Got (the Right) Milk? How a Blended Quality Improvement Approach Catalyzed Change.

BACKGROUND: The expression, storage, preparation, fortification, and feeding of breast milk are common ongoing activities in many neonatal intensive care units (NICUs) today. Errors in breast milk administration are a serious issue that should be prevented to preserve the health and well-being of NICU babies and their families. PURPOSE: This paper describes how a program to improve processes surrounding infant feeding was developed, implemented, and evaluated. METHODS: The project team used a blended quality improvement approach that included the Model for Improvement, Lean and Six Sigma methodologies, and principles of High Reliability Organizations to identify and drive short-term, medium-term, and long-term improvement strategies. FINDINGS/RESULTS: Through its blended quality improvement approach, the team strengthened the entire dispensation system for both human milk and formula and outlined a clear vision and plan for further improvements as well. The NICU reduced feeding errors by 83%. IMPLICATIONS FOR PRACTICE: Be systematic in the quality improvement approach, and apply proven methods to improving processes surrounding infant feeding. Involve expert project managers with nonclinical perspective to guide work in a systematic way and provide unbiased feedback. Create multidisciplinary, cross-departmental teams that include a vast array of stakeholders in NICU feeding processes to ensure comprehensive examination of current state, identification of potential risks, and "outside the box" potential solutions. IMPLICATIONS FOR RESEARCH: As in the realm of pharmacy, the processes involved in preparing feedings for critically ill infants should be carried out via predictable, reliable means including robust automated verification that integrates seamlessly into existing processes. The use of systems employed in pharmacy for medication preparation should be considered in the human milk and formula preparation setting.

Relationship Between Maternal COVID-19 Infection and In-Hospital Exclusive Breastfeeding for Term Newborns.

OBJECTIVE: To evaluate the relationship between maternal COVID-19 infection and the odds of in-hospital exclusive breastfeeding for term newborns. DESIGN: Retrospective descriptive quantitative. SETTING: A large, urban hospital with more than 6,000 births annually. SAMPLE: Term newborns born between March 1, 2020, and March 31, 2021 (N = 6,151). METHODS: We retrospectively extracted data from electronic health records to evaluate the relationship of maternal COVID-19 infection with the odds of in-hospital exclusive breastfeeding using univariate analysis and logistic regression models. The covariates included insurance type, race/ethnicity, glucose gel administration, length of stay, newborn gestational age, newborn birth weight, and maternal COVID-19 infection. RESULTS: Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding (p = .138) after adjustment for covariates in the logistic regression model. However, when newborns who received pasteurized donor human milk supplementation were excluded from the logistic regression model, maternal COVID-19 infection significantly decreased the odds of in-hospital exclusive breastfeeding (p = .043). CONCLUSION: Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding when newborns received donor human milk supplementation. Access to donor human milk for supplementation for term newborns may protect the odds of in-hospital exclusive breastfeeding.

Percent mother's own milk feedings for preterm neonates predicts discharge feeding outcomes.

INTRODUCTION: No studies have determined if there is a threshold whereby use of mother's own milk (MOM) during hospitalization predicts exclusive MOM feeding at discharge. METHODS: Among 113 very low birthweight neonates, the ratio of MOM to enteral feeds was measured in the first 14 days, 28 days, and overall hospital stay. The primary outcome was exclusive MOM feeding at discharge. RESULTS: For every 1% increase in MOM consumption in the first 14 and 28 days, the odds of being discharge home on an exclusive MOM diet increased nearly 7-fold (OR 7.01, 95% CI: 2.09-23.50) and 17-fold (OR 17.46, 95% CI 4.67-63.31), respectively. A threshold of >50%, >83%, and >85% MOM consumption compared to overall enteral feeds in the first 14 days, 28 days, and throughout hospitalization, respectively, is recommended. CONCLUSIONS: Promotion of MOM consumption in the first 2-4 weeks is of paramount importance, with negligible impact of increasing MOM consumption after 28 days.

A preoperative standardized feeding protocol improves human milk use in infants with complex congenital heart disease.

