The human milk project: a quality improvement initiative to increase human milk consumption in very low birth weight infants

Sequential interventions to maintain the safety and service provisions of human milk banking in India: keeping up with the call to action in response to the COVID-19 pandemic

BACKGROUND

WHO recommends donor milk as the next best choice if Mothers' own milk (MOM) is unavailable. At our milk bank, during the COVID 19 pandemic, we observed a steep decline in the collection of donor milk, while Pasteurised Donor human milk (PDHM) demand increased. This called for active intervention.

METHODS

We employed the quasi-experimental quality improvement initiative. During September 2020 (baseline period) the team members identified modifiable bottlenecks and suggested interventions (using WhatsApp to increase follow up, telehealth and digital tools) which were implemented in October 2020 and the impact was evaluated till March 2021. The SMART aim was "to meet the demand (estimated as 15,000 ml/month) of donor milk for adjoining 80-bedded NICU". Process measures were; daily amount of donor milk collected, pasteurized donor milk disbursed to NICU, number of donors and frequency of donations. The balancing measure was that the collection of donor milk should not undermine the provision of freshly expressed MOM for babies.

RESULTS

Collection of donor milk increased by 180% from baseline during the Intervention phase. This was sustained throughout the sustenance phase (November 2020 and March 2021) with an average monthly collection of 16,500 ml. Strikingly, the increased follow-up of mothers with emphasis on MOM decreased the NICU's donor milk requirement from 13,300 ml (baseline) to 12,500 ml (intervention) to 8,300 ml (sustenance). Monitoring of daily MOM used in the NICU revealed a 32% surge from 20,000 ml (baseline) to 27,000 ml (intervention) sustained at 25,000 ml per month.

CONCLUSION

By improving the provisions of human milk banks, near-exclusive human milk feeding can be ensured even during the pandemic time.

Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths

OBJECTIVE

The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants.

STUDY DESIGN

A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality.

RESULTS

Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change.

CONCLUSION

A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC.

KEY POINTS

· QI reduces surgical necrotizing enterocolitis.. · Reduction in NEC rate improves mortality.. · Human milk does not change SIP incidence..

Improving donor human milk collection in a hospital without a human milk bank: a quality improvement initiative at an urban tertiary-care teaching hospital

Feed intolerance and necrotising enterocolitis (NEC) are challenges while treating sick neonates. These can be reduced by giving human milk, but adequate availability of mother’s own milk or pasteurised donor human milk (PDHM) is a challenge in neonatal setups, like ours, without an attached human milk bank. Hence, this quality improvement initiative was taken to improve donor human milk collection in our urban tertiary-care teaching hospital, to at least 500 mL per week in 4 weeks. After analysing the problem, our quality improvement team identified a shortage of human milk donation that was due to low awareness among the stakeholders and lack of a system to collect and store human milk and transport it to a milk bank. The team first established a system of supplies needed for milk collection, storage and transportation. It then tested change idea of information, education and counselling to increase milk donation. The team carried out a few plan-do-study-act cycles (individual and group counsellings, and usage of videos and information leaflets) to test the change ideas and adapted a few and abandoned some. During this journey, the milk collection increased to above the target amount. Various challenges were addressed, and there was a need for constant motivation of the stakeholders, especially the mothers, and now there is sustained milk donation in the setup. This is incorporated in the standard operating procedure and as a quality indicator of the unit for sustaining the changes in the unit. Our initiative can be replicated in other setups for increasing collection of donor human milk. Greater PDHM availability for sick neonates will, in effect, reduce NEC and feeding intolerance rates, leading to reduced hospital stay, morbidity, mortality and economic burden.

