Infant Safe Sleep

HOSPITAL PRACTICE ROADMAP – SAFETY PIN PROJECT

Infant Safe Sleep Hospital Practice Roadmap – Safety PIN Project Launch January, 2017

To help hospitals effectively promote and model safe infant sleep practices, the Indiana Hospital Association’s (IHA) Patient Safety Center (IPSC), in collaboration with other state health care stakeholders, has created a toolkit to aid with hardwiring best practices to eliminate accidental suffocation deaths of Hoosier babies.

The resources included in this toolkit are intended to be a guide, allowing you to adapt to meet the unique needs of your organization and community while supporting the standardization of messaging and practice.

Within this toolkit, you will find the following tools and resources:

 ISDH announcement of the Safety PIN Grant program and awardees  Hospital infant safe sleep policy template – reflective of the most recent AAP Guidelines and Recommendations  Staff development PowerPoint template  Sample audit tools to assess staff compliance  Safe sleep distribution map from the Indiana State Department of Health  Information regarding the Cribs for Kids® National Safe Sleep Hospital Certification Program  Resources page with multiple links to programs to support internal efforts  Breastfeeding and safe sleep evidence-based practices guidance document  Indiana hospital model breastfeeding policy

IPSC is proud to walk alongside your hospital team to eliminate the 100% preventable deaths of our Hoosier babies due to accidental suffocation.

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

STATE HEALTH DEPARTMENT AWARDS $12.9 MILLION IN GRANTS TO HELP REDUCE INDIANA’S INFANT MORTALITY RATE

INDIANAPOLIS – The Indiana State Department of Health (ISDH) announced today it has awarded $12.9 million in competitive grants to hospitals, healthcare groups and nonprofit organizations for projects designed to help reduce Indiana’s infant mortality rate.

Ten entities will receive funding through the state’s Safety PIN (Protecting Indiana’s Newborns) grant program. Lawmakers appropriated a total of $13.5 million for grants and development of a mobile application designed to help connect pregnant women with resources and reduce Indiana’s infant mortality rate.

A total of 31 entities applied for the Safety PIN grants. Applications were evaluated on a number of criteria, which included innovation, community partnerships and geographical location. Projects chosen to move forward include ones focused on safe sleep practices, prenatal care, smoking cessation, one-on-one home visiting and key demographic groups with higher infant mortality rates, such as teenagers and African-American and Hispanic women.

“Every child in Indiana deserves the change to grow up, and we are heartened by the interest in the Safety PIN grants,” said State Health Commissioner Jerome Adams, M.D., M.P.H. “We are confident that these grants will create new opportunities to help women have healthy pregnancies and give their children the best start in life possible.”

Recipients of the Safety PIN grants are:  Aspire Indiana Health, serving Madison County  Community Hospital Anderson  Community Wellness Partners’ “Speak Life: Here to Stay” initiative, serving St. Joseph County  Goodwill Industries of Central Indiana  Greene County General Hospital  Indiana Hospital Association  IU WeCare Plus, serving central and eastern Indiana  Mental Health America of Lake County  One Community One Family, serving Franklin County  Union Hospital, serving Vigo County

Safety PIN Grantee Award Summaries: http://www.in.gov/isdh/files/safety%20pin.pdf

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Hospital Practice Infant Safe Sleep Policy Template

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

December 15, 2016

To: Indiana Hospitals

RE: Hospital Safe Sleep Policy Template

As infant mortality continues to be a problem in the State of Indiana, it is imperative that the hospitals across our state practice safe sleep for all infants in their care, thus providing a role model for parents, as well as educating family members on the key elements of a safe sleep environment for home.

To assist Indiana hospitals in developing a Hospital Safe Sleep Policy for infants, the Indiana Perinatal Quality Improvement Collaborative (IPQIC) subcommittee for Hospital safe sleep practices developed a detailed safe sleep policy template that is included in this toolkit. The Hospital Safe Sleep Policy template follows the ABC messaging format that has been approved by the IPQIC governing council. ABC refers to “All by myself, on my Back, in my Crib”. The content of the policy follows the American Academy of Pediatrics (AAP) Safe Sleep Guidelines.

The policy reviews the components of “ABC” in detail and how to implement them in the hospital setting. In addition, the policy reviews each patient population, including newborns, NICU babies, and infants admitted to Pediatric floors. Special situations that may arise are also addressed.

This policy may be adopted in its entirety or hospitals may use only the sections that apply to their patient populations. The content should remain the same, in keeping with the AAP guidelines, however, facilities may clarify items as needed for use in their facility.

We hope that this will be a useful tool to initiate safe sleep practices in each Indiana Hospital that cares for infants. Studies have shown that parents are more likely to continue behaviors at home that have been modeled for them in the hospital setting. Therefore, we must lay the framework at each opportunity. Thank you for joining us in this battle against Infant Mortality.

In addition to implementing a safe sleep policy, you will also find in this toolkit a sample method by which to implement safe sleep practices and culture change in your facility. This information is based on a project currently underway in many IU Health facilities, including Riley Hospital for Children. Please see the attached folder for tips to implementation.

Thank you! Please contact us with any questions about the Hospital Policy.

Kimberly S. Schneider, MD Pediatric Hospitalist IPQIC Hospital Subcommittee Physician Advisor

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] In the following six pages, you will find the Safe Sleep policy template elements reflective of current AAP guidelines and those best practices as determined by an IPQIC multidisciplinary hospital-practice work group. Below you will find links to the document for you to utilize within your organization.

Consistent messaging and modeling of safe sleep practices is paramount during the short period of time that hospitals have to positively influence a family’s safe sleep choices once they leave the hospital.

Utilize the elements of the policy template in its entirety or modify as is appropriate for your hospital; e.g. if you do not have a NICU, you may remove these elements.

PDF version: https://ihaconnect.boxcn.net/shared/static/38mobvvaogonz8z2rxoxj4ulaingl8lz.pdf

Word version: https://ihaconnect.boxcn.net/shared/static/5d04ot63yjb4b8n9ol9k42zghays10bi.docx

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Hospital Infant Safe Sleep Policy Template

Indiana Perinatal Quality Improvement Collaborative (IPQIC) Hospital Safe Sleep Policy Recommendation

The IPQIC QI Committee SUID Subcommittee Hospital Practice Task Force has developed the following Hospital Safe Sleep Policy to serve as a template for hospitals across Indiana who care for newborns and infants on their inpatient units. The committee recommends that all such hospitals adopt a policy similar to this to combat Sudden Unexpected Infant Death (SUID) in our state.

