Compliance with the "Baby-friendly Hospital Initiative for Neonatal Wards" in 36 countries

Journey toward Baby-Friendly Hospital Initiative designation: Healthcare professional's view on successful implementation process and maintenance of accreditation

PROBLEM

The Baby-Friendly Hospital Initiative has yet to achieve widespread global implementation.

BACKGROUND

The implementation of the Baby-Friendly Hospital Initiative has been recognised as complex. The challenge has been to maintain accreditation.

AIM

To explore and gain a deeper understanding of the healthcare professionals' perceptions of the implementation process and the maintenance of the Baby-Friendly Hospital Initiative.

METHODS

A qualitative descriptive study with focus groups (n = 10) of the nurses, midwives and unit leaders (n = 43) perceptions of the implementation process were analysed using inductive thematic analysis.

FINDINGS

Analysis of the data revealed five main themes: groundwork for the baby-focused breastfeeding context, management support throughout the process, promoting baby-friendly practices, effective communication ensuring the right track, and supporting the maintenance of BFHI designation. The main themes describe the implementation as a journey of climbing a hill and after reaching the top trying to maintain their position.

DISCUSSION

The starting point for implementation was an optimal environment supporting baby-friendly breastfeeding practices. The support of the management of the organisation was an important way of moving the implementation forward. Commitment to the common goal strengthened the baby-friendly approach and with concrete and immediate feedback the right pathway on a journey was ensured.

CONCLUSION

Practical ways to support the implementation journey include regular update education on breastfeeding and continuous monitoring, as well as providing statistics to health professionals. Global guidelines on how to sustain change are needed. This will ensure that the work done is not wasted.

Reported Adherence to the 10 Steps to Successful Breastfeeding Is Higher Among Baby-Friendly Hospitals

OBJECTIVE

Quantify and compare reported breastfeeding support practices in the Baby-Friendly Hospital Initiative (BFHI) and non-BFHI facilities.

DESIGN

Cross-sectional survey.

SETTING

Regions across the US.

PARTICIPANTS

Two hundred and eighty-six facilities (110 BFHI and 176 non-BFHI) selected by a stratified (by hospital size) random sample of 50% BFHI and 50% non-BFHI facilities.

INTERVENTION

Emailed survey Fall 2019 through Spring 2020.

MAIN OUTCOME MEASURE

Reported adherence to the 10 Steps to Successful Breastfeeding.

ANALYSIS

Wilcoxon rank sum test with continuity correction, Pearson chi-square test of independence, and Fisher's exact test.

RESULTS

Baby-Friendly Hospital Initiative facilities were more likely to report adherence to the 10 Steps to Successful Breastfeeding. Only 2 of the reported steps were not significantly different: immediate postnatal care and responsive feeding.

CONCLUSIONS AND IMPLICATIONS

This research supports breastfeeding support interventions within hospitals as both BFHI and non-BFHI facilities have room for improvement. Interventions targeting non-BFHI facilities are an opportunity to close the disparity in breastfeeding care.

Mothers' experiences of breast milk expression during separation from their hospitalized infants: a systematic review of qualitative evidence

BACKGROUND

Mother-infant separation, which is occurring with an increasing incidence, is a barrier to direct breastfeeding. Owing to the importance of breast milk to hospitalized infants, mothers are actively encouraged to express milk during their infants' neonatal intensive care unit (NICU) stay. However, mothers are often faced with a number of challenges in this process. There is a need to understand such mothers' real-life experiences of breast milk expression to develop supportive strategies to reduce the burden on mothers and increase breastfeeding rates.

METHODS

A comprehensive search of 12 databases was conducted for relevant studies published from database construction to December 2022. All qualitative and mixed-method studies published in English and Chinese that reported on mothers' experiences of human milk expression during separation from their hospitalized infants were included. Two reviewers independently conducted screening, data extraction, and quality appraisal, with disagreements resolved by a third reviewer. The process of searching followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The JBI Qualitative Assessment and Review Instrument was used to assess study quality and the credibility of study findings. Meta-aggregation was performed to integrate the results.

RESULTS

This systematic review aggregated mothers' experiences of milk expression during separation from their hospitalized infants. Database search yielded 600 records, of which 19 full-text documents were screened. Finally, 13 studies of good quality were included with data from 332 mothers across seven countries. A total of 61 primary findings with illustrations were extracted from the 13 eligible studies, the findings were generalized into 16 categories, and further were concluded as four synthesized findings: purpose and motivation, physical and emotional experiences, barrier factors, and coping styles.