The Interaction of Donor Human Milk Availability and Race/Ethnicity on Provision of Mother's Own Milk for Very Low Birth Weight Infants

Objective: To compare (1) differences in mother's own milk (MOM) provision and enteral feeding outcomes, (2) differences in preterm formula and donor human milk (DHM) uses as bridges to exclusive MOM feedings at discharge, and (3) MOM and enteral feeding outcomes for racial/ethnic subgroups before and after the implementation of a hospital DHM feeding program. Methods: Retrospective data from 313 very low birth weight (VLBW; birth weight <1,500 g) infants born between January 2011 to December 2012 (pre-DHM, n = 157) and April 2013 to March 2015 (DHM, n = 156) were analyzed. Results: For this predominantly low-income and minority VLBW infant cohort, the percent of enteral fed hospitalization days was higher in the DHM group (pre-DHM 94% [88, 97] versus DHM 98% [95, 99], p < 0.001). Although MOM remained the predominant first enteral feeding type, significantly fewer DHM infants received MOM (pre-DHM 89% versus DHM 75%, p = 0.001). During days of life 1-14, a lower percentage of DHM infants received 100% MOM (pre-DHM 68% versus DHM 55%, p = 0.02). For the entire cohort, the risk for MOM discontinuation was significantly associated with maternal young age, multiparity, non-Hispanic Black race/ethnicity, and low income. Implementation of a DHM program did not predict duration of MOM feedings. However, non-Hispanic White infants had a longer duration of MOM feedings with DHM availability. Conclusions: Our findings highlight the importance of using precise dose and exposure period methodology to determine the impact of DHM on MOM provision. In addition, DHM availability may be associated with varying effects on MOM provision among racial/ethnic groups.

Quality Improvement to Increase Breastfeeding in Preterm Infants: Systematic Review and Meta-Analysis

Background and Objective: Due to its numerous health benefits, breast milk (BM) is recommended for preterm infants. Despite such recommendations, the rates of breastfeeding in preterm infants are lower than that in term infants. Quality improvement (QI) bundles increase breastfeeding in preterm infants, but their replication in neonatal intensive care units has had inconsistent outcomes. Methods: We used the Population or Problem, Intervention, Comparison, and Outcomes (PICO) framework to develop our search strategy, and searched MEDLINE, Embase, and the Cochrane Library from inception through January 15, 2021. Studies describing any active QI intervention to increase BM use in preterm infants were included. The primary outcome measure was the rate of any breastfeeding or exclusive mother's own milk (MOM) at discharge or during hospitalization. Results: Sixteen studies were eligible for inclusion and showed an acceptable risk of bias, and included 1 interrupted time series, study 3 controlled before-and-after studies, and 12 uncontrolled before-and-after studies; of these, 3 studies were excluded due to insufficient dichotomous data, 13 were included in the meta-analysis. In the meta-analysis, the rate of any breastfeeding was significantly improved at discharge and during hospitalization after QI [risk ratio (RR) = 1.23, 95% confidence interval (CI): 1.14-1.32, P < 0.00001 and RR = 1.89, 95% CI: 1.09-3.29, P = 0.02, respectively]. The rate of exclusive MOM after QI was also significantly increased at discharge (RR = 1.51, 95% CI: 1.04-2.18, P = 0.03), but not during hospitalization (RR = 1.53, 95% CI: 0.78-2.98, P = 0.22). However, after sensitivity analysis, the comprehensive results still suggested that QI could significantly improve the rate of exclusive MOM during hospitalization (RR = 1.21, 95% CI: 1.08-1.35, P = 0.001). Funnel plots and Egger's test indicated publication bias in the rate of any BF at discharge. We corrected publication bias by trim and fill analysis, and corrected RR to 1.272, 95% CI: (1.175, 1.369), which was consistent with the results of the initial model. Conclusions: A QI bundle appears to be effective for promoting BM use in preterm infants at discharge or during hospitalization.

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.

Quality improvement initiative to improve mother's own milk usage till hospital discharge in very low birth weight infants from a tertiary care NICU

IMPORTANCE

Mother's own milk (MOM) for premature infants is a complete nutrition. It is an ideal issue for a quality improvement (QI) initiative.

OBJECTIVE

To increase the proportionate usage of MOM as enteral feeds.

