Effect of education and lactation support on maternal decision to provide human milk for very-low-birth-weight infants

Implementing a colostrum-kit reduces the time to first colostrum for neonates admitted to the NICU - a retrospective observational study

BACKGROUND

The World Health Organisation states that newborns should receive colostrum as soon as possible after birth. However, among newborns needing neonatal intensive care, initiation of lactation and access to colostrum might be delayed. At the centre of this study, a tertiary care hospital in Sweden (10,000 deliveries/year), few admitted infants received colostrum within the day of birth, warranting a quality improvement. In order to reduce the time from birth to first colostrum received by infants admitted to the Neonatal Intensive Care Unit (NICU), a new clinical routine including a colostrum-kit, was implemented as standard care in June 2018. The colostrum-kit contained information about hand expression of breastmilk as well as material for collecting, labelling and transporting the colostrum. The kit should be handed to all birthing parents with infants admitted to the NICU.

METHODS

Data on time in minutes from birth to first colostrum administered to the infant (oral mouth care, oral feeding or gavage feeding) was retrieved for all infants born between 1 September 2016 and 31 October 2023, admitted to the NICU within 1h from birth. Infants were divided into four time-cohorts, compared with nonparametric ANOVA.

RESULTS

The study included 3618 infants born at 22 + 0 - 43 + 0 weeks gestational age, of whom 2814 (78%) had available data on time to colostrum. Median (IQR) time in hours was 35 (20-36) pre-implementations, followed by 18 (7-38), 11 (4-26) and 8 (3-22) in the subsequent follow-up cohorts, p < 0.001. Subgroups of mode of delivery had median (IQR) pre-implementation of 30 (19-54) for vaginal and 47 (23-72) for caesarean section that reached 7 (2-18) and 9 (3-26) in the last follow-up. Subgroups of gestational age (< 28, 28-31, 32-36, > 36 weeks) had a pre-implementation time of 48 (26-80), 46 (23-73), 33 (20-60) and 32 (19-57), that in the last follow-up was reduced to 4 (2-20), 7 (2-29), 9 (2-33) and 9 (4-19).

CONCLUSIONS

Implementing a colostrum-kit for infants admitted to the NICU significantly reduced the time to first colostrum administered to the infant in all gestational ages. The difference between subgroups of gestational age or mode of delivery was reduced. The effect persisted over time.

Pasteurized Donor Human Milk Should Not Replace Mother's Own Milk in Preterm Neonates: A Quality Initiative Toward Decreasing the "PDHM Dependency"

Aim: Mother's own milk (MOM) is the preferred source of neonatal nutrition. Due to various challenges, mothers are often unable to provide exclusive MOM to neonates admitted in neonatal intensive care units (NICUs) and depend on pasteurized donor human milk (PDHM). The aim of this quality improvement (QI) initiative was to enable mothers to provide MOM and consequently decrease the "PDHM dependency." Methods: Neonates <32 weeks of gestation (n = 120) were included. A multidisciplinary team was formed, and a detailed root cause analysis was done to understand the cause of PDHM dependency during the observation phase (November 1 to December 15, 2019). Various evidence-based practices were planned, tested, and implemented through Plan-Do-Study-Act cycles during the intervention phase (December 16, 2019 to January 31, 2020). These were further strengthened and adopted as a unit culture during the maintenance phase (February 1 to July 31, 2020). Results from the observation and intervention phases were compared. Results: Within 6 weeks of QI interventions, the average proportion of MOM significantly increased from 74.4% to 93.5% (p = 0.0003), and the proportion of PDHM significantly decreased from 20.5% to 4.6% (p = 0.005). The proportion of MOM remained at 82.5% during the maintenance phase. There was a significant decrease in the number of days to reach full feeds and regain birth weight. Conclusions: Provision of PDHM from our newly functional milk bank led to a reduced drive to express MOM in mothers of NICU babies. Our QI project focused on various strategies to improve MOM feeding and reduce PDHM dependence.

A Quality Initiative to Improve Mother's Own Milk Feeding in Preterm Neonates

Background: The rates of "any" human milk use in neonatal intensive care units have improved during the last decade. However, efforts to help mothers in expressing and maintaining mother's own milk (MOM) through discharge remain a concern. This study aims to improve MOM in preterm neonates. Methods: The study was a quality improvement (QI) initiative conducted from May 2018 to April 2019. All preterm neonates <34 weeks were included. In the "initiation phase" (May 2018 to August 2018), a breastfeeding support group was formed and mothers were given structured antenatal and postnatal counseling regarding MOM using videos and leaflets. This improved MOM rates when compared with retrospective controls. In the continuation phase (August-2018 to April-2019), various plan-do-study-act cycles were conducted to test strategies such as frequent telephonic reminders, standardization of Kangaroo mother care, nonnutritive sucking protocols, and involving family members during daily counseling sessions. The initiation and continuation phases were compared with the retrospective baseline data. Results: Of a total of 125 preterm neonates, 27 were excluded for various reasons. Within 3 months of initiating the study, the proportion of neonates who received MOM within first 24 hours improved from 24% in retrospective controls to 82.9% in the initiation phase (p < 0.0001) and remained stable at 90.3% in the continuation phase. The amount of MOM received on day 1 increased significantly (p < 0.0001) from a median of 0 mL to 1 mL in the initiation phase and was maintained at 3 mL in the continuation phase. Amount of MOM increased significantly on day 3 (p = 0.0003) and day 7 (p = 0.03). Babies discharged on MOM also improved significantly (p = 0.005) from 48.3% in the retrospective cohort to 77.4% in the continuation phase. The number of babies receiving total parenteral nutrition decreased significantly (p = 0.02) from 54.6% to 26.7%. Conclusions: QI has shown promising results in improving MOM in preterm neonates.