Goals 1. To provide a uniform model hospital policy for healthcare providers in the newborn, NICU and pediatric settings. 2. To ensure that all recommendations are modeled and understood by caregivers and parents with consistent instructions given prior to discharge of newborn or infant. 3. To provide a safe sleep environment by reducing the risk of SUIDs and risk of injury due to falling from a parent/caregiver’s grasp.

Rationale The Center for Disease Control listed Indiana as 5th in the nation in unintentional infant deaths in 2015, the majority of which are due to unsafe sleep practices. All hospital employees are responsible to follow the American Academy of Pediatrics Recommendations for Safe Infant Sleeping Environment. This will provide a safe sleeping environment for hospitalized infants as well as model safe e sleep practices for the family in preparation for care of their infant at home and minimize the incidence of SUIDs or Sudden Unexpected Infant Death Syndrome.

Definitions Infant: A child aged 12 months or younger. Alone: Sleeping in a space free of other people or any other items such as loose blankets, stuffed animals, and crib bumpers. Bed sharing or cosleeping: The practice of a parent, sibling or other individual sleeping together with the infant on a shared sleep surface, i.e., a bed, sofa, recliner, etc. (not recommended). Room sharing: Sleeping arrangement in which the infant is in the same room with the mother/caregiver, but not on the same sleep surface (recommended). SUID: (Sudden Unexpected Infant Death) death of an infant less than 1 year of age that occurs suddenly and unexpectedly, and whose cause of death is not immediately obvious before investigation and may be due to SIDS, Accidental Strangulation and Suffocati on in bed (ASSB) or an unknown cause. SIDS: Sudden Infant Death Syndrome- the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and a review of the clinical history. NICU: Neonatal Intensive Care Unit- a level II, III or IV nursery that cares for newborns requiring more than routine newborn care.

Policy Statements Staff will teach and model the supine sleep position and safe sleep recommendations will be followed throughout the hospitalization for all neonates and infants. Practices will be based on the American Academy of Pediatrics recommendations f or a safe infant sleeping environment (2011).1 This policy uses the Alone, Back, Crib (ABC’s of safe sleep) format for safe sleep recommendations, in cooperation with the recommendations from the IPQIC committee for family education.

Supplies/Equipment 1. Open crib or bassinet with firm, well-fitting mattress and fitted sheet 2. Sleep sack or wearable blanket 3. Hat (for newborns)

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Hospital Infant Safe Sleep Policy Template

SUGGESTED POLICY FOR SAFE SLEEP FOR NEWBORNS AND INFANTS HOSPITALIZED IN INDIANA

I. SAFE SLEEP BASIC GUIDELINES

A. ALONE: Newborns and infants should always sleep ALONE, never with a parent or sibling.

Sleeping Environment

1. Room sharing must be done, without bed sharing with anyone (parents, children, siblings, multiples), with infant close to, but not in parent’s bed.

2. Neonates/Infants must always sleep alone in a crib/bassinet. Newborns who are part of multiples, (twins, triplets, etc.) should each sleep alone in their own crib/bassinet.

3. Parents/caregiver will not be allowed to sleep on couch, recliner, chair, bed, etc. with baby.

4. Neonates/Infants may be brought into the bed, chair or couch for nursing or comforting, but must be returned to their own crib/bassinet when:

a. The parent/caregiver is asleep. If the infant is found in bed with parent asleep, infant must be returned to bassinet/crib.

b. The parent/caregiver of the neonate/infant appears sleepy.

c. Pain medication is given to the hospitalized mother

5. The infant can be returned to the newborn nursery/infant holding area at the discretion of the nurse. The parent should be re-educated on safe sleep practices whenever unsafe sleep practices are noted.

a. If parents continue unsafe sleep practices (such as sleeping with the infant), re-educate parents/caregivers regarding safe sleep practices. Include the dangers/consequences of non- compliance with safe sleep practices; the most serious consequence being death. Confirm understanding through teach-back and document in findings and interventions in the medical record.

b. Hospitalized mothers will be encouraged to have another adult present to care for the neonate/infant.

B. BACK: Infants should always sleep on their back, never on their side or stomach.

Sleep Position

1. All infants will be placed on their backs to sleep in a bassinet/crib/incubator/infant warmer during every nap and nighttime for the first year of life unless otherwise ordered by the physician.

2. Staff will provide parents with verbal instructions, written materials, and model safe sleep practices for newborn/infant during their hospitalization, using the Alone, Back, Crib model.

3. Staff will request that parents share safe sleep message (Alone, Back, Crib) with everyone caring for their infant, including family members and sitters, and childcare facilities.

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Hospital Infant Safe Sleep Policy Template

C. CRIB: All infants should be placed to sleep in an EMPTY CRIB or bassinet for every sleep.

1. Sleep Surface

a. Mattresses must be firm and fit snugly in crib; no gaps between the mattress and the side of the crib or bassinet.

b. Sitting devices (car safety seats, “rock and play’s”, strollers, swings, infant carriers, infant slings) are unacceptable for routine sleep. Soft surfaces such as sofas, chairs, and adult beds are dangerous and must be avoided.

2. Bedding

a. Mattress must be covered with a tightly fitted crib sheet.

b. The crib/bassinet must contain “NOTHING BUT BABY”; keep all soft objects (stuffed toys) and loose bedding out of the crib/bassinet.

c. Appropriately sized sleep sacks/blanket sleepers are optimal; however, if sleep sacks/blanket sleepers are not available, infants must be swaddled/bundled no higher than the axillary or shoulder level of the neonate/infant, with legs able to move freely. No additional blankets or other loose bedding are to be used.

d. Swaddling must be discontinued when an infant develops sufficient motor skills that allow him/her to roll over from their back to their stomach (approximately 2 months of life)

3. Screening for safe sleep at home.

a. Hospitals will screen all newborns and infants for safe home sleep environment, including access to a crib or bassinet both at home and in other homes where the infant will be cared for.

b. Parents who do not have a crib or bassinet will be referred to the closest distribution site to obtain a crib.

II. OTHER SAFE SLEEP PARAMETERS:

Protective factors:

A. Pacifier Use

1. Pacifier is recommended throughout the first year of life when placing infant down for sleep unless contraindicated (breastfeeding babies should not use pacifier until breastfeeding is established, approximately 1 month of age).