METHODS

A QI study conducted in Tertiary care NICU involving all eligible very low birth weight (VLBW) infants and mother dyads. The proportionate usages of MOM as enteral feeds were the main outcomes.

EXPOSURE

Education, milk expression, and mother-infant interaction formed the key drivers.

RESULTS

We studied 282 mother infant dyads during the QI period. The proportionate usage of MOM as the enteral feed increased from 55% (±34) at baseline to 80% (±27) during the intervention and to 88% (±16) in sustenance phase.

CONCLUSIONS

A QI initiative resulted in 60% relative improvement in proportionate usage of MOM as enteral feeds in VLBW infants during hospital stay.

A Quality Improvement Initiative to Increase Mother's Own Milk Use in a Chinese Neonatal Intensive Care Unit

Background: To evaluate the efficacy of a multidisciplinary quality improvement intervention to promote mother's own milk feeding and reduce necrotizing enterocolitis (NEC) in very low-birth-weight infants. Materials and Methods: We conducted a pre (January 2014 to March 2015)-post (April 2015 to June 2016), nonrandomized, interventional cohort study of infants born at <1,500 g birth weight and admitted to the Fudan University Children's Hospital level III neonatal intensive care unit in Shanghai. The intervention included establishing a breast milk promotion team and breast milk pumping room, educating staff and parents, and distributing teaching materials. The primary outcome was breast milk feeding rate. Secondary outcomes included incidences of NEC, NEC needing surgery, mortality, and time to full enteral feeds. Results: A total of 488 infants (210 baseline, 278 intervention) <1,500 g were enrolled. The intervention group had significantly increased feeding rates for any mother's milk (34.76% vs. 80.58%; p < 0.01) and high-volume mother's milk (≥50% of feeds; 22.86% vs. 61.15%; p < 0.01), and decreased incidence of NEC needing surgery (7.62% vs. 3.24%; adjusted odds ratio [OR] 0.32, 95% confidence interval [CI] 0.14-0.76). There were no significant differences in rates of mortality (0.5% vs. 1.49%; adjusted OR 2.10, 95% CI 0.22-19.6), NEC (10.00% vs. 7.55%; adjusted OR 0.59, 95% CI 0.31-1.14), and time to full enteral feeds (20.18 ± 1.67 days vs. 24.15 ± 1.65 days; adjusted OR = 1.09, 95% CI 0.99-1.21). Conclusions: Our quality improvement initiative increased the consumption of mother's own milk and reduced the severity of NEC in very low-birth-weight infants.

Current Trends in Research on Human Milk Exchange for Infant Feeding

Breastfeeding is critical for the healthy growth and development of infants. A diverse range of infant-feeding methods are used around the world today. Many methods involve feeding infants with expressed human milk obtained through human milk exchange. Human milk exchange includes human milk banking, human milk sharing, and markets in which human milk may be purchased or sold by individuals or commercial entities. In this review, we examine peer-reviewed scholarly literature pertaining to human milk exchange in the social sciences and basic human milk sciences. We also examine current position and policy statements for human milk sharing. Our review highlights areas in need of future research. This review is a valuable resource for healthcare professionals and others who provide evidence-based care to families about infant feeding.

A Quality Improvement Initiative: Improving Exclusive Breastfeeding Rates of Preterm Neonates

This study is a single center quality improvement (QI) initiative in a tertiary care neonatal intensive care unit which was done with an objective to increase the proportion of neonates receiving mother's own milk (at postnatal age of 7 d) from the current rate of 12.5% to 30% over a period of six weeks. Additional objectives were to evaluate the proportion of mothers' expressing breast milk within 3 h of birth, on day one and three and the amount of expressed breast milk (EBM) on day one and day seven. A team was formulated to evaluate the reasons for inadequate breast milk expression and to plan the steps for promoting the same. Comprehensive postnatal breast feeding counseling (CPNC) to promote early breast milk expression was initiated soon after the birth of a preterm neonate. CPNC was done for next fifteen mothers and their breast feeding support was streamlined. The effect of CPNC and teamwork was discussed amongst the team members every day and adjustments incorporated (Plan-Do-Study-Act cycle). The proportion of neonates receiving mother's only milk (MOM) on day 7 increased to 80% (12/15) after 4 wk of QI. Thus, a simple and feasible CPNC package lead to improved breast milk output in mothers.

