National Prevalence of Donor Milk Use Among Level 1 Nurseries.

BACKGROUND AND OBJECTIVES: Donor milk use has increased among very preterm infants because of mounting evidence of health benefits; however, the extent that donor milk is used among healthy term infants in level 1 nurseries is unclear. We aimed to determine (1) national prevalence of and (2) hospital factors associated with donor milk use in level 1 nurseries. METHODS: Among 3040 US birthing hospitals, we randomly selected hospitals from each of 4 US regions (119 in northeast, 120 in Midwest, 116 in west, and 103 in south) for a total of 458 hospitals. We surveyed the nursing leaders of these hospitals from October to December 2017 regarding routine use of donor milk in the level 1 nursery (yes or no). To estimate national prevalence, we weighted responses according to the number of birthing hospitals within each region. We examined relationships between routine donor milk use in the level 1 nursery and hospital characteristics using multivariable logistic regression. RESULTS: In total, 214 of 458 (47%) nursing leaders responded. The national prevalence of routine donor milk use in level 1 nurseries was 17.6%. Eighty-five percent of donor milk programs were ≤5 years old. Donor milk use occurred more often in hospitals with ≥1500 annual births (41.7%), compared to ≤500 annual births (6.3%) (adjusted odds ratio 7.8; 95% confidence interval 1.8-34.4), and in the west (30.9%), compared to the northeast (10.5%) (adjusted odds ratio 4.1; 95% confidence interval [1.1-14.9]). CONCLUSIONS: Although there is limited evidence to support donor milk for healthy infants in the nursery, nearly one-fifth of level 1 US nurseries routinely used donor milk in 2017.

Prevalence and predictors of donor milk programs among U.S. advanced neonatal care facilities.

OBJECTIVE: (1) Determine national prevalence and predictors of donor milk programs among levels 2-4 advanced neonatal care facilities; (2) describe characteristics of donor milk programs. STUDY DESIGN: We randomly selected 120 U.S. hospitals with levels 2-4 advanced neonatal care facilities among each of four U.S. regions and surveyed the medical directors from July 2017 to November 2017 regarding donor milk use. We weighted responses according to the number of birthing hospitals in each region. RESULTS: Response rate was 213/480 (44%). Twenty-eight percent of level 2 and 88% of levels 3 and 4 neonatal care facilities had donor milk programs. Donor milk programs occurred more often in the South vs. Northeast (aOR 3.7 [1.1, 12.5] and less often in safety-net hospitals (≥75% Medicaid patients) vs. nonsafety-net hospitals (aOR 0.3 [0.1, 0.8]). CONCLUSION: In 2017, the vast majority of levels 3 and 4 neonatal care facilities had donor milk programs but disparities existed according to the safety-net hospital status and region.

A Quality Improvement Project to Increase Mother's Milk Use in an Inner-City NICU.

Mother's milk is recommended for preterm infants due to numerous health benefits. At our inner-city hospital, >80% of mothers of infants younger than 34 weeks' gestation initiated milk production, but fewer continued until discharge. Among infants younger than 34 weeks' gestation, we aimed to (1) increase any mother's milk use in the 24 hours before discharge/transfer to >75%; (2) increase exclusive mother's milk use in the 24 hours before discharge/transfer to >50%; and (3) reduce racial/ethnic disparities in mother's milk use. METHODS: We conducted a quality improvement project from January 2015 to December 2017 focused on prenatal education, first milk expression ≤6 hours after birth, and skin-to-skin care in the first month. We tracked process measures and main outcomes with run and control charts among 202 infants younger than 34 weeks' gestation eligible to receive mother's milk born at our hospital; We tracked results according to maternal race/ethnicity subgroups. RESULTS: Forty-seven percent of mothers were non-Hispanic black, 28% were Hispanic, and 13% were non-Hispanic white. We improved the rate of first milk expression ≤6 hours after birth and skin-to-skin care in the first month but did not improve rates of any/exclusive mother's milk use at discharge/transfer. Eight-five percent of infants had mothers that initiated milk production, but only 55% received any mother's milk at discharge/transfer. CONCLUSIONS: Our single-center quality improvement effort focused on infants younger than 34 weeks' gestation whose mothers were predominately Hispanic and non-Hispanic blacks. We successfully increased first milk expression ≤6 hours after birth and skin-to-skin care but did not increase mother's milk use at discharge/transfer.

Addressing Disparities in Mother's Milk for VLBW Infants Through Statewide Quality Improvement.

