1. Breastfeeding in the NICU

2. Facts 60-90% of mothers provide some breast milk in the first week of life for their VLBW infants (Casavant, 2015; Smith, 2003) Fewer than half (32.8 to 48%) of those infants are still receiving BM at discharge. (Bonet, 2015; Casavant, 2015; Pineda, 2011)

3. Myths Breast feeding is more difficult and slower to obtain full oral feeds and discharge. FALSE: Briere (2015), Nyqvist (2008) and Dodrill et al, (2008) report no difference in time to transition to full oral feeds whether breast or bottle fed. Rather it was the moderate premies (28-32 weeks) who were the slowest to transition. (Dodrill et al, 2008)

4. Myths Breastfed babies have slower growth. TRUE: From Zachariassen: Not exclusively BF: SD (birth to discharge) -1.36 to -1.02 (0.34) Exclusively BF: SD (birth to discharge) -1.09 to -1.19 (-0.10)

5. Myths Pacifier Use is good/bad for breastfeeding. BOTH: Admitting mother directly to NICU and minimizing use of pacifier during breastfeeding transition could contribute to earlier establishment of exclusive BMF. (Masstrup, 2014). Conversely, other study showed no detrimental of effect of pacifier use in premie discharged with all BF (Collins, 2004).

6. Myths Nipple Shields decrease breastfeeding success. FALSE: In a study of 34 preterm dyads, mean milk transfer was greater with the nipple shield without decreasing the duration of breastfeeding. (Meier, 2000)

7. Proposed Improvement Project

8. Model for Improvement http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

9. What are we trying to accomplish?

10. Scope/Limitations NOT addressing whether or not to use donor BM. NOT addressing BM banking issues NOT addressing fortification—liquid vs powder vs HHMF NOT addressing when or how to get from here to there with oral feed initiation and advancement—but may track that as a secondary issue.

11. Aim Increase breastfeeding at discharge for the NICU infant

12. How will we know that a change is an improvement?

13. Possible Goals > 25% of all oral feeds during the last week of hospitalization of NICU infants will be at breast 100% of mothers will receive prenatal consultation for lactation from neonatologist/NNP/Lactation prior to delivery 50% of mothers will initiate pumping within the first hour after birth 100% of mothers will initiate pumping within 6 hours of birth 90% of NICU infant will have the first STS experience before 3 days of age 90% of the NICU infants will have their first oral feed at breast rather than bottle

14. What changes can we make that will result in improvement?

15. Factors for Success In addition to married, older, vaginal delivery, less pulmonary disease, more maturity, singletons, shorter stay, bigger babies higher social class non-smokers successful breastfeeding at discharge is associated with… (Bartington, 2006; Casavant, 2015; Dodrill, 2008; Falking, 2007; Killersreiter, 2001; Zachariassen, 2010; Perrella, 2012)

16. Factors for Success Mothers with clear breast feeding goals (Briere, 2015; Sisk, 2006) Prenatal consultation with neonatologist (Friedman, 2004; Briere, 2014) Beginning milk expression before 6 hours post-delivery, better still if before 1 hour post-delivery (Parker, 2012) (Furman, 2002) (Hill, 2005) Expressing > 5x/day (Furman, 2002) (Hill, 2005) Kangaroo Care/STS (Furman, 2002; Renfrew, 2009; Flacking; Hake-Brooks 2008; Gathwala)

17. Factors for Success First oral feed at breast: 8X more likely for BM at discharge (Casavant, 2015; Pineda, 2011; Briere, 2015) −Earlier start of oral feeds (Mamemoto, 2013; Pineda, 2011; Nyqvist, 2008) −Any direct breast feeding (Smith, 2003; Powers, 2003; Pineda) −Number of times put directly at breast (Pineda, 2011) −NG rather than bottle feeds when not breastfed (Kliethermes, 1999)

18. Factors for Success Implementing a donor milk program (increased 6X) (Parker, 2015) Lactation support (Nyqvist, 2008; Bonet, 2015) and availability of pumps (Bonet, 2015) Supportive NICU healthcare provider messaging (Hoban, 2015; Bonet, 2015; Cricco-Lizza, 2009; Cricco-Lizza, 2015) BF success also correlated with nurse staffing, acuity- adjusted nurse staffing and managerial leadership. (Hallowell, 2014).

19. Causes of Low BF Rates at Discharge Diminished milk production as NICU hospitalization progressed, especially if pumping only (Hogan, 2015; Flacking, 2003; Kirchner, 2009) Need to monitor milk intake (Bonet, 2015) Long distances between home and hospital (Dall’Oglio, 2007) Limited experience at breast

20. Improvement Actions Assess level of lactation support available in your NICU Prenatal consultation about importance of expressing BM and early pumping First Pumping as soon after delivery as possible (goal < 6 hours, stretch goal < 1 hour) Facilitate skin-to-skin early and often Offer first oral feed directly at breast Offer multiple direct-to-breastfeeds/day to increase likelihood of BM at discharge.

21. PDSA PLAN STUDYDO ACT Prenatal consultation Early pumping Early, freq STS 1 st oral feed at breast Multiple direct breastfeeds

22. Additional Info & Thoughts

23. Alternative approaches to Measuring BF intake A.Maternal estimation: If letdown, strong suck, emptier breasts—no supplement If latched but < 5 minutes—half gavage If latched, not nursing—full gavage. B.Pre/Post Weights: We abandoned test-weighing for inaccuracy (Stine, 1990). Not shown to affect duration of BF after discharge (Hurst et al). Comparison in Sweden to “Estimated BF” with daily reduction of NG volume based on daily total weight gain. (Ericson, 2013). C.Physiologic estimation: Reduce NG volume by 5cc/feed each 24 hours if weight gain adequate, until infant receiving 10cc/feed, then NG removed. (Ericson, 2013)

24. BabyFriendly Criteria can be modified to reflect the needs of the VLBW infant in the NICU (Nyqvist 2013). The BabyFriendly program has been shown to increase the number of mothers who initiate breastfeeding but does not affect continuation of breastfeeding at one month (Bartington, 2006).

25. References Available