[Effect of breastfeeding quality improvement on breastfeeding rate in very low birth weight and extremely low birth weight infants]

OBJECTIVE

To study the effect of breastfeeding quality improvement on the breastfeeding rate in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in the neonatal intensive care unit (NICU).

METHODS

A retrospective analysis was performed for the clinical data of VLBW and ELBW infants who were admitted from July 2014 to July 2015 (pre-improvement group) and those who were admitted from August 2015 to June 2016 after the implementation of breastfeeding quality improvement measures (post-improvement group). The parameters including condition of breastfeeding (breastfeeding rate, breastfeeding amount, and breastfeeding time), duration of parenteral nutrition, time to enteral feeding, and incidence of feeding intolerance were compared between the two groups.

RESULTS

The implementation of breastfeeding quality improvement measures significantly increased breastfeeding rate and amount, significantly shortened time to addition of human milk fortifier, duration of parenteral nutrition, and time to enteral feeding, and significantly decreased the incidence of feeding intolerance.

CONCLUSIONS

Breastfeeding quality improvement measures can increase breastfeeding rate in the NICU and decrease gastrointestinal complications in preterm infants.

Use of Donor Human Milk and Maternal Breastfeeding Rates: A Systematic Review

The number of human milk banks is growing worldwide. The introduction of donor human milk (DHM) to neonatal units has been advocated as a strategy to promote maternal breastfeeding. However, concern has been raised that the introduction of DHM may actually lead to a decrease in maternal breastfeeding. To address this question, we conducted a systematic literature review of studies that assessed maternal breastfeeding rates before and after the introduction of DHM. We searched 7 electronic databases, carried out citation tracking, and contacted experts in the field. Where data for breastfeeding rates before and after the introduction of DHM were directly comparable, a relative risk was calculated. Our search identified 286 studies, of which 10 met the inclusion criteria. Definitions of patient populations and study outcomes varied, limiting meaningful comparison. Where possible, relative risks (RR) were calculated on aggregated data. The introduction of DHM had a significant positive impact on any breastfeeding on discharge (RR, 1.19; 95% confidence interval [CI], 1.06-1.35;P= .005) but none on exclusive maternal breastfeeding on discharge (RR, 1.12; 95% CI, 0.91-1.40;P= .27) or on exclusive administration of own mother's milk (OMM) days 1 to 28 of life (RR, 1.08; 95% CI, 0.78-1.49; P= .65). A single-center study demonstrated a significant decrease in the percentage of feeds that were OMM after the introduction of DHM. In conclusion, the available data demonstrate some evidence of positive and negative effects on measures of maternal breastfeeding when DHM is introduced to a neonatal unit.

The Association of Low Social Support with Breast Milk Expression in Low-Income Mother-Preterm Infant Dyads

BACKGROUND

Premature infants benefit from receiving expressed breast milk (BM), but expressing breast milk is difficult for new mothers. Little is known about mothers' social support and BM expression during the premature infant's hospital stay.

OBJECTIVE

We examined whether low maternal social support was associated with breast milk expression initiation and low breast milk expression among low-income mothers of premature infants.

METHODS

Maternal intake interview data and daily infant data on proportion of nutrition from BM during hospitalization were analyzed from a larger randomized trial testing a developmental intervention on 181 mother-premature infant dyads with at least 2 of 10 social-environmental risks. Multivariable modified Poisson regression was used to examine the relationship between social support (Personal Resources Questionnaire 2000; dichotomized as low for lowest quartile), initiation (any breast milk expressed vs none), and low breast milk expression (if BM was < 30% of infant total milk/formula intake during hospitalization).