CONCLUSION

Mothers were driven by extrinsic motivation in their decision to express breast milk. They experienced physical exhaustion and many negative emotional feelings while expressing. This process was affected by numerous barriers. Social support was essential to the initiation and maintenance of milk expression. Medical staff and families should pay more attention to the mental health of mothers with infants in the NICU. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing milk expression.

SYSTEMATIC REVIEW REGISTRATION

[ www.crd.york.ac.uk ], identifier [PROSPERO 2022 CRD42022383080].

Breastfeeding and human milk in the NICU: From birth to discharge

It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.

Exclusive breastfeeding: Relation to gestational age, birth weight, and early neonatal ward admission. A nationwide cohort study of children born after 35 weeks of gestation

OBJECTIVES

Prematurity, being small for gestational age and early neonatal ward admission are the major neonatal conditions that may interfere with breastfeeding supportive practices in infants born at gestational age ≥35+0 weeks. We aimed to investigate the associations between gestational age, small for gestational age, early neonatal ward admission and exclusive breastfeeding at one and four months.

METHODS

A register-based cohort-study of all Danish singletons with gestational age ≥35+0 weeks born in 2014-2015. In Denmark, health visitors routinely conduct free home visits throughout infants' first year and thereby report breastfeeding data to The Danish National Child Health Register. These data were linked with data from other national registers. Logistic regression models estimated the odds ratio for exclusive breastfeeding at one and four months, adjusted for confounding variables.

RESULTS

The study population comprised 106,670 infants. Compared to gestational age 40 weeks, the adjusted odds ratio for exclusive breastfeeding at one month showed a decreasing tendency from gestational age ≥42 (n = 2,282) (1.07; 95% confidence interval (CI) 0.97-1.17) to 36 weeks (n = 2,062) (0.80; 95% CI 0.73-0.88). Small for gestational age (n = 2,342) was associated with decreased adjusted odds ratio for exclusive breastfeeding at one month (0.84; 95% CI 0.77-0.92). Neonatal ward admission was associated with increased adjusted odds ratio for exclusive breastfeeding at one month among late preterm infants (gestational age 35-36 weeks; n = 3,139) (1.31; 95% CI 1.12-1.54), as opposed to among early term (gestational age 37-38 weeks; n = 19,171) (0.84; 95% CI 0.77-0.92) and term infants (gestational age >38 weeks; n = 84,360) (0.89; 95% CI 0.83-0.94). The associations seemed to persist at four months.

CONCLUSIONS

Decreasing gestational age and small for gestational age were associated with decreased exclusive breastfeeding rates. Neonatal ward admission was associated with increased exclusive breastfeeding rates among late preterm infants, whereas the opposite was observed among early term and term infants.

Baseline status regarding compliance with neo-BFHI recommendations in South African neonatal wards: a cross-sectional survey

BACKGROUND

In 2009, the World Health Organization and the United Nations Children's Fund issued a revised Baby-friendly Hospital Initiative (BFHI) package to encourage all healthcare facilities to promote the advice of exclusive breastfeeding. The scope of the BFHI was expanded to include neonatal units by the Nordic and Quebec Working Group.

AIM

To determine the level of compliance with the recommendations outlined in the "Baby-friendly Hospital Initiative for neonatal wards" (Neo-BFHI) in the South African neonatal wards.

METHOD

In this cross-sectional survey, the sample included neonatal wards (N = 33) from public and private hospital facilities. Using EasyTrial software, the Neo-BFHI self-assessment questionnaire was utilized to collect the data. The data was transferred to MS Excel (version 15.0.5127.1000) and analysed with the Statistical Package for Social Sciences version 24.

RESULTS

The South African median score for Neo-BFHI compliance was 77. Neonatal wards in public hospitals scored higher (85) than those in private hospitals (73). Neonatal wards in hospitals that were accredited Baby-friendly had higher compliance scores than those without accreditation. The country had the highest compliance scores (100, 90) on Guiding Principle 1 (respect towards mothers) and step 5 (breastfeeding support), respectively. However, it scored low (71, 58) on steps 4 (enhancing kangaroo mother care) and 7 (maternal infant "togetherness"), respectively. Level 1 and 2 care facilities scored significantly higher than level 3.

CONCLUSION

Although South Africa successfully implemented the Neo-BFHI recommendations, private hospitals had a smaller number of BFHI-accredited facilities and lower compliance than public hospitals. Strategies should be developed to strengthen and improve BFHI accreditation and compliance, particularly in private hospitals.

An international study on implementation and facilitators and barriers for parent-infant closeness in neonatal units

Importance

Parent-infant closeness and active parent participation in neonatal care are important for parent and infant health.

Objective

To give an overview of current neonatal settings and gain an in-depth understanding of facilitators and barriers to parent-infant closeness, zero-separation, in 19 countries.