2. Do not force infant to take a pacifier.

3. Do not reinsert a pacifier once the infant falls asleep.

4. Do not attach pacifier to infant’s clothing or use a cord of any kind on the pacifier.

B. Breastfeeding

1. Educate parents that breastfeeding is recommended to reduce risk of SUID.

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Hospital Infant Safe Sleep Policy Template

2. If possible, provide donated breastmilk if supplementation is necessary

C. Immunizations:

1. Immunizations are found to be protective against SUID.

2. It is recommended that all infants be kept up to date on immunizations using the CDC and AAP immunization schedule.

3. Infants should be screened for any missing immunizations prior to discharge and given missing vaccines whenever possible.

Risk Factors:

A. Overheating/over bundling

1. Avoid overheating or over-bundling infant (dress infant with no more than one additional layer than an adult would be comfortable wearing).

2. Room temperature should be maintained between 68-72° F in the hospital.

3. Do not cover the infant’s face or head.

4. When infant is under radiant warmer, temperature probe must be used.

B. Smoking

1. Educate parents to avoid exposing their infant to smoke or smoking in the infant’s environment.

2. Remind parents/visitors to cover clothing that has been exposed to smoking before holding the baby.

III. Infants admitted to inpatient pediatric wards after discharge from the Newborn Nursery or NICU:

Special situations may arise for older infants who are admitted to hospital inpatient units. The following guidelines should be used for these children.

A. The policy content above is also recommended for all hospitalized infants from age birth to 1 year.

B. Tummy Time:

1. Supervised, awake tummy time is encouraged for all infants as early as possible to promote motor development and upper body conditioning.

2. Infants should be placed on their tummy daily, while awake and alert and always with close supervision by caregiver in order to encourage upper body strength and motor development.

3. If infant becomes irritable or sleepy, they must be returned to a back-lying position.

C. Older infants: Infants who are developmentally able to roll from back to front must still be placed on their back to initiate sleep.

1. These infants must no longer be swaddled in blankets.

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Hospital Infant Safe Sleep Policy Template

2. Infants should be placed in a wearable blanket without a swaddler, with long sleeve sleeper or gown underneath, whenever possible. No loose blankets should be used. If a wearable blanket is not available, only warm sleep clothes should be used.

3. If sleep sacks with a swaddle option are used, the swaddle part should be secured under the armpits of the infant with the arms free.

D. Plagiocephaly:

1. Infants can develop flattening of their head due to back lying position. Methods to recommend to parents include:

a. Limiting time in car seats, infant carriers, bouncers and swings

b. Encouraging parents to hold infants when possible

c. Alternating head tilt when infant is sleeping, by passive movement of head to the opposite side. Positioning devices should not be used, unless otherwise ordered by a physician for a specific medical condition.

E. Positioning devices: NO positioning devices are to be used, including wedges, special mattresses, cosleeping aids, and special sleep surfaces.

F. Monitoring devices: Cardiac Apnea Monitors (CAM) may be required for patients admitted to the hospital during their hospital stay.

1. CAM should only be used in the hospital when medically necessary

2. Safe Sleep practices must continue to be used even when CAM is in use.

3. Parents should be educated that CAM do not prevent death from SUID and are not recommended for home use except in extreme medical situations.

IV. LEVEL II, III and IV NURSERIES or neonatal intensive care unit patients:

Special consideration should be given to infants admitted to the Neonatal Intensive Care Unit, including the following:

A. Infants 34 weeks’ gestation or >1500 gms must be placed on their back for sleep in a recommended sleep environment as noted above, well prior to discharge, and as soon as medically stable to do so.

1. Preterm infants and ill newborns may require prone or side lying positioning due to their medical and developmental condition, while continuously monitored and observed.

a. Infants with upper airway compromise, respiratory distress, or less than 34 weeks’ gestation may be placed prone with approval of physician, until symptoms resolve.

b. Other situations may require prone or side-lying positioning and should be evaluated on a case-by- case basis with the approval of the physician.

B. Infants with Neonatal Abstinence Syndrome (NAS) with difficult to control symptoms, may be placed in prone position for brief periods of time with approval of the physician.

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Hospital Infant Safe Sleep Policy Template

1. If NAS infant has irritability not responsive to usual comfort measures, prone positioning may be attempted with the approval of the physician or nurse practitioner.

2. All infants placed prone for this reason should be continuously monitored and observed, and must remain in this position for brief periods of time only.

3. Infants should be reassessed daily for the ability to console with supine positioning.

4. Infants who are requiring prone positioning should be transitioned to supine positioning no less than 1 week prior to discharge.

5. Parents should be educated on safe sleep recommendations and that prone positioning must never be done after discharge.

C. Transition to supine positioning of all NICU infants should be done no less than 1 week prior to discharge whenever possible to assist in conditioning the infant to this practice and to model safe sleep for parents

1. If there is less than 1 week prior to discharge, the infant must be transitioned as soon as medically stable to supine sleep positioning, unless otherwise ordered by a physician for a specific medical condition, which would be rare.

2. Home sleep environment must be modeled at this time and includes:

a. Head of bed is flat, never raised.

b. All positioning devices and loose bedding are removed.

i. Infants with developmental concerns that may benefit from therapeutic positioning should have an order from the physician for such and should be evaluated with physical or occupational therapy to obtain the safest equipment to achieve the requested positioning.

c. Infant sleep attire should include a long sleeve sleeper or gown, and a wearable blanket or sleep sack whenever possible. If these are not available, infant should be swaddled snugly in a blanket no higher than the axillary or shoulder level of the neonate/infant, with legs able to move freely.

d. This practice may be modified only with a physician order. The physician order should specify the specific safe sleep environment modifications that should be used.

D. Parents and Caregivers should receive safe sleep education with focus on Sudden Unexplained Infant Death risks and the recommended home sleep environment as set forth by the American Academy of Pediatrics.