OBJECTIVES: Among very low birth weight infants born from January 2015 to December 2017, the Massachusetts statewide quality improvement collaborative aimed to increase provision of (1) any mother's milk at discharge or transfer from a baseline of 63% to ≥75%, (2) exclusive mother's milk at discharge or transfer from a baseline of 45% to ≥55%, and (3) to reduce racial and ethnic disparities in provision of mother's milk. METHODS: We used the Institute for Healthcare Improvement Breakthrough Series framework in which our main process measures were receipt of prenatal education regarding human milk education, first milk expression within 6 hours after birth, and any skin-to-skin care on 4 weekly audit days in the first month. We examined changes over time among all very low birth weight infants and for 3 racial and ethnic subgroups (non-Hispanic white, non-Hispanic black, and Hispanic) using control and run charts, respectively. RESULTS: Of 1670 infants eligible to receive mother's milk at 9 hospitals, 43% of their mothers were non-Hispanic white, 19% were non-Hispanic black, 19% were Hispanic, 11% were of other races or ethnicities, and 7% were unknown. Hospital teams conducted 69 interventions. We found improvement in all 3 process measures but not for our main outcomes. Improvements in process measures were similar among racial and ethnic subgroups. Hospitals varied substantially in the rate of any mother's milk at discharge or transfer according to race and ethnicity. CONCLUSIONS: Our collaborative achieved similar improvements in process measures focused within the first month of hospitalization among all racial and ethnic subgroups. Reduction in racial and ethnic disparities in mother's milk at discharge was not reached. Future efforts will focus on factors that occur later in the hospitalization.

Timing of First Milk Expression to Maximize Breastfeeding Continuation Among Mothers of Very Low-Birth-Weight Infants.

OBJECTIVE: To estimate the time of first milk expression among mothers of very low-birth-weight (VLBW, 1,500 g or less) infants that predicts the maximal duration of mother's milk provision during hospitalization in the neonatal intensive care unit (NICU). METHODS: We performed a secondary analysis and studied 1,157 mother-VLBW infant pairs in nine Massachusetts hospitals born from January 2015 until December 2017. We determined the cut-point for timing of first milk expression after delivery that was associated with the highest probability of any and exclusive provision of mother's milk for the infant at NICU discharge or transfer using recursive partitioning. We estimated hazard ratios (HRs) comparing the probability of continued provision of mother's milk during the hospitalization between mothers who initiated milk expression before compared with after the cut-point (within 8 hours after delivery [referent] vs 9-24 hours), adjusting for gestational age, birth weight, maternal race and ethnicity, and clustering by hospital and plurality in Cox proportional hazards models. RESULTS: Sixty-eight percent of mothers first expressed milk within 8 hours after delivery. First milk expression at 9-24 hours was associated with lower odds of any mother's milk provided to the infant on day 7 (adjusted odds ratio [aOR] 0.39 [0.24-0.60]) and discharge or transfer (aOR 0.45 [0.33-0.62]), compared with expression within 8 hours. Findings were similar for exclusive mother's milk. Mothers who first expressed 9-24 hours stopped providing milk earlier in the neonatal hospitalization (adjusted HR 1.64 [1.33-2.01]) compared with mothers who first expressed within 8 hours. CONCLUSION: Using a data-driven approach, we identified that first milk expression within 8 hours was superior to 9-24 hours with respect to maximal duration of provision of mother's milk for hospitalized VLBW infants. Randomized control trials are needed to further establish the causal relationship between timing of first milk expression and long-term lactation success among mothers of VLBW infants.

Racial and Ethnic Disparities in the Use of Mother's Milk Feeding for Very Low Birth Weight Infants in Massachusetts.

OBJECTIVE: To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month). STUDY DESIGN: We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects. RESULTS: Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites. CONCLUSIONS: Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.

Outcomes of Implementation of a NICU-Based Late Preterm Infant Feeding Guideline.

BACKGROUND AND OBJECTIVES: Late preterm (LPT) infants are at risk for feeding difficulties. Our objectives were to reduce the use of intravenous (IV) fluids and increase breastfeeding at discharge among LPT infants admitted to our NICU. METHODS: We implemented a feeding guideline and evaluated its effect using a pre-post design. We examined rates of our main outcomes, IV fluid use, and any or exclusive breastfeeding at discharge, as well as several secondary outcomes, including hypoglycemia (glucose <50 mg/dL) at >8 hours of life, by using χ2 and t tests. We excluded infants that were <2000 g, admitted to the NICU at >8 hours of life, or needed IV fluids at ≤8 hours of life for a medical reason. We used multivariable logistic regression to examine odds ratios and 95% confidence intervals of our main outcomes. RESULTS: Fifty percent of infants were eligible. Of those eligible, 18 of 52 (35%) vs 14 of 65 (22%) received IV fluids at >8 hours of life (P = .06). In the 24 hours before discharge, 35 of 52 (75%) vs 46 of 65 (78%) received any breast milk (P = .67), and 10 of 52 (30%) vs 10 of 65 (21%) received exclusive breast milk (P = .43). More infants had hypoglycemia in the posttime period (16 of 65 [25%]) compared with the pretime period (3 of 52 [6%]; P = .01). CONCLUSIONS: After implementation of a LPT feeding guideline in our NICU that defined specific expected feeding volumes, we did not find changes in IV fluid use or breastfeeding.