Methods

Neonatal intensive care unit (NICU) professionals, representing 45 NICUs from a range of geographic regions in Europe and Canada, were purposefully selected and interviewed June-December 2018. Thematic analysis was conducted to identify, analyze and report patterns (themes) for parent-infant closeness across the entire series of interviews.

Results

Parent-infant separation during infant and/or maternity care is very common (42/45 units, 93%), despite the implementation of family integrated care (FICare) practices, including parent participation in medical rounds (17/45, 38%), structured education sessions for parents (16/45, 36%) and structured training for healthcare professionals (22/45, 49%). NICU professionals encountered four main themes with facilitators and barriers for parent-infant closeness on and between the hospital, unit, staff, and family level: Culture (jointly held characteristics, values, thinking and behaviors about parental presence and participation in the unit), Collaboration (the act of working together between and within different levels), Capacities (resources and policies), and Coaching (education to acquire and transfer knowledge and skills).

Interpretation

Implementing parent-infant closeness in the NICU is still challenging for healthcare professionals. Further optimization in neonatal care towards zero-separation and parent-infant closeness can be achieved by enforcing the 'four Cs for Closeness': Culture, Collaboration, Capacities, and Coaching.

Saudi Hospitals Compliance With the (Baby-Friendly Hospitals Initiative) Evaluation Study

Introduction

National surveys from Saudi Arabia have shown that the breastfeeding rate in Saudi Arabia is lagging behind the global recommendations. The UNICEF and WHO have launched the 10-step Baby-Friendly Hospital Initiative (BFHI) for encouraging healthcare facilities across the world to support breastfeeding in a better way. In this study, we validated the Arabic version of the self-appraisal and monitoring tool based on the BFHI as well as assessed the determinants of breastfeeding practice in Saudi Arabia.

Methods

This was an analytical cross-sectional study. We used the free validated tool-Questionnaire for Breastfeeding Mother based on the BFHI Session 4.2 Guidelines. The tool was translated and validated in Arabic. A nonprobability sample included mothers of children based on the following inclusion criteria: 1) mothers living in Saudi Arabia; 2) mothers of children aged 0-12 months. The Arabic version was modified into six parts, and the questionnaire was left open for respondents for a period of six months. Descriptive statistics were performed using the Statistical Package for the Social Sciences, version 21 (IBM Corp., Armonk, NY).

Results

The sample size was 584, and during prenatal visits, 23.6% of mothers were provided with information about skin-to-skin contact immediately after childbirth. Of these, 40% started breastfeeding immediately and 43% were encouraged to breastfeed postnatally. On discharge, 34.6% of mothers received help for feeding-related issues.

Conclusion

Our hospitals are well set to adopt the BFHI in terms of policy making and coordinated postnatal care. However, prenatal care should be more focused on promoting breastfeeding. Massive and coordinated quality improvement steps are highly indicated to completely implement the initiative.

Healthcare Professionals' Breastfeeding Attitudes and Hospital Practices During Delivery and in Neonatal Intensive Care Units: Pre and Post Implementing the Baby-Friendly Hospital Initiative

BACKGROUND

The Baby-Friendly Hospital Initiative represents a global effort to support breastfeeding. Commitment to this program has been associated with the longer duration and exclusivity of breastfeeding and improvements in hospital practices. Further, healthcare professionals' breastfeeding attitudes have been associated with the ability to provide professional support for breastfeeding.

RESEARCH AIMS

To determine healthcare professionals' breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative.

METHODS

Using a quasi-experimental pretest-posttest study design, healthcare professionals (N = 131) from the single hospital labor and delivery, maternity care, and neonatal intensive care were recruited before and after the Baby-Friendly Hospital Initiative intervention during 2017 and 2019. Breastfeeding attitudes with the validated Breastfeeding Attitude Questionnaire, breastfeeding-related hospital practices, and background characteristics were collected.

RESULTS

The healthcare professionals' breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased.

CONCLUSIONS

After the Baby-Friendly Hospital Initiative and Baby-Friendly Hospital Initiative for neonatal wards (Neo-BFHI) interventions were concluded, we found significant improvements in the breastfeeding attitudes of healthcare professionals and in breastfeeding-related care practices.This RCT was registered (0307-0041) with ClinicalTrials.gov on 03/03/2017.

Predicting exclusive breastfeeding in maternity wards using machine learning techniques

BACKGROUND AND OBJECTIVE

Adequate support in maternity wards is decisive for breastfeeding outcomes during the first year of life. Quality improvement interventions require the identification of the factors influencing hospital benchmark indicators. Machine Learning (ML) models and post-hoc Explainable Artificial Intelligence (XAI) techniques allow accurate predictions and explaining them. This study aimed to predict exclusive breastfeeding during the in-hospital postpartum stay by ML algorithms and explain the ML model's behaviour to support decision making.