References: 1. Moon RY; American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. Policy statement: SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011; 128(5):1030– 1039 2. Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med. 1993;329(6):377–382 3. www.napss.org 4. www.firstcandle.org/modelbehavior/docs/WBU_booklet1.pdf 5. www.firstcandle.org/modelbehavior/docs/NICU_booklet1.pdf

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected] Staff Development

Staff Development PowerPoint Template

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Staff Development

Below are links to three staff development presentation examples:

Staff development PowerPoint sample #1 – from Community Hospital, Munster https://ihaconnect.boxcn.net/shared/static/li7gcbrx4h40jhk3l4gp6amfsdropyes.pptx

Staff development PowerPoint sample #2 – from IU Health Riley Hospital https://ihaconnect.boxcn.net/shared/static/zah4bnbly0loqs5bdq7sepzvjmczw5c6.pptx

Pre and Post-test sample – from IU Health Riley Hospital https://ihaconnect.boxcn.net/shared/static/lstbiqupil5jgo0tqdw0b7890hakykpb.docx

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Sample Audit Tools

Sample Audit Tools For Staff Practice Evaluation

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Sample Audit Tools

MB Safe Sleep Audit Tool document link: https://ihaconnect.boxcn.net/shared/static/gu24ylpp51t4l0kod7om7zi2pis8mp66.docx

Courtesy of Mary Puntillo, MSN Community Hospital, Munster Safe Sleep Advisor [email protected]

NICU Safe Sleep Audit Tool document link: https://ihaconnect.boxcn.net/shared/static/mio85axsvlbe1gog1p23yqhzpg62fbi6.docx

Courtesy of Mary Puntillo, MSN Community Hospital, Munster Safe Sleep Advisor [email protected]

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Safe Sleep Distribution Map

Indiana State Department of Health Safe Sleep Distribution Site Map

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Safe Sleep Distribution Map

The Indiana State Department of Health has established partnerships with agencies in the State of Indiana to provide safe sleep education and Infant Survival Kits (one infant portable crib, fitted sheet with safe sleep message imprinted on it, wearable blanket, pacifier and safe sleep recommendations) for families who do not have safe places for their infants to sleep. As part of the program we will provide a number of educational materials that will help caregivers learn more about safe sleep. Our educational messages focus on three key risk reduction recommendations from the American Academy of Pediatrics and National Institutes of Health: that infants sleep safest alone, on their backs and in a separate, safe sleep environment.

Holly Wood Safe Sleep Coordinator Indiana State Department of Health [email protected] [email protected]

Information and referral assistance for mom and baby: MCH MOMs Helpline 1-844-MCH-MOMS

Map revised: 10/26/2017

Contact information for all locations as of 1.23.17 and PDF version of Safe Sleep Distribution Map: https://ihaconnect.app.boxcn.net/s/gl0pjnyhqwhedhqkugnpm590fsfc8ac9

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Cribs for Kids Hospital Safe Sleep Certification

Cribs for Kids® Hospital Safe Sleep Certification

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Cribs for Kids Hospital Safe Sleep Certification

http://www.cribsforkids.org/hospitalinitiative/

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Resources Page

Safe Infant Sleep Resources & References

American Academy of Pediatrics: Positioning and SIDS, AAP Task Force on Infant Positioning and SIDS. Pediatrics 1992; 89:6 1120-1126

Moon RY; American Academy of Pediatrics, Task Force on Sudden Infant Death Syndrome. Policy statement: SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011; 128(5):1030– 1039

Ponsonby AL, Dwyer T, Gibbons LE, Cochrane JA, Wang YG. Factors potentiating the risk of sudden infant death syndrome associated with the prone position. N Engl J Med. 1993;329(6):377–382

PEDIATRICS Vol. 107 No. 3 March 2001, pp. 530-536 Sudden Infant Death Syndrome, Bed sharing, Parental Weight, and Age at Death. Cindie Carroll- Pankhurst* and Edward A. Mortimer Jr.

www.firstcandle.org/modelbehavior/docs/WBU_booklet1.pdf

www.firstcandle.org/modelbehavior/docs/NICU_booklet1.pdf

www.cribsforkids.org/wp-content/uploads/HPT10-Infant-Sleep-Safety-Nursing- Education-Module-V-2-21-15.pdf

Shapiro-Mendoza, C. et al. Trends in Infant Bedding Use: National Infant Sleep Position Study, 1993–2010, Pediatrics 2014 135: e1-7.

Willinger M, Ko CW, Hoffman HJ, Kessler RC, Corwin MJ. Factors associated with caregivers' choice of infant sleep position, 1994–1998: The National Infant Sleep Position Study. JAMA. 2000;283(16):2135–2142

VonKohorn I, Corwin MJ, Rybin DV, Heeren TC, Lister G, Colson ER. Influence of prior advice and beliefs of mothers on infant sleep position. Arch Pediatr Adolesc Med. 2010;164(4):363–369

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Breastfeeding and Safe Sleep Evidence Based Practices Guidance Document

Breastfeeding and Safe Sleep Evidence-Based Practices Guidance Document

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Breastfeeding and Safe Sleep Evidence Based Practices Guidance Document

2017 Breastfeeding and Safe Sleep Evidence-Based Practices Guidance Document

IPQIC Governing Council Approved May 24, 2017

Breastfeeding and Safe Sleep Evidence Based Practices Guidance Document

Table of Contents

Goals ...... 3

Rationale ...... 3

Definitions ...... 4

Breastfeeding and Safe Sleep Promotion in the Prenatal Period ...... 4

Breastfeeding and Safe Sleep Promotion in the Mother-Baby Unit ...... 5

Breastfeeding and Safe Sleep in the NICU ...... 6

Breastfeeding and Safe Sleep in Infants Readmitted to the Hospital ...... 7

Breastfeeding and Safe Sleep Support in the Primary Care Provider’s Office ...... 7

Breastfeeding and Safe Sleep and the Community ...... 8

References ...... 8

Appendix 1 – Sample Hospital Policy Promoting Breastfeeding and Safe Sleep Promotion in the

Mother-Baby Unit ...... 9

Appendix 2 – Breastfeeding and Safe Sleep Promotion Counseling Points for Families ...... 11

Appendix 3 – Community Resources ...... 13

Breastfeeding and Safe Sleep Evidence Based Practices Guidance Document

Breastfeeding and Safe Sleep Evidence-Based Practices Health Care Provider Guidance Document

Increased breastfeeding in combination with safe sleep practices will reduce the infant mortality and morbidity and both should be supported by all health care providers in Indiana. Introductions to these important health behaviors should begin as soon as prenatal care is initiated. Continued education and follow-up throughout pregnancy and the infant’s first twelve months will enhance compliance and outcomes.

Goals: 1. To promote a standard policy for all health care providers in the state of Indiana for the practice of breastfeeding in conjunction with safe sleep to optimize the health and safety of Indiana’s infants. 2. To establish guidelines for providers regarding methods for counseling families on how to breastfeed successfully, while still practicing safe sleep at all times. 3. To ensure families across Indiana have information and necessary resources to achieve success in both breastfeeding and adherence to safe sleep guidelines.