RESULTS

Breast milk expression was initiated by 70.2% of mothers, and 32.3% of those mothers had low breast milk expression. In adjusted multivariable analyses, social support did not relate to the initiation of breast milk expression but was significantly associated with low breast milk expression among mothers who initiated (adjusted relative risk = 1.57; 95% confidence interval, 1.00-2.47).

CONCLUSION

Low social support was not associated with initiation but was associated with low breast milk expression during hospitalization. Interventions to enhance social support for mothers of premature infants, especially those reporting low social support from family and friends, may increase in-hospital expression and long-term breastfeeding.

Continuous Quality Improvement in a Level IIIB NICU to Increase Human Milk Use at Day of Life 14, Day of Life 28, and Discharge

Despite the known benefits of human milk (HM) feedings for high-risk infants, many barriers still remain to providing HM. We implemented a quality improvement (QI) project to increase HM use at 3 time points. All first admissions to the neonatal intensive care unit (NICU) from 2008 to 2012 were included in the dataset. We documented any HM use for infants in our NICU at day of life 14 (DOL14), day of life 28 (DOL28), and discharge. We used run charts to track our progress through the project period and used logistic regression to test for trend, using STATA for data analysis. HM use was explored for all infants and separated out by gestational age (<32 weeks and ≥32 weeks) and by birth weight (very low-birth-weight [VLBW] infants). For all admitted infants, HM use increased from 64.95% to 73.66% at DOL14, from 55.03% to 70.06% at DOL28, and from 31.15% to 36.28% at discharge. For infants who were less than 32 weeks gestation, HM use increased from 67.63% to 82.44% at DOL14, from 57.14% to 80.00% at DOL28, and from 37.93% to 38.58% at discharge. For VLBW infants, HM use increased from 70.73% to 82.08% at DOL14 and from 58.12% to 80.00% at DOL28. After implementation of the QI project, overall HM use has increased. It was noted that documentation of HM use at discharge needed improvement.

Intervention for promoting breast milk use in neonatal intensive care unit: a pilot study

OBJECTIVE

The health benefits provided by breast milk are significant in preterm infants. Despite recommendations, rates of breastfeeding in preterm infants are lower than in term infants. The aim of this study was to evaluate the efficacy of a multidisciplinary intervention in promoting any breastfeeding in preterm infants at discharge.

METHODS

A prospective non-randomized interventional cohort study was conducted. One hundred and twenty-two preterm infants constituted the historical group. A multidisciplinary intervention was performed including staff training and setting up and implementation of a written breastfeeding procedure.

RESULTS

One hundred and ten preterm infants were enrolled in the intervention group. The percentage of infants fed human milk at discharge was 69 and 62 in the intervention group and in the historical group, respectively. The percentage change from any breastfeeding at full enteral feeding attainment to formula feeding at discharge was lower in the intervention group than in the historical group (-9 versus -23). Belonging to the intervention group and having at least one stress factor during pregnancy were independently associated with any breast milk feeding at discharge.

CONCLUSIONS

The multidisciplinary intervention performed appears to be effective in promoting any breastfeeding in preterm infants at discharge.

Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals

OBJECTIVE

To determine acceptance of donor human milk (DM) for feeding preterm infants and whether offering DM, alters mothers' milk (MM) feeding.

STUDY DESIGN

Infant feeding data were collected from medical records of 650 very preterm infants enrolled between 2006-2011 in two hospital level III neonatal intensive care units (NICUs) in Cincinnati, Ohio. The study was conducted during the implementation of a program offering 14 days of DM.

RESULT

From 2006-2011, any DM use increased from 8 to 77% of infants, largely replacing formula for the first 2 weeks of life; provision of MM did not change. DM was more likely to be given in the first 2 weeks of life, if infants never received MM or were >1000 g birth weight, but DM use did not differ by sociodemographic factors.

CONCLUSION

Offering DM dramatically increased human milk feeding and decreased formula use, but did not alter MM feeding in hospital.