METHODS

The dataset included 2042 mothers giving birth in 18 hospitals in Eastern Spain. We obtained information on demographics, mothers' breastfeeding experiences, clinical variables, and participating hospitals' support conditions. The outcome variable was exclusive breastfeeding during the in-hospital postpartum stay. We tested algorithms from different ML families. To evaluate the ML models, we applied 10-fold stratified cross-validation. We used the following metrics: Area under curve receiver operating characteristic (ROC AUC), area under curve precision-recall (PR AUC), accuracy, and Brier score. After selecting the best fitting model, we calculated Shapley's additive values to assign weights to each predictor depending on its additive contribution to the outcome and to explain the predictions.

RESULTS

The XGBoost algorithms showed the best metrics (ROC AUC = 0.78, PR AUC = 0.86, accuracy = 0.75, Brier = 0.17). The main predictors of the model included, in order of importance, the pacifier use, the degree of breastfeeding self-efficacy, the previous breastfeeding experience, the birth weight, the admission of the baby to a neonatal care unit after birth, the moment of the first skin-to-skin contact between mother and baby, and the Baby-Friendly Hospital Initiative accreditation of the hospital. Specific examples for linear and nonlinear relations between main predictors and the outcome and heterogeneity of effects are presented. Also, we describe diverse individual cases showing the variation of the prediction depending on individual characteristics.

CONCLUSION

The ML model adequately predicted exclusive breastfeeding during the in-hospital stay. Our results pointed to opportunities for improving care related to support for specific mother's groups, defined by current and previous infant feeding experiences and clinical conditions of the newborns, and the participating hospitals' support conditions. Also, XAI techniques allowed identifying non-linearity relations and effect's heterogeneity, explaining specific cases' risk variations.

Breastfeeding practices in neonatal wards in Spain. Neo-BFHI international survey

INTRODUCTION

In 2017, a worldwide survey was conducted on compliance with the practices promoted by Neo-BFHI (Baby-friendly Hospital Initiative expansion to neonatal wards).

OBJECTIVE

To present the results of the Spanish wards that participated in the global survey and compare them with those obtained internationally.

MATERIAL AND METHODS

Cross-sectional study through a survey on compliance with the Neo-BFHI ("Three basic principles", "Ten steps adapted to neonatal wards" and "the compliance with the International Code of Marketing of Breast-milk Substitutes" and subsequent relevant World Health Assembly resolutions). Compliance was calculated as the mean in each indicator and a final mean score for each neonatal unit. For the partial and final scores for each country and at the international level, the median was used. All scores ranged between 0 and 100.

RESULTS

The response rate in Spain was 90%. The range of the national mean for neonatal wards were from 37 to 99, with no differences in the final score according to the level of care. The global score for Spain (72) is below the international median (77) and this also occurs in 8 of 14 items. The neonatal wards from BFHI designated hospitals, obtained a significantly higher mean global score, and in 9 of 14 items than the non-accredited ones.

CONCLUSIONS

Both international and national results indicate an improvement in breast feeding practices in neonatal units. The benefits of the BFHI accreditation of maternity reach neonatal wards. Spain has several key points below the international score.

The Baby-friendly Hospital Initiative for neonatal wards. A mini review

The Baby-friendly Hospital Initiative for Neonatal Wards (Neo-BFHI) is an expansion of the WHO/UNICEF Ten Steps to Successful Breastfeeding to address the needs of infants and families in all levels of neonatal care. The Neo-BFHI includes Three Guiding Principles as basic tenets, Ten Steps to protect, promote and support breastfeeding closely following the original Baby-friendly Hospital Initiative, and adherence to the International Code of Marketing of Breast-milk Substitutes. In 2020, the WHO/UNICEF published recommendations for breastfeeding small, sick and preterm newborns that aligns with the Neo-BFHI. Conclusion: This mini review provides a brief description of the content in the Neo-BFHI.

Breastfeeding Supportive Services in Baby-Friendly Hospitals Positively Influenced Exclusive Breastfeeding Practice at Hospitalization Discharge and Six Months Postpartum

BACKGROUND

Studies have shown that implementing the Ten Steps to Successful Breastfeeding of the Baby-Friendly Hospital Initiative can protect, promote, and support breastfeeding. However, few studies have valuated the quality of breastfeeding supportive services provided by Baby-Friendly Hospitals from the perspective of service users.