Rationale: The Center for Disease Control listed Indiana as 5th in the nation in unintentional infant deaths in 2015, the majority of which are due to unsafe sleep practices. Breastfeeding has been found to have a protective effect on infant morbidity and mortality by decreasing the risk of hospitalization in the first year of life, the development of chronic health conditions, as well as the occurrence of Sudden Unexpected Infant Death (SUID) by at least 50%. All health care providers are encouraged to follow the American Academy of Pediatrics (AAP) Recommendations for Safe Infant Sleeping Environment. In addition, all health care providers should promote the AAP recommendations for exclusive breastfeeding throughout the first 6 months of life and continued breastfeeding through 12 months of age, or longer if desired by the family. This document provides a template for health care providers to incorporate ongoing support of breastfeeding while following safe sleep guidelines, beginning in the prenatal period through the first 12 months of life.

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Definitions: Infant: A child aged 12 months or younger. The ABC’s of Safe Sleep: The practices recommended by the American Academy of Pediatrics to decrease an infant’s risk of SUID and SIDS may be summarized as below. 1. A= All by myself: The baby may not sleep in the hospital bed with a sleeping parent. 2. B= on my Back: infants should be placed to sleep on their backs, never on their stomachs. 3. C=in my Crib: Parents should be instructed on placing baby to sleep in a bassinet next to mother’s bed for every sleep. The bassinet must be free of any loose objects and contain only the baby, dressed in appropriate sleep attire or a sleep sack. The bassinet should remain flat. Bed sharing or cosleeping: The practice of a parent, sibling or other individual sleeping together with the infant on a shared sleep surface, i.e., a bed, sofa, recliner, etc. (not recommended).

Room sharing: Sleeping arrangement in which the infant is in the same room with the mother/caregiver, but not on the same sleep surface (recommended). SUID: (Sudden Unexpected Infant Death) death of an infant less than 1 year of age that occurs suddenly and unexpectedly, and whose cause of death is not immediately obvious before investigation and may be due to SIDS, Accidental Strangulation and Suffocation in bed (ASSB) or an unknown cause. SIDS: Sudden Infant Death Syndrome- the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and a review of the clinical history.

Mother-Baby Unit: The hospital unit where postpartum mothers and newborns are cared for together, encompassing level I newborn care.

NICU: Neonatal Intensive Care Unit- a level II, III or IV nursery that cares for newborns requiring more than routine newborn care.

Breastfeeding and Safe Sleep Promotion in the Prenatal Period It is recommended that:

1. Obstetric Providers begin anticipatory guidance discussions at the first prenatal visit. This guidance includes information on the benefits of breastfeeding and its protective effect against SUID. In addition, discussion of AAP recommendations for infant safe sleep occurs at this visit, allowing parents time to prepare for their infants’ arrival.

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2. OB providers review this information with the expectant mother at each subsequent prenatal visit. 3. Screening for barriers to both breastfeeding and safe sleep be done no later than 24 weeks EGA, or at first prenatal visit. Mothers in need of assistance are referred at this time to relevant providers or community partners for breastfeeding support or receipt of a portable crib or similar item. (See Appendix 3 for links to Community Resources) 4. Prenatal offices are aware of local community resources available in their community for home visits for new mothers, as well as their deadlines for referrals.

Breastfeeding and Safe Sleep Promotion in the Mother-Baby Unit It is recommended that: 1. All hospitals that care for newborns have a policy on the promotion of breastfeeding. 2. All hospitals that care for newborns have a policy on infant safe sleep practices in the hospital. 3. The breastfeeding policy and safe sleep policies integrate to allow promotion of both practices simultaneously as outlined in this document. 4. All maternity staff receive yearly education on the importance and management of both breastfeeding and safe sleep. All maternity staff are trained in the promotion and teaching of breastfeeding and safe sleep practices to new families. 5. All families receive education in the hospital on the initiation and management of breastfeeding, safe sleep practices in the hospital, and the incorporation of breastfeeding with safe sleep practices in their home. 6. All hospitals promote early skin-to-skin contact in the delivery room if mother is awake and able to respond to the infant and the dyad is medically stable. This skin-to-skin contact should continue for at least one hour after birth. 7. The initial breastfeed ideally occurs within the first hour of life in the well newborn. 8. Well newborns share a room with their mothers in the hospital. This allows mothers to learn and attend to baby’s feeding cues, in addition to allowing the family to be engaged in all aspects of infant care. All families are educated on the ABC’s of Safe Sleep. Families are also educated on recognizing their own tiredness, risks of falling asleep while holding the baby and how to request assistance. 9. Newborns are fed on demand with a goal of 8 – 12 feeds in a 24-hour period. 10. Lactation support is available to all new mothers in the hospital to perform expert care and guidance on the initiation and maintenance of breastfeeding. 11. All hospitals promote exclusive breastfeeding. If mother chooses to breastfeed, babies should receive no formula or other liquid unless medically indicated. 12. Breastfeeding newborns are not routinely given pacifiers during the newborn hospitalization.

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13. Families are screened for a home safe sleep environment prior to hospital discharge. For families who do not have a safe sleep environment at home, a safe sleep infant bed is arranged for the family prior to discharge home. If a hospital is not able to provide a bed, such as a portable crib or playpen, they may utilize local community partners to provide such an item. 14. All newborns have a follow-up visit with their pediatric provider arranged for 24-48 hours following hospital discharge to ensure that breastfeeding is progressing appropriately, assess baby for any previously undiagnosed medical problems and reinforce the importance of safe sleep and breastfeeding practices within the home. 15. Hospitals provide all mothers with information about local community and hospital- based lactation support groups at the time of discharge.

Breastfeeding and Safe Sleep in the NICU: It is recommended that: 1. All Hospital NICUs promote breastfeeding in NICU infants as soon as the infant is medically stable. a. Mothers of NICU patients are encouraged to begin pumping as soon as she is medically able. Lactation consultation is provided to educate mom on the benefits of breastfeeding and breastmilk on premature and critically ill neonates (improved outcomes, decreased risk of necrotizing enterocolitis, improved immunity, etc.) b. Donor milk is offered with mother’s consent whenever possible, but particularly for preterm infants < 32 weeks or < 1500 grams, until maternal milk supply reaches adequate amounts. c. As soon as infant is medically and developmentally able, he is put to the breast to begin feedings. When mother chooses to breastfeed, bottles will not be offered unless medically indicated or mother is unavailable. 2. NICUs begin practicing safe sleep well before discharge per AAP safe sleep guidelines. a. At 32 weeks’ gestation, infants who are medically stable are placed in a safe sleep environment for every sleep, following the ABC’s of Safe Sleep. Medically unstable infants, such as those requiring respiratory support or narcotic weaning, are assessed at least weekly for ability to follow safe sleep recommendations b. Please see separate Hospital Safe Sleep Policy for further details. (Appendix 1) 3. All mothers of NICU infants are counseled on the importance of continued breastfeeding and the protective effects on the health of premature infants. In addition, mothers are counseled about the increased importance of safe sleep in this age group, as premature infants have an increased risk of SUID and sleep related deaths.

