The EHM NCCC Odyssey

April 10, 2013

Use of Maternal Milk in the NCCC

Of the various therapies used routinely in the NICU, HM ranks among those with the most empiric support for safety, efficacy, availability and cost-effectiveness. Maternal milk is medicine.

Breastfeeding Updates for the Pediatrician Supporting Breastfeeding in the Neonatal Intensive Care Unit. Paula P. Meier, Aloka L. Patel, Harold R. Bigger, Beverly Rossman, and Janet L. Engstrom. Pediatric Clinics of North America, 2013-02-01, Volume 60, Issue 1, Pages 209-226

The Case for EHM

Higher doses of Maternal Milk reduces:
enteral feeding intolerance late-onset sepsis necrotizing enterocolitis chronic lung disease retinopathy of prematurity neurocognitive delay rehospitalization at 18 and 30 months of age.

EHM NCCC
Action Plan
Early Pumping Skin to Skin Documenting milk production (500 cc/day at 2 weeks) Moms time to obtaining pump Frequency of mothers use of a breast pump

EHM NCCC Data

Admission Discharge Daily DOL 1-14 Day 21 and 28

EHM NCCC Goal: Increase use of exclusive maternal milk by 50% at 28 days

EHM NCCC: Early Pumping Challenges

Benefits potentially of expressing/pumping by 1 hour
Sustain supportive milk production

Coordination with Labor and Delivery

Maternal order sets include pumping

Education of staff and families

Meier, Paula P., PhD, RN, Pediatric Clinics of North America, Volume 60, Issue 1, 209-226 Copyright 2013

( From Rush Mothers' Milk Club, Rush University Medical Center, Chicago, IL; with permission.) Supporting Breastfeeding in the Neonatal Intensive Care Unit Meier, Paula P., PhD, RN, Pediatric Clinics of North America, Volume 60, Issue 1, 209-226 Copyright 2013

EHM NCCC:Skin to Skin Challenges

Definition of stability
Only 40% of NICUs have formal guidelines for defining stability

Technology
Variable with vent, CPAP, central lines

Institutional Factors
Orders required Education

Familial Factors
Education Mothers health
1. Lee HC, Martin-Anderson S, Dudley RA. Breastfeed Med. 2012 Apr;7(2):79-84. 2. Franck LS. Bernal H. Gale G. Neonatal Netw. 2002;18:1320.

EHM NCCC: Skin to Skin

Benefits of Skin-to-Skin Contact or Kangaroo Care
Increases maternal milk supply and guards against insufficient lactation. 1,2 Improves oxygen saturation 3 Improves stress responses 4 Reduces hypothermia, bradycardia, and stabilizes respiratory rates. 5
1. Hurst NM. Valentine CJ. Renfro L, et al. J Perinatol. 1997;17:213217. 2. Rojas MA. Kaplan M. Quevedo M, et al. J Dev Behav Pediatr. 2003;24:163168. 3. Roberts KL. Payntner C. McEwen B. Neonatal Netw. 2000;19:3135. 4. Bier JB. Ferguson AE. Morales Y, et al. Arch Pediatr Adolesc Med. 1996;150:12651269. 5. Neu M. Laudenslager ML. Robinson J. Biol Res Nurs. 2209;10:226240. 7. Bergman NJ. Linley LL. Fawcus SR. Acta Pdiatr. 2007;93:779785.

Close to Me
Partnership with March of Dimes Bilingual education for families & staff Educational materials Equipment
Kangaroo Chairs

Milk Volume Targets

Milk output during the first 2 postnatal weeks predicts the adequacy of milk volume during the late NICU hospitalization.