METHODS

This was a hospital-based prospective study, conducted at eight Baby-Friendly Hospitals with a total of 707 pregnant women in Shanghai, China between October 2016 and September 2021. Breastfeeding supportive services during hospitalization were assessed at childbirth discharge using a 12-question questionnaire based on the Chinese "Baby-Friendly Hospital Evaluation Standards". Women were followed up on six months postpartum. The impact of breastfeeding supportive services during hospitalization on the exclusive breastfeeding at discharge and six months postpartum were assessed.

RESULTS

Of the 707 mothers who completed the survey at discharge, 526 were followed up on six months after delivery. The overall exclusive breastfeeding rate among participants was 34.4% at discharge and 52.1% at six months postpartum. Mothers who received better breastfeeding supportive services during hospitalization were more likely to practice exclusive breastfeeding at hospitalization discharge compared with mothers who received poorer services (aOR: 3.00; 95% CI: 2.08, 4.35; p < 0.001). Furthermore, they were also more likely to exclusively breastfeed at six months postpartum (aOR: 1.50; 95% CI: 1.03, 2.22; p = 0.033).

CONCLUSION

Better breastfeeding supportive services during hospitalization were significantly associated with higher rate of exclusive breastfeeding at discharge and six months postpartum. More effective measures should be adopted to improve the implementation of the breastfeeding supportive services in Baby-Friendly Hospitals to promote exclusive breastfeeding and better maternal and child health.

Compliance With the "Baby-Friendly Hospital Initiative for Neonatal Wards" in Russian Hospitals

BACKGROUND

The expansion of the Baby-Friendly Hospital Initiative to neonatal wards, known as the Neo-BFHI, provides recommendations to support breastfeeding, as outlined in the Three Guiding Principles, the expanded Ten Steps, and the International Code for Marketing of Breast-Milk Substitutes. In 2017, Russia participated in an international survey about compliance with the Neo-BFHI.

RESEARCH AIM

To assess breastfeeding support policies and practices in Russian neonatal wards at the country and federal district level in accordance with the Neo-BFHI recommendations.

METHODS

This study was a prospective cross-sectional survey. We used the Neo-BFHI Self-Assessment questionnaire to collect data from neonatal wards that had all levels of care. A total of N = 60 Russian neonatal wards in hospitals that have ever been designated Baby-Friendly or planned to do so participated in the survey.

RESULTS

Compliance scores at the federal district and country level ranging from 0-100 were used to summarize results. The median country overall score was 90 (IQR = 83 - 93). Respect for mothers, continuity of care, having a breastfeeding policy, and rooming-in had the highest median scores. Family-centered care, antenatal informing, skin-to-skin contact, and human milk use had the lowest median scores. Neonatal wards in the hospitals that were ever designated as Baby-Friendly had significantly higher scores than those that were never designated. Most respondents (n = 48, 80%) expressed a desire to obtain Neo-BFHI designation in their neonatal wards.

CONCLUSION

Neo-BFHI recommendations can be successfully implemented in Russian neonatal wards at hospitals designated Baby-Friendly or planning to be designated.

Baby-Friendly Hospital Initiative for Neonatal Wards: impact on breastfeeding practices among preterm infants

OBJECTIVE

to assess breastfeeding support practices for preterm infants at two Baby-Friendly hospitals in southeastern Brazil, comparing the effect of implementing the guidelines for Baby-Friendly Hospital Initiative for Neonatal wards.

METHODS

a quasi-experimental study, pre- and post-intervention with control. Implementation of this initiative in the intervention hospital using Knowledge Translation. Data collection on compliance with the adapted Ten Steps, Three Guiding Principles and the Code before and after the intervention was carried out via interviews with mothers of preterm babies and professionals, unit observation and documentary analysis in the intervention and control hospitals. Intra-intergroup comparison was performed.

RESULTS

increases in global compliance with the Three Principles, Ten Steps, the Code, partial compliance with each Principle and in most Steps was greater in the intervention hospital. Conclusion: this initiative improved practices related to breastfeeding in the intervention hospital, demonstrating the potential to improve care and breastfeeding in neonatal wards.

[Breastfeeding practices in neonatal wards in Spain. Neo-BFHI international survey]

INTRODUCTION

In 2017, a worldwide survey was conducted on compliance with the practices promoted by Neo-BFHI (Baby-friendly Hospital Initiative expansion to neonatal wards).

OBJECTIVE

Present the results of the Spanish wards that participated in the global survey and compare them with those obtained internationally.

MATERIAL AND METHODS

Cross-sectional study through a survey on compliance with the Neo-BFHI ("Three basic principles", "Ten steps adapted to neonatal wards" and "the compliance with the International Code of Marketing of Breast-milk Substitutes" and subsequent relevant World Health Assembly resolutions). Compliance was calculated as the mean in each indicator and a final mean score for each neonatal unit. For the partial and final scores for each country and at the international level, the median was used. All score ranged between 0 and 100.