OBJECTIVE: To evaluate the hypothesis that implementation of a preoperative standardized feeding protocol increases human milk use in infants with complex congenital heart disease (CHD). STUDY DESIGN: Single-center, quasi-experimental study of infants with complex CHD. A cohort of 546 infants pre protocol was compared to 55 patients post protocol. Feeding regimen and peri-operative outcomes information were collected. RESULT: Human milk use increased significantly (58.4% versus 100%, p < 0.01) and there was no formula use post protocol (18.7% versus 0%, p < 0.01). Preoperative necrotizing enterocolitis occurred in 18/546 (3.3%) infants pre protocol versus 1/55 (1.8%) post protocol, p = 1.00. Days to full feeds and length of hospital stay in both cohorts were not significantly different. CONCLUSION: Successful implementation of a preoperative standardized feeding protocol can increase human milk and decrease formula use in infants with complex CHD without significant adverse outcomes. A larger study is needed to evaluate the association of human milk use with peri-operative outcomes.

Optimizing the Use of Human Milk Cream Supplement in Very Preterm Infants: Growth and Cost Outcomes.

BACKGROUND: An exclusive human milk-based diet has been shown to decrease necrotizing enterocolitis and improve outcomes for infants ≤1250 g birth weight. Studies have shown that infants who received an exclusive human milk diet with a donor-human milk-derived cream supplement (cream) had improved weight and length velocity when the cream was added to mother's own milk or donor-human milk when energy was <20 kcal/oz using a human milk analyzer. Our objective was to compare growth and cost outcomes of infants ≤1250 g birth weight fed with an exclusive human milk diet, with and without human milk cream, without the use of a human milk analyzer. METHODS: Two cohorts of human milk-fed premature infants were compared from birth to 34 weeks postmenstrual age. Group 1 (2010-2011) received a donor-human milk fortifier, whereas Group 2 (2015-2016) received donor-human milk fortifier plus the commercial cream supplement, if weight gain was <15 g/kg/d. RESULTS: There was no difference in growth between the 2 groups for weight (P = 0.32) or head circumference (P = 0.90). Length velocity was greater for Group 1 (P = 0.03). The mean dose of donor-human milk fortifier was lower in Group 2 (P < 0.001). Group 2 saved an average of $2318 per patient on the cost of human milk products (P < 0.01). CONCLUSIONS: Infants receiving a human milk diet with cream supplementation for growth faltering achieve appropriate growth in a cost-effective feeding strategy.

Personal Infant Feeding Experiences of Postpartum Nurses Affect How They Provide Breastfeeding Support.

OBJECTIVE: To describe the experiences of postpartum nurses when feeding their own infants and explore how these experiences influence the breastfeeding support they provide to new mothers. DESIGN: Qualitative research with interviews using dialogic data generation and analysis. SETTING: Large academic women and children's hospital in the Southern United States. PARTICIPANTS: Nine postpartum nurses who gave birth and breastfed or mixed-fed infants at any time in the past. METHODS: Individual, semistructured, face-to-face interviews. RESULTS: Participants described breastfeeding experiences similar to those of other women: some were positive, some negative. Most participants reported that they received less breastfeeding support than they needed during the maternity hospitalization. They attributed this to the fact that they were nurses. The infant feeding experiences of participants led them to promote breastfeeding in a more personal way and establish deeper connections with the mothers in their care. The practice of all participants changed because of their desire to prevent other mothers from experiencing the physical or psychological pain they experienced with breastfeeding. CONCLUSION: Personal infant feeding experiences shaped the breastfeeding practice of participants in unique and unpredictable ways. Nurses may benefit from increased breastfeeding education and support during their own maternity hospitalizations. Additionally, the inclusion of reflective narrative processes in breastfeeding education could encourage nurses to explore their personal, empirical, and clinical knowledge and construct an approach to breastfeeding practice that integrates these sources of information.

Nutritional considerations in the care of conjoined twins.

Conjoined twins represent an interesting nutritional challenge as nutrient delivery and absorption is greatly affected by anatomy and, therefore, unique to each twin pair. Nutritional support is essential to optimize growth and development in the neonatal period; however, very little data exists on the topic in this population. Conjoined twins require individualized nutritional assessment that focuses on the interaction between the metabolic rate, nutrient uptake, and nutrient delivery of each twin in the dyad. This report describes one center's experience with monitoring growth, establishing nutrient requirements, and determining substrate utilization in three sets of conjoined twins.

Exploring the skin-to-skin contact experience during cesarean section.