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4. Families are screened for a home safe sleep environment prior to hospital discharge. For families who do not have a safe sleep environment at home, a safe infant bed is arranged for the family prior to discharge home. If a hospital is not able to provide a bed, such as a portable crib or playpen, they may utilize local community partners to provide such an item.

Breastfeeding and Safe Sleep in Infants Readmitted to the Hospital It is recommended that:

1. All hospitals that admit infants after discharge from the Mother-Baby Unit or NICU support breastfeeding practices while promoting safe sleep guidelines. 2. The mother-baby dyad is supported in maintaining their breastfeeding relationship. If baby is not able to orally feed due to illness, the mother is provided a breast pump. Breastmilk (either through breastfeeding or via bottle/enteral feeding tube) is provided as the preferred method of nutrition once the infant can resume feeding. 3. The ABC’s of Safe Sleep are followed. a. For more details, please see the separate policy on Hospital Safe Sleep Practices for both newborns and infants. 4. Families are screened for a home safe sleep environment prior to hospital discharge. For families who do not have a safe sleep environment at home, a safe sleep infant bed is arranged for the family prior to discharge home. If a hospital is not able to provide a bed, such as a portable crib or playpen, they may utilize local community partners to provide such an item.

Breastfeeding and Safe Sleep Support in the Primary Care Provider’s Office It is recommended that: 1. Primary care providers (PCP) for newborns and infants are knowledgeable on safe sleep guidelines and breastfeeding management. Both safe sleep and breastfeeding are equally encouraged at each well child visit starting with the first newborn visit. 2. PCP screen all families for safe sleep practices at home. If a family does not have a safe place for the infant to sleep, PCP refers to a local distribution site for a portable crib and safe sleep education. In addition, sleep sacks or sleepers are encouraged to avoid use of loose blankets. a. PCP’s discuss any potential barriers to practicing breastfeeding and safe sleep in the home with the family. If the family expresses conflict to this message or an inability to follow safe sleep recommendations, PCPs will discuss solutions with

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the family to make the infant’s sleeping environment as safe as possible (see appendix 2). PCPs will continue to educate the family on safe sleep recommendations as an important means of preventing SUID and SIDS.

Breastfeeding and Safe Sleep and the Community It is recommended that: 1. Referral to appropriate resources within the medical home or local community partnerships such as home nursing, Healthy Families, or similar, be made when concern regarding achievement of safe sleep with breastfeeding arises. 2. Local community partnerships encourage continued breastfeeding and have skilled knowledge of safe sleep guidelines to facilitate achievement of both practices simultaneously. 3. WIC offices continue to encourage breastfeeding practices in accordance with AAP recommendations while supporting safe sleep practices when counseling mothers on breastfeeding. 4. Delivering hospitals offer ongoing lactation support to breastfeeding families, even after discharge from the Mother-Baby Unit, through breastfeeding support groups, individual follow-up visits, or referral to community partners. 5. Regulated child care providers in Indiana are required to follow the AAP Safe Sleep guidelines. Both regulated and unregulated child care providers educate all staff who care for infants on the AAP Infant Safe Sleep Guidelines, and ensure that they are practicing the AAP Infant Safe Sleep Guidelines while infants are in their care. In addition, staff education on supporting the breastfeeding family will be provided.

References – 1. Centers for Disease Control- Maternal Practices in Infant Care and Nutrition (MPINC) 2016. http://www.cdc.gov/breastfeeding/data/mpinc/maternity-care-practices.htm

2. Feldman-Winter, L. et. al. “Safe Sleep and Skin-to-Skin Care in the Neonatal Period for Healthy Term Newborns.” Pediatrics 2016; 138 (3): e1-e10. 3. Task Force on Sudden Infant Death Syndrome. “SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment.” Pediatrics 2016; 138 (5): 1-12.

4. Section on Breastfeeding. “Breastfeeding and the Use of Human Milk.” Pediatrics 2012; 129 (3): e827 – e841. 5. Younger Meek, J. et al. “The Breastfeeding-Friendly Pediatric Office Practice.” Pediatrics 2017; 139 (5): e1-e9.

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6. Baby Friendly USA – Ten Steps to Successful Breastfeeding. http://www.babyfriendlyusa.org/about-us/baby-friendly-hospital-initiative/the-ten-steps.

Appendix 1 – Sample Hospital Policy Promoting Breastfeeding and Safe Sleep Promotion in the Mother-Baby Unit

It is recommended that: 1. All maternity staff receive yearly education on the importance and management of both breastfeeding and safe sleep. All maternity staff should be trained in the promotion and teaching of breastfeeding and safe sleep practices to new families. 2. All families receive education in the hospital on the initiation and management of breastfeeding, safe sleep practices in the hospital, and the incorporation of breastfeeding with safe sleep practices in their home. 3. Skin-to-skin contact should be initiated in the delivery room if mother is awake and able to respond to the infant and the dyad is medically stable. This skin-to-skin contact should continue for at least 1 hour after birth. a. Safe positioning during skin-to-skin care includes: i. Baby’s face can be seen ii. Baby’s head is in “sniffing” position iii. Baby’s nose and mouth are not covered iv. Baby’s head is turned to one side v. Baby’s neck is straight, not bent vi. Baby’s shoulders and chest face mother vii. Baby’s legs are flexed viii. Baby’s back is covered with blankets ix. Mother-baby dyad is monitored continuously by staff in the delivery room and regularly on the postpartum unit. x. When mother wants to sleep, baby is placed in bassinet or with another support person who is awake and alert. b. Skin-to-skin contact may be done in the operating room following routine deliveries without complications. If not initiated in the OR, skin-to-skin care should be started in the recovery room. c. All medical staff should be trained in close monitoring of newborns during skin- to- skin care. Frequent and repetitive assessments of the newborn’s position, breathing, activity, color and tone should occur by trained staff during skin-to- skin contact. This must be documented in the medical record. d. If baby required aggressive resuscitation (i.e. positive pressure ventilation), skin- to-skin care must be postponed until after the infant has been monitored