RESULTS

The response rate in Spain was 90%. The range of the national mean for neonatal wards were from 37 to 99, with no differences in the final score according to the level of care. The global score for Spain (72) is below the international median (77) and this also occurs in 8 of 14 items. The neonatal wards from BFHI designated hospitals, obtained a significantly higher mean global score, and in 9 of 14 items than the non-accredited ones.

CONCLUSIONS

Both international and national results indicate an improvement in breastfeeding practices in neonatal units. The benefits of the BFHI accreditation of maternity reach neonatal wards. Spain has several key points below the international score.

Impact of Institutional Breastfeeding Support in Very Low-Birth Weight Infants

Background and Objectives: Feeding of human milk is associated with improved health outcomes in preterm infants. Mothers of preterm infants have difficulty establishing and maintaining an adequate milk supply. Our institution participated in Best Fed Beginnings (BFB), a national breastfeeding quality improvement collaborative, in 2012. Although most practice changes targeted healthy term infants, we hypothesized that mother's milk feeding (MMF) to preterm infants would also improve. Our objective was to compare MMF in very low-birth weight (VLBW) infants at discharge before and after our participation in BFB. Materials and Methods: We completed a retrospective chart review of VLBW infants born between January 2006 and June 2016. The primary outcome measure was the percentage of VLBW infants receiving MMF at hospital discharge. We used Fisher's exact test to determine the difference before and after 2012 and performed the Kruskal-Wallis test to determine changes in median time to pump initiation in mothers of VLBW infants. Multiple logistic regression was used to determine variables associated with the primary outcome. Results: A total of 1,077 VLBW infants were eligible. After launching BFB, MMF at discharge increased in VLBW infants, from 35.2% to 46.0%, p < 0.001. Median time to pump initiation decreased from 11 to 5 hours after 2012, p = 0.0001. Factors significantly associated with receiving MMF at discharge included birth post-BFB; private insurance; non-Black race; shorter length of stay; older maternal age; and mother's milk as first feeding. Conclusions: Hospital culture supportive of breastfeeding impacts not only healthy term infants but also VLBW infants. Earlier initiation of milk expression significantly improves provision of MMF to preterm infants at discharge.

Barriers and facilitators to breastfeeding support practices in a neonatal intensive care unit in Colombia

OBJECTIVES

To assess breastfeeding support practices and related barriers and facilitators in a large Intensive Care Unit, Neonatal (NICU) in Medellín, Colombia, as part of a broader quality improvement initiative to enhance breastfeeding support.

METHODS

A mixed-methods descriptive design was used to collect data on care practices and outcomes related to NICU breastfeeding support. Data sources included the Neo-BFHI's self-assessment questionnaire of breastfeeding policies and practices, clinical observations, and a retrospective review of 51 patient charts.

RESULTS

Of the 51 charts reviewed, 98% of the infants received breastmilk during their hospitalization but the majority (84%) also received formula and only 8% of infants were exclusively breastfed at the time of NICU discharge. All NICU staff received education on mother and baby-friendly care, and the unit complied with the International Code of Marketing of Breast-milk substitutes. However, resources to support lactation (e.g., access to breastfeeding specialists, breast pumps, written teaching materials for parents) were limited, and infants were only allowed to consume milk expressed within the hospital. Mother-infant separation, as well as staff beliefs and care routines, also limited important breastfeeding support practices such as skin-to-skin care and early initiation of direct breastfeeding.

CONCLUSIONS

The self-assessment questionnaire and observations revealed a high value for breastfeeding and a family-centered approach to care in the NICU. Key challenges to sustaining breastfeeding in the NICU included a lack of facilities for supporting parental presence, barriers to expression and provision of mother's milk, and a high rate of bottle-feeding with formula.

Developing the Preterm Breastfeeding Attitudes Instrument: A tool for describing attitudes to breastfeeding among health care professionals in neonatal intensive care

OBJECTIVE

The aim of this study was to develop an instrument that measures health care professionals' (HCPs) attitudes to breastfeeding and skin-to-skin contact in relation to the Baby-Friendly Hospital Initiative for neonatal intensive care.

DESIGN

The study was part of a larger project aiming to revive the Ten Steps to Successful Breastfeeding for both full-term and preterm infants. The study had a pre-test/post-test design using online questionnaires distributed by email before and after a training programme.

SETTING AND PARTICIPANTS

A total of 70 specialist registered nurses, registered nurses, assistant nurses and physicians working at a Swedish neonatal intensive care unit answered 55 breastfeeding attitudes questions online before the training. The Preterm Breastfeeding Attitudes Instrument (PreBAI) consists of twelve of these 55 items/questions, selected using exploratory factor analysis.

