1. Breastfeeding and Vitamin D Supplementation Broadway Clinic QI Project Rakhee Bowker, Michael Goldman, Stuart Holzer, Lisa Kurz, Lacy-Ann Landell, Robbie Majzner, Lindsay McGann, Lisa McReynolds, Lisa Nowell, Anne Pierog, Gabe Rama, Corinna Rea, Daniel Stephens, Emily Whitesel, Kristal Woldu Heidi Beutler, Renie Eis, Mariellen Lane, Pran Saha, Nan Salamon, John Rausch, Laura Robbins-Milne

2. Breastfeeding It is well demonstrated that breastfeeding provides benefits for both mothers and infants, including: Infants- Stimulate GI motility and growth, decrease risk of NEC Increased immune response due to transmission in breastmilk of maternal antibodies Decrease risk of diseases such as asthma, obesity, and diabetes Mothers- Stimulate oxytocin release and acceleration of recovery from childbirth Increased weight loss Increased bonding with infant Prolonged annovulation postpartum Economic savings on formula Reduced risk of breast and ovarian cancer Decreased risk of cardiovascular disease

3. Vitamin D Important in calcium homeostasis Transferred across the placenta from mother to fetus Often low in infants if maternal levels low or infant premature Amount of vitamin D in breastmilk is low, especially if mom is vitamin D deficient

4. AAP Recommendations The AAP recommends exclusively breastfeeding infants until 6 months and then supplementing with breastmilk up to and beyond the first year of life The AAP now recommends starting vitamin D supplementation within the first few days of life to any infant breastfeeding or taking less than 27oz of formula per day

5. Baseline Data For Broadway Breastfeeding (exclusive and partial) 2 months- 32% 4 months- 16% Vitamin D supplementation 2 months- 57% 4 months- 57%

6. AIM Statement We aim to improve collective breastfeeding rates in the Washington Heights community, specifically to 30% at the 4 month well child visit in the Broadway Ambulatory Clinic pediatric population. Within this patient population, we aim to increase vitamin D supplementation per current AAP guidelines to 90% in all nursing infants (including both fully and partially breastfed infants).

7. Interventions Breastfeeding Resource Sheet in English & Spanish created and distributed to mothers at the newborn visit

8. Interventions Breastfeeding Resource Sheet in English & Spanish created and distributed to mothers at the newborn visit Didactic educating clinic providers regarding breastfeeding and vitamin D supplementation guidelines

9. Interventions Breastfeeding Resource Sheet in English & Spanish created and distributed to mothers at the newborn visit Didactic educating clinic providers regarding breastfeeding and vitamin D supplementation guidelines Breastfeeding checklist placed in all exam rooms with guidelines for providers regarding vitamin D supplementation

10. Interventions Breastfeeding Resource Sheet in English & Spanish created and distributed to mothers at the newborn visit Didactic educating clinic providers regarding breastfeeding and vitamin D supplementation guidelines Breastfeeding checklist placed in all exam rooms with guidelines for providers regarding vitamin D supplementation Schedule breastfeeding newborns for a weight check/breastfeeding check at one month of age to troubleshoot and encourage continued breastfeeding

11. Other Interventions Also Happening At Broadway

12. Centering Group Prenatal counseling at Broadway for teenage expecting mothers Residents developed a breastfeeding and Vitamin D supplementation presentation. Each month the outpatient resident gives the presentation to the expectant mothers in the group Breastfeeding Your Baby: Healthy and Natural Sitting comfortably with the baby at breast height using a pillow for support (excellent options are My Breast Friend or Boppy pillows), tuck the baby's tush in the crook of the opposite arm of the breast being fed. The mother's forearm should be positioned up the length of the baby's back. The baby's head is supported by her thumb and forefinger, right behind the ears. The baby is held tummy-to-tummy with the mother Cross Cradle Position

13. Breastfeeding Support Group Meets every 1 st and 3 rd Wednesday morning Mothers can walk-in For expecting and new mothers of Broadway Clinic Organized by Dr. Salamon and Alyssa Wynn

14. Percent of Infants Receiving Any Breastmilk

15. Percent of Breastfed Infants Receiving Vitamin D Supplementation

16. Lessons We Learned We were unable to improve our 4 month breastfeeding rates. This reinforced that to positively Influence breastfeeding rates interventions need to reach mothers prior to the first outpatient office visit. As shown in other studies, effective prenatal counseling and Baby Friendly Hospitals are important factors in educating mothers and families and improving breastfeeding rates. Educational interventions and reminders in clinic aimed at providers were able to increase vitamin D prescription rates.

17. References Carol L. Wagner, MD, Frank R. Greer, MD and the Section on Breastfeeding and Committee on Nutrition. Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics Vol. 122 No. 5 November 2008, pp. 1142-1152. Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS. Influence of breastfeeding and nipple stimulation on postpartum uterine activity. Br J Obstet Gynaecol. 1994 Sep;101(9):804-5. Dellifraine J, Langabeer J 2 nd, Williams JF, Gong AK, Delgado RI, Gill SL. Cost comparison of baby friendly and non-baby friendly hospitals in the United States. Pediatrics. 2011 Apr;127(4):e989-94. Epub 2011 Mar 21. Dewey KG, Heining MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr. 1993 Aug;58(2):162-6. Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ, Eidelman AI: American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005, Feb;115(2):496-506. Office of the Surgeon General. Call to Action to Support Breastfeeding. http://www.surgeongeneral.gov/topics/breastfeeding/index.html. 2011. http://www.surgeongeneral.gov/topics/breastfeeding/index.html Walter F. The Parathyroid and Vitamin D. Medical Physiology: A Cellular And Molecular Approach, 1300, Elsevier/Saunders, Boron. 2003, 1094. Wang IV, Fraser IS. Reproductive function and contraception in the postpartum period. Obstet Gynecol Surv. 1994 Jan;49(1):56-63.