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and is deemed stable by medical providers. Newborns with additional risk (i.e. 5 min APGAR < 7 or other medical complications) must also be assessed carefully to ensure stability before initiation of skin-to-skin care. 4. The initial breastfeed should ideally occur within the first hour of life in the well newborn. 5. Well newborns should room-in with their mothers in the hospital. This allows mothers to learn and attend to baby’s feeding cues, in addition to allowing the family to be engaged in all aspects of infant care. a. All families must be educated on the ABC’s of Safe Sleep. b. Mother must be educated about recognizing their own level of tiredness and the risks of falling asleep while holding their baby in the hospital bed, including the risks of the infant falling, and the risk of the infant suffocating. c. Mothers must be encouraged to place the infant’s bassinet right next to her own bed, to allow for ease of transfer to the mother for breastfeeding, as well as the ease of transfer back after the feeding. All mothers must be educated to continue this practice at home as well, to facilitate ease of feedings, and to ensure infant is sleeping safely. Having the infant near helps mothers respond to early feeding cues without having to sleep with the infant in the parent bed. The infant should be placed back in their bassinet at the end of the feeding if mother is returning to sleep. d. Mother must be educated to either ask her support person or utilize her call light to call medical staff for help if she finds herself sleepy while holding her baby. e. Mother’s support person(s) must be educated to be available to take the newborn from mom and place the newborn in the bassinet if mom becomes sleepy. f. During the night and early morning hours, mother-baby dyads should be observed every 30-60 minutes to ensure safe sleep. g. Postpartum units must be staffed no more than 3 dyads to 1 nurse so that nursing staff is always available to respond to a mother’s request for help and continuously monitor dyads for safety. Nursing assistants or patient care assistants may be utilized to augment support for mothers. 6. Newborns should be fed on demand with a goal of 8 – 12 feeds in a 24-hour period. 7. Lactation support must be available to all new mothers in the hospital to perform expert care and guidance on the initiation and maintenance of breastfeeding. 8. Exclusive breastfeeding should be promoted. If mother chooses to breastfeed, babies should receive no formula or other liquid unless medically indicated. 9. Newborns should not be routinely given pacifiers during the newborn hospitalization, instead focusing on the baby being at the breast if rooting or showing feeding cues. Pacifiers may be used for painful procedures (i.e. circumcision or blood draws) or at mother’s request after education is provided about possible interference with

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breastfeeding success in the immediate newborn period. However, families should be instructed to consider introducing a pacifier at home once breastfeeding is well established (typically 2-3 weeks of age) as pacifiers have shown to be protective against SIDS. 10. Families must be screened for a home safe sleep environment prior to hospital discharge. For families who do not have a safe sleep environment at home, a safe infant bed should be arranged for the family prior to discharge home. If a hospital is not able to provide a bed, such as a baby box, portable crib or playpen, they may utilize local community partners to provide such an item. 11. All newborns must have a follow-up visit with their pediatric provider arranged for 24- 48 hours following hospital discharge to ensure that breastfeeding is progressing appropriately, assess baby for any previously undiagnosed medical problems and reinforce the importance of safe sleep and breastfeeding practices within the home. 12. Hospitals should provide all mothers with information about local community and hospital-based lactation support groups at the time of discharge.

Appendix 2 – Breastfeeding and Safe Sleep Promotion Counseling Points for Families

It is recommended that: 1. Mothers should be encouraged to exclusively breastfeed (or offer their baby expressed breast milk) for the first 6 months of life, and then breastfeed with the addition of complementary foods through 1 year of life or longer if desired. Exclusive breastfeeding is most protective against SIDS; however, any breastfeeding is more protective than no breastfeeding. 2. Breastfeeding benefits include but are not limited to: a. Perfect nutrition for the infant b. Improved immunity to common illnesses such as Otitis Media and viral illnesses such as lower respiratory tract infections and diarrhea. c. Decreased risk of chronic conditions such as asthma, allergies, leukemia, etc. d. Protective effect against SUID e. Improved bonding of mother-baby dyad f. Decreased risk of maternal conditions such as postpartum depression, metabolic syndrome, type II diabetes, and breast and ovarian cancer. 3. Babies should share the same room, but not the same bed, as their parents. Ideally, this should occur for the first year of life, but at least for the first 6 months of life. a. AAP infant safe sleep guidelines should be followed and include:

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i. A= All by myself. Infant should sleep in its own sleep space, never in a sleep space with another person. The baby should be in the parents’ room until up to age 1 year, but at least for the first 6 months. However, the baby should NOT sleep in the parent bed. ii. B= on my Back: Infant should always be placed to sleep on her back, never on her stomach. iii. C= in my Crib: Infant should always sleep in a crib or similar sleep item (such as playpen or bassinet). 1. The crib must be empty, and contain NO loose bedding, decorations, diapers, toys, etc. 2. Pacifiers may be used once breastfeeding is well established, and may remain in the crib. Recent evidence shows a protective effect of their use. 3. Swings, rock and plays, bouncy seats, car seats should NOT be used for routine sleep. Infants can become strangled by the straps, or slump, causing their airway to be compromised. 4. The head of the bed must remain flat at all times. b. The newest AAP Guidelines acknowledge that mothers may occasionally fall asleep while breastfeeding their infant, particularly at night. While it is NOT recommended to sleep with your infant at any time, it is safer for the mother to fall asleep with her baby in her own bed rather than in an armchair or on a sofa. If a mother brings her baby into her bed to breastfeed, she should make the bed as safe as possible and remove all blankets, sheets and pillows that could obstruct baby’s breathing or cause overheating. If a mother does fall asleep while breastfeeding her baby in bed, the baby should be returned to his/her own sleeping space (i.e. bassinet/crib) immediately when the mother wakes up. c. The risk of death from bed-sharing is significantly higher than baby sleeping in their own space. The following circumstances increase this risk even further: i. Babies less than 4 months of age ii. Bed-sharer smokes or mother smokes during pregnancy iii. Bed-sharer is on sedating medications or substances (alcohol, illicit drugs) iv. Beds-sharer is not the baby’s parent v. Bed-sharing on a soft surface (waterbed, couch, armchair) vi. Bed-sharing with pillows/blankets vii. Bed-sharing with other children present, such as twins or siblings.