MEASUREMENTS AND FINDINGS

Higher scores indicated more positive attitudes and the median total PreBAI score was 42 points (out of 48), on both the pre- and the post-test questionnaires, showing no significant difference. In the pre-test questionnaire, the majority of HCPs (84%) stated that they needed further breastfeeding training. They also stated that they perceived breastfeeding as very important, scoring a median of 10 (range 5-10) points on a 10-point scale. Three separate underlying dimensions were identified in the questionnaire, indicating different attitudes: Facilitating (five items), Regulating (four items), and Breastfeeding- and skin-to-skin contact-friendly (three items). A positive correlation was found between how many years the HCPs had worked in neonatal care, and their PreBAI score (r_s = 0.383, p = 0.001). Those who had previously received extra breastfeeding education scored higher on the instrument.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Neonatal intensive care units need to increase their efforts to support breastfeeding. An important factor for mothers when establishing breastfeeding is support from well-trained professionals with a positive attitude to breastfeeding. The PreBAI could be a useful tool for identifying attitudes among HCPs before and after attending a breastfeeding training programme.

Breastfeeding in hospitalised preterm infants: A survey from 18 tertiary neonatal intensive care units across mainland China

AIM

To understand the use of breast milk and breastfeeding in preterm infants in neonatal intensive care units (NICUs) in mainland China.

METHODS

An online questionnaire survey of reported practices was conducted among 18 tertiary NICUs distributed across all seven districts in mainland China. The items of the questionnaire consisted of the following areas: breastfeeding rate of preterm infants (<37 weeks' gestation) at discharge, the standards used for guiding the clinical practice and the use of breast milk and breastfeeding.

RESULTS

On average, across all hospitals, breastfeeding rate for preterm infants at discharge was 65%, with 41% preterm infants being exclusively breastfed during the hospitalisation prior to discharge. Sixteen (89%) NICUs had policies designating breast milk as the preferred first feed for preterm infants. Donor milk was available in 3 of 18 (17%) NICUs. Kangaroo care was provided in 11 of 18 (61%) NICUs, and 14 of 18 (78%) allowed parental access to the hospitalised preterm infants. A large variation was found in clinical practices around the breast milk testing, breast milk storage and transportation and breast milk fortification methods among different NICUs.

CONCLUSIONS

The use of breast milk in hospitalised preterm infants has increased greatly but still needs to be further improved. A recommendation is made to conduct high-quality original trials to find evidence of the controversial problems, develop evidence-based guidelines, promote the best implementation of the guidelines and provide updated breastfeeding education to health-care providers in order to standardise the use of breast milk and breastfeeding in hospitalised preterm infants.

Eight principles for newborn care in neonatal units: Findings from a national survey

AIM

To assess, at national level, the implementation of eight principles for infant- and family-centred developmental care (IFCDC) in neonatal units. A European expert group established eight 'Principles of care' in 2018 that define neurodevelopmental and family-centred care.

METHODS

The implementation of each principle was assessed by a survey sent to level-III Spanish units. A principle was considered to be implemented if all answers to the principle-associated questions were positive.

RESULTS

The response rate was 84.5% (65/77). No unit had implemented eight principles. Principle 1 (free parental access) was implemented in 21.5% of the centres; Principle 2 (psychological support) 40%; Principle 3 (pain management) 7.7%; Principle 4 (environmental influences) 29%; Principle 5 (postural support) 84.6%; Principle 6 (kangaroo-care) 67.7%; Principle 7 (breastfeeding) 23% and Principle 8 (sleep protection) in 46%. In units attending ≥50 very low birth weight (VLBW) infants, four or more principles had been implemented in 31% vs 13% <50 VLBW neonates (odds ratio 3.0 CI 95% 0.9-10.1, P .07).

CONCLUSION

The principle with the highest implementation was related to newborn body positioning. Pain management was the principle with lowest implementation. More principles for IFCDC tend to be implemented in units providing care for a higher number of VLBW infants.

