (12/12 mothers in epoch 1 and 14/14 mothers in epoch 2) and more than 80% respectively (10/12 neonates in epoch 1 and 13/14 neonates in epoch 2).

Discussion

The present study suggests that a simple and feasible CPNC package can lead to improved milk output in mothers of pre- term neonates admitted in NICU. Another welcome change noted in authors’ unit was the decrease in the requirement of formula milk by almost 50% after the first week of interven- tion phase.

Similar QI initiatives to increase early milk expression in mothers of preterm or very low birth weight (VLBW) infants have been published previously. However, these studies were

Fig. 1 Plan-Do-Study-Act Cycle

Indian J Pediatr (April 2017) 84(4):322–325 323

Improving Exclusive Breastfeeding Rates of Preterm Neonates.

 

either externally funded and/or also required additional work- force [7–10].

The present study is a single centre small quality improve- ment initiative utilising the existing caregivers (including ma- ternity unit health care professionals) and no extra external funding of manpower which suggests the importance of a simple and feasible CPNC package implementation using team approach.

The problem of reduced sleep time for mothers was man- aged by expression of milk from both breasts simultaneously and managing the timing of milk expression so that she gets at least four hours of continuous sleep in the night. This is the first reported QI project related to promotion of expression of breast milk in NICU without the requirement of any external support or funding and carried out by the actual caregivers of the unit. Improving Exclusive Breastfeeding Rates of Preterm Neonates.

For sustenance; an extra breast pump from the NICU was given to the maternity ward to ensure breast milk expression within the maternity ward. In addition, the results of this in- tervention (run chart) were put up in the unit and shared with new mothers and newly joined staff nurses and finally the authors celebrated each success and have been acknowledging nurse champions every month till date.

Conclusions

A simple quality improvement approach using CPNC package with team of physicians and nurses helped to increase exclusive MOM feeding among the NICU ad- mitted preterm neonates.

Table 1 Elements of comprehensive post-natal counseling (CPNC) package

S. No. Description Various actions taken Staff involved

1. Education and sensitization of health care providers (HCP) 1. Teaching and training of HCP by showing webinars and videos regarding its importance

2. Making sister-incharge of the unit as the team leader 3. Early expression and 4 hourly expression of milk

included in doctor’s treatment order 4. Primary nurse was assigned responsibility of early

milk expression 5. Nurse whose neonate was on exclusive breast milk

only on Day 7 given a Bcertificate of best nurse^ of the month

• Faculty incharge [1] • Resident physicians [2] • Nurse educator [1] • Senior staff nurses [2]

2. Education and sensitization of family members 1. Teaching and counseling of mothers and family by the HCP

2. Explaining the importance of early and regular milk expression to the bedside caretaker and mother

3. Advising night expression at 20:00, 22:00, 00:00 and then at 04.30 h

4. Faculty to proactively ask the proportion of EBM and early expression on routine rounds

5. Encouraging mother for Kangaroo mother care

• Faculty incharge [1] • Resident physicians [2] • Nurse educator [1] • Senior staff nurses [2]

Table 2 Outcome variables Outcome Observation Phase

(n = 8) Intervention Phase (n = 15)

P value

Mothers expressing milk within 3 h of birth 0 (0) 15 (100) <0.0001

Proportion of mothers expressing milk on day 1

1 (12.5) 13 (86.6) 0.001

Proportion of mothers expressing milk on day 3

2 (25) 15 (100) <0.0001

EBM on day 1 (ml) 1 2 (1–4)

EBM on day 7 (ml) 100 (91–127) 360 (169–483) 0.001

Proportion of neonates on MOM on day 7 (%)

1 (10) 13 (81.3) 0.001

Data expressed as number (%), median (range)

MOM Mother’s only milk; EBM Expressed breast milk

324 Indian J Pediatr (April 2017) 84(4):322–325

Improving Exclusive Breastfeeding Rates of Preterm Neonates.

 

Acknowledgements The authors acknowledge the contribution by nursing staff (Ms Kiran Singh, Ms. Veena Bahri, Ms. Geeta George, Ms. Sneh Dixon) and Dr. Poonam Joshi (Lecturer, Nursing College, AIIMS) without whom this study would not have been possible.

Contributions AS: Primary responsibility for protocol develop- ment, study implementation, data management and writing the manuscript; MJ: Primary responsibility for protocol development, supervised implementation of the study and contributed to writing of the manuscript; JSD: Participated in implementation of study and provided inputs in manuscript writing; AT and AKD: Participated in development of the protocol, supervised implemen- tation of the study and contributed to writing of the manuscript. AKD will act as guarantor for the paper.