A Quality Improvement Project to Increase Mother's Milk Use in an Inner-City NICU.

Mother's milk is recommended for preterm infants due to numerous health benefits. At our inner-city hospital, >80% of mothers of infants younger than 34 weeks' gestation initiated milk production, but fewer continued until discharge. Among infants younger than 34 weeks' gestation, we aimed to (1) increase any mother's milk use in the 24 hours before discharge/transfer to >75%; (2) increase exclusive mother's milk use in the 24 hours before discharge/transfer to >50%; and (3) reduce racial/ethnic disparities in mother's milk use. METHODS: We conducted a quality improvement project from January 2015 to December 2017 focused on prenatal education, first milk expression ≤6 hours after birth, and skin-to-skin care in the first month. We tracked process measures and main outcomes with run and control charts among 202 infants younger than 34 weeks' gestation eligible to receive mother's milk born at our hospital; We tracked results according to maternal race/ethnicity subgroups. RESULTS: Forty-seven percent of mothers were non-Hispanic black, 28% were Hispanic, and 13% were non-Hispanic white. We improved the rate of first milk expression ≤6 hours after birth and skin-to-skin care in the first month but did not improve rates of any/exclusive mother's milk use at discharge/transfer. Eight-five percent of infants had mothers that initiated milk production, but only 55% received any mother's milk at discharge/transfer. CONCLUSIONS: Our single-center quality improvement effort focused on infants younger than 34 weeks' gestation whose mothers were predominately Hispanic and non-Hispanic blacks. We successfully increased first milk expression ≤6 hours after birth and skin-to-skin care but did not increase mother's milk use at discharge/transfer.

Addressing Disparities in Mother's Milk for VLBW Infants Through Statewide Quality Improvement.

OBJECTIVES: Among very low birth weight infants born from January 2015 to December 2017, the Massachusetts statewide quality improvement collaborative aimed to increase provision of (1) any mother's milk at discharge or transfer from a baseline of 63% to ≥75%, (2) exclusive mother's milk at discharge or transfer from a baseline of 45% to ≥55%, and (3) to reduce racial and ethnic disparities in provision of mother's milk. METHODS: We used the Institute for Healthcare Improvement Breakthrough Series framework in which our main process measures were receipt of prenatal education regarding human milk education, first milk expression within 6 hours after birth, and any skin-to-skin care on 4 weekly audit days in the first month. We examined changes over time among all very low birth weight infants and for 3 racial and ethnic subgroups (non-Hispanic white, non-Hispanic black, and Hispanic) using control and run charts, respectively. RESULTS: Of 1670 infants eligible to receive mother's milk at 9 hospitals, 43% of their mothers were non-Hispanic white, 19% were non-Hispanic black, 19% were Hispanic, 11% were of other races or ethnicities, and 7% were unknown. Hospital teams conducted 69 interventions. We found improvement in all 3 process measures but not for our main outcomes. Improvements in process measures were similar among racial and ethnic subgroups. Hospitals varied substantially in the rate of any mother's milk at discharge or transfer according to race and ethnicity. CONCLUSIONS: Our collaborative achieved similar improvements in process measures focused within the first month of hospitalization among all racial and ethnic subgroups. Reduction in racial and ethnic disparities in mother's milk at discharge was not reached. Future efforts will focus on factors that occur later in the hospitalization.

Timing of First Milk Expression to Maximize Breastfeeding Continuation Among Mothers of Very Low-Birth-Weight Infants.

OBJECTIVE: To estimate the time of first milk expression among mothers of very low-birth-weight (VLBW, 1,500 g or less) infants that predicts the maximal duration of mother's milk provision during hospitalization in the neonatal intensive care unit (NICU). METHODS: We performed a secondary analysis and studied 1,157 mother-VLBW infant pairs in nine Massachusetts hospitals born from January 2015 until December 2017. We determined the cut-point for timing of first milk expression after delivery that was associated with the highest probability of any and exclusive provision of mother's milk for the infant at NICU discharge or transfer using recursive partitioning. We estimated hazard ratios (HRs) comparing the probability of continued provision of mother's milk during the hospitalization between mothers who initiated milk expression before compared with after the cut-point (within 8 hours after delivery [referent] vs 9-24 hours), adjusting for gestational age, birth weight, maternal race and ethnicity, and clustering by hospital and plurality in Cox proportional hazards models. RESULTS: Sixty-eight percent of mothers first expressed milk within 8 hours after delivery. First milk expression at 9-24 hours was associated with lower odds of any mother's milk provided to the infant on day 7 (adjusted odds ratio [aOR] 0.39 [0.24-0.60]) and discharge or transfer (aOR 0.45 [0.33-0.62]), compared with expression within 8 hours. Findings were similar for exclusive mother's milk. Mothers who first expressed 9-24 hours stopped providing milk earlier in the neonatal hospitalization (adjusted HR 1.64 [1.33-2.01]) compared with mothers who first expressed within 8 hours. CONCLUSION: Using a data-driven approach, we identified that first milk expression within 8 hours was superior to 9-24 hours with respect to maximal duration of provision of mother's milk for hospitalized VLBW infants. Randomized control trials are needed to further establish the causal relationship between timing of first milk expression and long-term lactation success among mothers of VLBW infants.

Racial and Ethnic Disparities in the Use of Mother's Milk Feeding for Very Low Birth Weight Infants in Massachusetts.

OBJECTIVE: To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month). STUDY DESIGN: We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects. RESULTS: Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites. CONCLUSIONS: Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.

"I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants.

Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.

Outcomes of Implementation of a NICU-Based Late Preterm Infant Feeding Guideline.

BACKGROUND AND OBJECTIVES: Late preterm (LPT) infants are at risk for feeding difficulties. Our objectives were to reduce the use of intravenous (IV) fluids and increase breastfeeding at discharge among LPT infants admitted to our NICU. METHODS: We implemented a feeding guideline and evaluated its effect using a pre-post design. We examined rates of our main outcomes, IV fluid use, and any or exclusive breastfeeding at discharge, as well as several secondary outcomes, including hypoglycemia (glucose <50 mg/dL) at >8 hours of life, by using χ2 and t tests. We excluded infants that were <2000 g, admitted to the NICU at >8 hours of life, or needed IV fluids at ≤8 hours of life for a medical reason. We used multivariable logistic regression to examine odds ratios and 95% confidence intervals of our main outcomes. RESULTS: Fifty percent of infants were eligible. Of those eligible, 18 of 52 (35%) vs 14 of 65 (22%) received IV fluids at >8 hours of life (P = .06). In the 24 hours before discharge, 35 of 52 (75%) vs 46 of 65 (78%) received any breast milk (P = .67), and 10 of 52 (30%) vs 10 of 65 (21%) received exclusive breast milk (P = .43). More infants had hypoglycemia in the posttime period (16 of 65 [25%]) compared with the pretime period (3 of 52 [6%]; P = .01). CONCLUSIONS: After implementation of a LPT feeding guideline in our NICU that defined specific expected feeding volumes, we did not find changes in IV fluid use or breastfeeding.