Incidence and risk of necrotizing enterocolitis in Denmark from 1994-2014

Introduction. We suspected that the incidence of NEC in Denmark had increased during the last 20 years but hypothesized that this could be explained by the increased neonatal survival. Methods. We conducted a retrospective, observational cohort study of all registered liveborn infants in Denmark in the period from January 1, 1994 to December 31, 2014. Data were obtained from the Medical Birth Registry, National Patient Register, and Cause of Death register in Denmark. The primary outcome was the registration of NEC (ICD-10: DP77.9) during a hospital admission within 6 months after birth. The statistical analysis used ‘death before NEC’ as a competing risk. Results. The cohort consisted of 1,351,675 infants, of which 8,059 died. There was a strongly significant decreasing risk of death over the period for the all infants (p<0.0001 in all gestational age groups). In total, 994 infants were diagnosed with NEC which lead to an incidence of 7.4 per 10,000 live-born infants. During the observation period, the incidence increased from 6.3 to 7.9 per 10,000 births (p = 0.006). When accounting for ‘death before NEC’ as a competing risk, the increase could be explained by the increased neonatal survival. There was, however, a GA-group/epoch interaction (p = 0.008) in the cause-specific hazard ratios with a trend towards an increasing risk of NEC in the most preterm infants and a decreasing risk of NEC in the term infants. Conclusion. While the overall incidence of NEC increased over the study period, the overall risk of NEC did not increase when considering the increased survival. Nevertheless, there seemed to be an increased risk of NEC in the most premature infants which was masked by a decreased risk in the term infants. This study suggests that research to prevent NEC in the most preterm infants is more important now than ever.

Exploring the Gap Between Needs and Practice in Facilitating Breastfeeding Within the Neonatal Intensive Care Setting: An Italian Survey on Organizational Factors

Introduction: The system-level factors of the neonatal intensive care unit work environment contribute to breastfeeding promotion in the preterm population. The aim of this study was to investigate the operative policies related to breastfeeding support in a sample of Italian Neonatal Intensive Care Units. Materials and Methods: A multicenter cross-sectional survey was conducted, including a sample of 17 head nurses. The items of the questionnaire investigated the following areas: breastfeeding policies, staff education, family centered care, and breastfeeding promotion and support both in the neonatal intensive care units and after discharge. Results: Written breastfeeding policies were available for staff in all the neonatal intensive care units, most commonly addressing procedures related to skin-to-skin contact, human milk expression, and preterm infant breastfeeding. Most of the neonatal intensive care units correctly advised the mothers to initiate milk expression within 6 h from delivery and to pump milk at least 6 times/days. Breastfeeding training for the nursing staff was planned in the majority of the neonatal intensive care units although according to different schedules. With regard to the family centered care implementation, time restrictions were present in seven neonatal intensive care units, mostly occurring during the night shift, and the morning hours concomitantly with medical rounds. Moreover, in the majority of the investigated neonatal intensive care units, the parents were asked to leave the ward when their infant underwent a major invasive procedure or during the nurse/physician shift change report. With regard to breastfeeding promotion and support, eight neonatal care units had a multidisciplinary team with several health care professionals and 10 provided information about community-based support services. Most of the units assessed breastfeeding after discharge. Conclusion: Based on the present findings, enrolled Neonatal Intensive Care Units appear to provide breastfeeding-supportive environments with special regard to breastfeeding policies, milk expression practices, interprofessional collaboration, and continuity of care. Health care professionals should exert efforts to ensure continuous and updated breastfeeding staff education and promote parent-infant closeness and family centered care.

Compliance with the "Baby-friendly Hospital Initiative for Neonatal Wards" in 36 countries

In 2012, the Baby‐friendly Hospital Initiative for Neonatal Wards (Neo‐BFHI) began providing recommendations to improve breastfeeding support for preterm and ill infants. This cross‐sectional survey aimed to measure compliance on a global level with the Neo‐BFHI's expanded Ten Steps to successful breastfeeding and three Guiding Principles in neonatal wards. In 2017, the Neo‐BFHI Self‐Assessment questionnaire was used in 15 languages to collect data from neonatal wards of all levels of care. Answers were summarized into compliance scores ranging from 0 to 100 at the ward, country, and international levels. A total of 917 neonatal wards from 36 low‐, middle‐, and high‐income countries from all continents participated. The median international overall score was 77, and median country overall scores ranged from 52 to 91. Guiding Principle 1 (respect for mothers), Step 5 (breastfeeding initiation and support), and Step 6 (human milk use) had the highest scores, 100, 88, and 88, respectively. Step 3 (antenatal information) and Step 7 (rooming‐in) had the lowest scores, 63 and 67, respectively. High‐income countries had significantly higher scores for Guiding Principles 2 (family‐centered care), Step 4 (skin‐to‐skin contact), and Step 5. Neonatal wards in hospitals ever‐designated Baby‐friendly had significantly higher scores than those never designated. Sixty percent of managers stated they would like to obtain Neo‐BFHI designation. Currently, Neo‐BFHI recommendations are partly implemented in many countries. The high number of participating wards indicates international readiness to expand Baby‐friendly standards to neonatal settings. Hospitals and governments should increase their efforts to better support breastfeeding in neonatal wards.