A quality initiative to improve exclusive breast milk feeding in preterm neonates

Background and Objective

Preterm babies thrive well on exclusive breastfeeding with fewer complications. In a retrospective analysis, challenges were noticed in the form of delayed first milk expression and frequency of expression, which was limited to 2–3 times a day. A quality improvement initiative was designed to increase the exclusive breast milk feeding rates in admitted preterm babies. The purpose of the present study is to evaluate the proportion of preterm neonates receiving mother's own milk by day 7 of life after such an initiative.

Methods

The quality improvement initiative was conducted at a level 3 neonatal intensive care unit from May 10, 2018, to August 10, 2018. Inborn preterm neonates <34 weeks with a minimum hospital stay of 7 days were included. Neonates of critically sick mothers and neonates having major congenital malformations were excluded. Mothers were given structured antenatal counseling regarding expressing breast milk (EBM). Postnatal visits were conducted to provide information through a video and a leaflet and formation of breastfeeding support group.

Results

A total of 30 babies were recruited during a period of 3 months and compared to historical controls. The median age of the first EBM improved from 2.5 days to 1.16 days, and the amount of EBM on the first day improved from 0.24 ml to 2.6 ml (p = .002). The proportion of babies receiving EBM on the first day improved from 24% to 80% (p = .0001), and at the end of 7 days, it increased to 73% from 46% (p = .02). The factors time to reach full enteral feeds, time to regain birth weight, rate of necrotizing enterocolitis, rate of sepsis, and proportion of babies on exclusive mother's milk during discharge appear comparable in both the groups.

Conclusions

A simple quality improvement approach through the formation of breastfeeding support group, antenatal counseling, and postnatal support for breast milk expression has made a significant improvement in milk expression from mothers delivered prematurely. It reflects on a team approach using the available resources.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

Goals for Human Milk Feeding in Mothers of Very Low Birth Weight Infants: How Do Goals Change and Are They Achieved During the NICU Hospitalization?

BACKGROUND

Little is known about human milk (HM) feeding goals for mothers of very low birth weight (VLBW) (<1,500 g birth weight) infants, especially for black mothers, for whom rates of VLBW birth are higher and lactation rates lower. This study examined the establishment, modification, and achievement of HM feeding goals during neonatal intensive care unit (NICU) hospitalization for mothers of VLBW infants and the influence of maternal race and income.

MATERIALS AND METHODS

A prospective cohort study measured maternal HM feeding goals (exclusive [EHM], partial, none) predelivery and during three time intervals: day of life (DOL) 1-14, 15-28, and 29-72. Goal achievement compared the goal for the time interval with the proportion of HM feedings received by the infant. Goal establishment, modification, and achievement were examined using chi-squared and contingency tables.

RESULTS

Three hundred fifty-two mother-infant dyads (53% black; 70% low-income; mean birth weight, 1,048 g) were studied. Predelivery, 55% of mothers planned to provide EHM; fewer black and low-income mothers chose EHM. During DOL 1-14, 63% of mothers chose EHM, and predelivery racial differences disappeared. Only 10% of mothers chose exclusive at-breast EHM feedings. EHM feeding goals decreased during NICU hospitalization, especially for black mothers. Whereas most mothers met their HM feeding goals initially, achievement rates declined during hospitalization. Mothers' EHM goal achievement was not influenced by race or income.

CONCLUSIONS

Mothers changed their predelivery HM feeding goals after birth of a VLBW infant. Longitudinally, HM feeding goals and achievement reflected less HM use, highlighting the need to target lactation maintenance in this population.

The influence of early postnatal nutrition on retinopathy of prematurity in extremely low birth weight infants

BACKGROUND

Retinopathy of prematurity(ROP) is the most common serious ophthalmic disease in preterm infants. Human milk may provide a protective effect for ROP; however, beneficial effects of human milk preclude randomized trials. Therefore, we conducted a retrospective analysis comparing early postnatal nutrition with ROP development.

OBJECTIVE

Evaluate relationship between early postnatal nutriture and ROP surgery.

DESIGN/METHODS

Nutrition data was collected for inborn AGA infants, BW 700-1000 g. ROP surgery was the primary outcome variable. A single pediatric ophthalmologist supervised examinations. All infants received triweekly IM vitamin A as chronic lung disease prophylaxis (Tyson: NEJM, 1999).

RESULTS

BW and gestational age were 867+/-85 g and 26.3+/-1.2 weeks (n=77, mean+/-1SD). ROP surgery infants(n=11) received more parenteral nutrition, 1648 mL, and less human milk, 13.8 mL/kg-day, and vitamin E, 1.4 mg/kg-day, during the second postnatal week. Human milk was a negative predictor for ROP surgery, odds ratio=0.94. Both groups met vitamin A recommendations; however, 74% was administered via IM injections. Neither group met vitamin E recommendations.

CONCLUSIONS

Human milk feeding, parenteral nutrition volume and vitamin E intake were predictors for ROP surgery. IM vitamin A injections provided the majority of vitamin A; vitamin E administration was insufficient. Improving human milk feeding rates and vitamin dosing options may affect ROP surgery rates.