Risk Stratification to Support Antibiotic Stewardship and Breastfeeding Exclusivity in a Military Treatment Facility.

OBJECTIVE: To safely reduce unnecessary antibiotic exposure in neonates exposed to chorioamnionitis and inadequately treated Group B Streptococcus (GBS) using the early-onset sepsis (EOS) calculator for risk stratification and a 36-hour antibiotic duration. DESIGN: Evidence-based quality improvement initiative. SETTING/LOCAL PROBLEM: Obstetric service at a midsized military treatment facility with approximately 2,000 births annually and no standard process for neonatal EOS risk assessment. PARTICIPANTS: Clinical nurse specialist, physicians, nursing leadership, unit-level nursing champions, and nurses assigned to the mother-baby and labor and delivery units. INTERVENTION/MEASUREMENTS: An interdisciplinary working group created a protocol to institute an EOS risk assessment calculator, a note for the electronic heath record, and interdisciplinary education for all staff providing care to neonates in our facility. RESULTS: Before implementation of the EOS calculator, 97.6% of neonates exposed to chorioamnionitis or inadequate maternal GBS treatment received antibiotics; after implementation, the mean rate dropped to 32%. Exclusive breastfeeding rates before discharge in neonates exposed to chorioamnionitis or inadequate maternal GBS treatment also increased during this time, from 40% to a mean of 89%. After implementation, there were no readmissions to our institution for culture-proven sepsis within 14 days of discharge. CONCLUSION: Multidisciplinary team-led implementation of the EOS calculator and of shortened antibiotic duration were associated with safely reduced antibiotic exposure in well-appearing neonates exposed to chorioamnionitis and GBS. In addition, dramatically improved rates of exclusive breastfeeding at discharge were observed in this population.

Historical background to maternal-neonate separation and neonatal care.

Maternal-neonate separation after birth is standard practice in the modern obstetric care. This is however a relatively new phenomenon, and its origins are described. Around 1890, two obstetricians in France expanded on a newly invented egg hatchery as a method of caring for preterm newborns. Mothers provided basic care, until incubators became part of commercial exhibitions that excluded them. After some 40 years hospitals accepted incubators, and adopted the strict separation of mothers from babies observed at the exhibitions. The introduction of artificial infant formula made the separation practical, and this also became normal practice rather than breastfeeding. Incubators and formula were unquestioned standard practices before randomized controlled trials were introduced, and therefore never subjected to such trials. The introduction of Kangaroo Care began 40 years ago in Colombia, now as a novel intervention. Recent trials do in fact show that maternal-neonate separation is detrimental to mothers and babies. Recent scientific discoveries such as the microbiome, epigenetics, and neuroimaging provide the scientific explanations that have not been available before, suggesting that skin-to-skin contact and breastfeeding are defining for the basic reproductive biology of human beings.