Milk Volume Targets

Support infant in the NICU at the time,
Small amounts due to prematurity, surgical complications, or fluid restrictions

Protect and support the milk supply by early programming that enables their infants to receive exclusive HM feedings after the NICU hospitalization.
Minimal milk volumes of 350 mL per day Volumes closer to 1000 mL per day ensure enough milk later

EHM NCCC Enrollment

Infants Enrolled in EHM NCCC
80 70 60 50 40 30 20 10 0 Mar '12 LCL CL UCL

Monthly Enrollment

16.485 8.000 0.000 Apr '12 May '12 Jun '12 Jul '12 Aug '12 Sep '12 Oct '12 Nov '12 Dec '12 Jan '13 Feb '13 Mar '13

EHM NCCC Months

SPC Charts
Determining Significance
1 point outside the upper or lower control limits 2 of 3 successive points in the outer third of the control limit 8 successive points above or below the center line 6 consecutive points increasing or decreasing
Benneyan JC, Lloyd RC, Plsek PE Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003;12(6):458464

EHM NCCC: Breastfeeding Support

% Days With Breas:eeding Support
45% 40% % Days With Breas:eeding support Delivered 35% 30% 25% 20% 15% 10% 5% 0% Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Interven?on Month UCL CL LCL

425% Increase in Breas:eeding Support!

0.4074

0.3418

0.2762

EHM NCCC: Skin to Skin

Days in 1st Week of Life With Skin To Skin
0.400 0.350 0.300 % of Days With STS Time 0.250 0.200 0.150 0.100 0.050 0.000 Mar '12 Apr '12 May'12 Jun '12 Jul '12 Aug '12 Sep '12 Oct '12 Nov '12 Dec '12 Jan '13 0.1010 0.085 0.0697 0.2521 0.3806

450% increase in days of STS Time!

0.3163

0.1300 0.108 0.0857

Interven?on Months

EHM NCCC: Pumping Events

EHM NCCC: Average Daily Pumping Episodes Reported
5.000 4.500 4.000 Average Daily Pumping Events 3.500 3.000 2.500 2.000 1.500 1.000 0.500 0.000 12-Mar Apr-12 May-12 Jun-12 Jul-12 Aug-12 Interven?on Months Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 UCL CL LCL 4.6367 4.2348 3.8329

1.6855 1.567 1.4488

EHM NCCC: Daily Pumping Volume

Average Reported Daily Volume of Breast Milk Pumped
300

Average reported daily volume pumped increased by 645%!

250 243.016 200.533 158.050 150 UCL CL 50 LCL

200 Defects

100

0 Mar-12

Apr-12

May-12

Jun-12

Jul-12

Aug-12 Mar-12 - Jan-13

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

EHM NCCC: Pump Types

EHM NCC Pump Delay

EHM NCCC Pump Delay
9 UCL 8 7 6 5 4 3 2 1 0 1 2 3 4 Months 5 6 7 CL 3.000 8.196

Days

EHM NCCC: Exclusive Maternal Milk

EHM NCCC: Infants Fed Exclusive Maternal Milk Thru 28 Days
0.700 0.600 0.500 0.400 0.300 0.200 0.100 0.000 LCL 0.1107 CL

34% Increase in VLBW Infants Fed Exclusive Maternal Milk

0.6313

UCL 0.3710

% Infants With Exclusive Maternal Milk

Interven?on Months

Innovations
Reducing time to first pumping Reducing time to moms getting a pump
Supplying pumps Improving quality of pumps provided

Pumping diaries Kangaroo Days/Kangaroo Marathons Increasing Lactation Support

Metrics for Human Milk

Proportion of infants received HM Average daily dose of HM, days 1 to 14 Average daily dose of HM, days 1 to 28 Average daily dose of HM, NICU hospitalization Proportion of feedings from HM days 1-14 Proportion of feedings from HM, days 1-28

Metrics for Human Milk

Proportion of feedings from HM, NICU hospitalization Total number of NICU days of any HM feedings Total number of NICU days of exclusive HM feedings HM feeding status (partial, exclusive, none) at discharge

Added Data
VON PQCNC Data
Identifier codes for facilities in 2009-2011 reports
NEC Infection CLD Growth Any HM

Have codes for Forsyth, Moore, Womens, CFV, UNC

Going Forward
This work must continue Data system will remain active Reporting will be operational