PURPOSE: To explore and describe the mother's experience of holding her neonate in skin-to-skin contact (SSC) immediately after cesarean delivery during surgical closure and recovery. DATA SOURCES: Eleven women between the ages of 23 and 38 years, who had achieved 39.1-40.2 weeks gestational age, participated in an ethnographic study using observations and interviews with the mothers conducted at 24-48 h postdelivery. Interviews were transcribed verbatim and content analysis of both observational notes and transcripts were used to analyze the data. CONCLUSIONS: Findings from this study describe the mother's experience of SSC during cesarean section. The primary theme that emerged was mutual caregiving: the mother-neonatal interaction and their shared and reciprocal relationship and benefits during SSC. Two contextual issues also were illuminated (a) the father's influence on the SSC experience and (b) the cesarean environment. IMPLICATIONS FOR PRACTICE: With cesarean section the most common surgical procedure among American women, advanced practice nurses are in a unique position to encourage and educate women on the use of SSC for their benefit and that of their newborn. Advanced practice nurses are also empowered to influence institutional policy on SSC during cesarean deliveries at the local and national level.

Mothers performing in-home measurement of milk intake during breastfeeding of their preterm infants: maternal reactions and feeding outcomes.

This study compares feeding outcomes and perceptions of mothers using in-home test weights and those who did not use test weights to manage breastfeeding of their preterm infants during the first month after hospital discharge. There were no significant differences in daily weight gain between the 2 groups during the study period. Maternal concerns cited in both groups were similar, namely, knowing how much milk infant is taking, infant gaining adequate weight, and infant getting enough milk. All women in the experimental group and two-thirds in the control group reported that in-home measurement of milk intake by test-weighing had been or would have been helpful. This prospective randomized study demonstrated that mothers of premature infants who performed in-home test-weighing procedures found the technique to be helpful and experienced no increased stress or lower achievement of breastfeeding goals when compared to mothers not performing test weighs.

Providing mother's own milk in the context of the NICU: a paradoxical experience.

BACKGROUND: Mothers of very preterm infants continue to face challenges related to providing their expressed breast milk in the neonatal intensive care unit (NICU). OBJECTIVE: This qualitative study sought to understand the experience of mothers of hospitalized very preterm infants related to their daily pumping routine during the NICU stay. METHODS: Fourteen women who were pumping breast milk for their hospitalized infants were interviewed. Sequential, semistructured, audiotaped individual interviews were conducted at 2 different time points: within 2 weeks following delivery when the mothers were pumping only, and 4 to 6 weeks once breastfeeding had been initiated. RESULTS: The central themes found were: becoming a "mother-interrupted" and negotiating a paradoxical experience of separation and connection. Unique to these findings were the paradoxical view of the pump as both a wedge and a link to their infants, the intense dislike the mothers had for the tasks required to provide their expressed breast milk, and diversionary tactics used during pumping sessions. CONCLUSION: The complexity of thoughts, actions, and behaviors revealed in the mothers' narrative accounts provides a guide to direct future breastfeeding interventions and management.

A comparison of the efficiency, efficacy, comfort, and convenience of two hospital-grade electric breast pumps for mothers of very low birthweight infants.

OBJECTIVE: Many mothers of very low birthweight infants are breast pump-dependent for weeks or months and need a breast pump that is efficient, effective, comfortable, and convenient. STUDY DESIGN: This multisite, blinded, randomized clinical trial compared the efficiency, efficacy, comfort, and convenience of the Symphony breast pump (Medela, McHenry, IL) (SBP) to the Classic breast pump (Medela) (CBP) and also compared these same outcome measures for single- and multiphase suction patterns used in the SBP. All 100 mothers initiated lactation with the CBP and were randomized to single- and multiphase suction patterns in the SBP when daily milk output was at least 350 mL/day. Protocol I included 35 mothers who compared each of three suction patterns in the SBP on two separate occasions (six observations) in the neonatal intensive care unit and used the CBP for all other pumpings. Protocol II included 65 mothers who compared single- and multiphase patterns in the SBP for 7 days and then returned to the CBP for 5 days. RESULTS: The onset of milk ejection was quicker (P < 0.05) for the single- versus multiphase patterns in the SBP, suggesting that mothers had become conditioned to the unphysiolologic single-phase pattern in the CBP. However, all other measures of efficiency and efficacy were not significantly different, including milk output at 5-minute intervals. When asked to compare the SBP and the CBP, mothers in Protocol 1 rated the SBP as significantly more efficient, effective, comfortable, and convenient than the CBP (P < 0.05), regardless of the suction pattern in the SBP. Similarly, mothers in Protocol II rated the SBP significantly (P < 0.05) more comfortable than the CBP, regardless of the specific pattern in the SBP. CONCLUSIONS: These findings suggest that the SBP was as efficient and effective as the CBP but was significantly more comfortable to use for pump-dependent mothers of very low birthweight infants.

Recognizing and treating delayed or failed lactogenesis II.

Delayed or failed achievement of lactogenesis II--the onset of copious milk volume--occurs as a result of various maternal and/or infant factors. Early recognition of these risk factors is critical for clinicians who interact with breastfeeding women so that intervention and achievement of full or partial breastfeeding can be preserved. This article describes the maternal and infant conditions that contribute to the unsuccessful establishment of a full lactation. Treatment modalities that can maximize maternal lactation capacity and infant growth rates are offered.

The 3 M's of breast-feeding the preterm infant.

Mother's own milk is considered best for preterm infants. Given the often protracted period between birth and breast-feeding for most preterm newborns, a number of challenges exist for mothers and neonatal intensive care unit nurses in establishing lactation, providing mother's own milk, and achieving breast-feeding. This article conceptualizes breast-feeding the preterm infant in the context of the neonatal intensive care unit as a 3-phase process, the 3 M's of breast-feeding: medication, mother's milk feedings, and the mechanics of breast-feeding.

Randomized trial of donor human milk versus preterm formula as substitutes for mothers' own milk in the feeding of extremely premature infants.

OBJECTIVE: Compared with preterm formula (PF), mother's milk (MM) is associated with lower rates of late-onset sepsis (LOS) and necrotizing enterocolitis (NEC) among premature infants. Because not all mothers of premature infants produce sufficient milk to supply their infants throughout hospitalization, we reasoned that pasteurized donor human milk (DM) would be a suitable alternative. METHODS: Extremely premature infants (<30 weeks of gestation) whose mothers intended to breastfeed were assigned randomly to receive either pasteurized DM or PF if the supply of their own MM became insufficient during the study (birth to 90 days of age or hospital discharge). Infection-related events (LOS, NEC, meningitis, presumed sepsis, or urinary tract infection) that occurred after the attainment of a milk intake of 50 mL/kg, dietary intake, growth, skin-to-skin contact, and duration of hospital stay were compared. The primary analysis compared groups DM and PF on an intent-to-treat basis. If no differences were noted, then these groups were combined and compared with the reference group, group MM. If differences were noted, then the subsequent analyses compared each group with group MM. RESULTS: Of 243 infants, 70 (29%) received only MM; group DM included 81 infants and group PF included 92 infants. Because of poor weight gain, 17 infants (21%), all in group DM, were switched to PF. There were no differences in birth weight, gestational age, multiple births, and age at attainment of feeding of 50 mL/kg among groups. There were no differences between group DM and group PF in LOS and/or NEC, other infection-related events, hospital stay, or number of deaths. Group DM received a greater intake of milk and more nutritional supplements but had a slower rate of weight gain, compared with group PF. Compared with groups DM and PF, group MM had fewer episodes of LOS and/or NEC and total infection-related events and a shorter duration of hospital stay. Group MM also had fewer Gram-negative organisms isolated from blood cultures than did the other groups. CONCLUSIONS: In this randomized, blinded trial of feeding of extremely premature infants, we found that, as a substitute for MM, DM offered little observed short-term advantage over PF for feeding extremely premature infants. Advantages to an exclusive diet of MM were observed in terms of fewer infection-related events and shorter hospital stays.

Increased epidermal growth factor levels in human milk of mothers with extremely premature infants.

Maternal milk is the major source of nutrients and growth-promoting substances in the first weeks of life for the majority of neonates. Epidermal growth factor (EGF) and transforming growth factor-alpha (TGF-alpha) are trophic peptides present in human milk with significant healing effects on injured gastrointestinal mucosa. Decreasing gestational age of neonates is associated with higher risk of developing gastrointestinal disorders, and human milk provides better protection against these diseases compared with formula. The aim of this study was to evaluate the concentrations of EGF and TGF-alpha in human milk collected from mothers with infants born: extremely preterm, preterm, and full term. Milk samples were collected at the end of first, second, and fourth week postpartum from each mother of infants born in one of the three gestational age groups: extremely preterm (23-27 wk, n = 16), preterm (32-36 wk, n = 16), and full term (38-42 wk, n = 15). Milk concentrations of EGF and TGF-alpha were quantified with a homologous RIA in the milk aqueous fraction. Concentrations of EGF in human milk from the extremely preterm group (23-27 wk) were significantly higher compared with values from the preterm and full-term groups throughout the first month of lactation. A similar pattern was observed with human milk TGF-alpha; however, milk TGF-alpha levels were lower than EGF. In conclusion, we have found higher concentrations of EGF and TGF-alpha in human milk of mothers with extremely preterm babies. These data may indicate the potential importance of milk-borne EGF and TGF-alpha for the development of extremely premature infants.