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Appendix 3 – Community Resources For a list of up to date community resources, please refer to the Indiana Labor of Love’s Website: http://www.in.gov/laboroflove/664.htm

For a list of breastfeeding support in Indiana by county, refer to Indiana Perinatal Network’s Website http://www.indianaperinatal.org/?page=MF_Breastfeeding

For a list of licensed child care centers, refer to child care finder: http://www.childcareinder.in.gov

For Industry Best standards for child care, refer to: http://www.cfoc.nrckids.org/

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Indiana Hospital Model Breastfeeding Policy

Courtesy of: Kathy Detweiler, BSN, RN, CLS [email protected]

Back to Home Page | For questions, contact Annette Handy, IPSC Clinical Director, at [email protected]

Indiana Hospital Model Breastfeeding Policy

Indiana Hospital Model Breastfeeding Policy

Introduction and Purpose This comprehensive document outlines recommended policies intended to serve as a long term guide that can be adapted over time to fit your hospital’s needs. These policies should be viewed in the particular context of the facility and will require a strong commitment by facility leadership and management to communicate, follow and implement these important practices.

Methodology The specific policies contained in this document are based on evidence-based practices and are closely aligned with The Baby-Friendly Hospital Initiative, the US Surgeon General’s Call to Action to Support Breastfeeding, the CDC’s Guide to Breastfeeding Interventions and the 2010 White House Taskforce on Childhood Obesity’s Report to the President. The US Breastfeeding Committee disseminated a national request for model policies, and documents from the states of New York, Texas and California were reviewed along with policy documents proposed by the Association of Breastfeeding Medicine and the American Academy of Pediatrics. Input was also received from a number of hospital-based IBCLC’s in the state of Indiana and staff from the Maternal and Child Health Division at the Indiana State Department of Health. The NY Model Policy was used as a starting point for categorizing steps that are recommended by many organizations to include in a hospital policy. We have re-classified these to indicate the progression that a hospital could take in developing a policy that reflects the long-term goals of the institution.

First Steps For hospitals that are beginning to develop their breastfeeding policies and have limited resources, this content will provide a good place to start. These points will work best if initiated together.

Important Next Steps These will replace some of the initial policy content and are more rigorous than the first steps. They will also require more staff education and staffing time, but will improve effectiveness of evidence-based care and patient satisfaction.

Additional Evidence-Based Steps These steps include more of the language that is consistent with the Baby Friendly Hospital Initiative. While not inclusive, these will bring a higher level of Baby Friendly practice to your institution.

There were many sources of model policies and implementation toolkits that were used to design this template that can be utilized by your hospital. They are listed in the references at end of the policy.

Indiana Hospital Model Breastfeeding Policy

Recommended Implementation Strategies 1. Create an interdisciplinary team with a dedicated project leader to review and strengthen breastfeeding policies. This team should include a wide range of stakeholders who:  Support breastfeeding  Understand the breastfeeding process  Represent the culture and ethnic diversity of the communities served by the institution

2. Evaluate hospital data relevant to breastfeeding support services on a regular basis, and, if necessary, revise hospital policies and develop a plan of action to implement needed changes

3. Use current, evidence-based research to examine, review and if necessary update breastfeeding policies

4. Implementing new or revised policies should be accompanied by staff education and training and patient education materials

5. Conduct regular auditing and monitoring to ensure that staff is adhering to the policy and determine whether any adjustments are needed

Sections Page 1 - Training for Staff in Hospitals that Provide Maternity Services ...... 3 2 - Breastfeeding Education in Maternal and Prenatal Settings ...... 4 3 - Breastfeeding Initiation and Skin-to-Skin Contact ...... 5 4 - Breastfeeding Assistance and Assessment ...... 7 5 - Unrestricted Breastfeeding/Feeding on Demand ...... 8 6 - Rooming-In ...... 9 7 - Separation of Mother and Baby ...... 10 8 - Formula Supplementation and Bottle Feeding ...... 11 9 - Artificial Nipples and Pacifier Use ...... 12 10 - Discharge Support ...... 13 11 - Formula Discharge Packs ...... 14 References ...... 15

This model policy template was created in collaboration with the Indiana State Department of Health, Maternal and Child Health Division.

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Indiana Hospital Model Breastfeeding Policy

1 - Training for Staff in Hospitals that Provide Maternity Services

First Step All staff that directly cares for women, infants and/or children will have basic orientation and training in breastfeeding benefits, management and practical details as well as competency-based skills needed to implement the breastfeeding policy.

Important Next Steps a. The hospital will designate at least one person who is thoroughly trained in breastfeeding physiology and management to be responsible for ensuring the implementation of an effective breastfeeding program. (NYCRR) b. At least one hospital maternity staff member will be an International Board Certified Lactation Consultant (IBCLC). (ABM #7) c. Perinatal centers will staff lactation support (number of FTE’s per 1000 deliveries) consistent with AWHONN, ILCA, and Indiana Perinatal Hospital Standards by Obstetric Level of Care. (IN Standards) d. Staff will be trained on the policy within 6 months of hire and will be provided ongoing continuing education on principles of policy.

Additional Evidence-Based Steps a. All staff with primary responsibility for the care of new mothers and their infants will complete 20 hours of comprehensive, competency-based training on breastfeeding physiology and management and 5 hours of supervised clinical experience, with annual updates and competency verification, as well as continuing education in breastfeeding and lactation management. (Baby Friendly USA, Inc.) b. All medical providers who have privileges to provide care to new mothers and/or newborn infants will complete training (minimum of 3 credit hours) with annual updates in breastfeeding promotion and lactation management, as well as continuing education in breastfeeding and lactation management. (Baby Friendly USA, Inc.) c. All hospital staff, including support staff, will provide consistent, positive messages about breastfeeding to all mothers who deliver within the hospital. Staff will be trained to provide safe, effective, evidence-based and patient-centered care to support breastfeeding and informed infant-feeding decisions. (NY Model Policy) d. All hospital staff, including support staff, will not use note pads, post-its, pens, or any other incentives obtained from commercial formula companies or other companies that violate the international code of marketing of breast milk substitutes. (NY Model Policy)

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Indiana Hospital Model Breastfeeding Policy

2 - Breastfeeding Education in Maternal and Prenatal Settings

First Step Pregnant and postpartum women will be provided accurate information on breastfeeding by health care providers in prenatal and postnatal periods.

Important Next Steps a. Pregnant and postpartum women will be provided information prior to birth, following birth, and before discharge regarding the benefits and management of breastfeeding and the risks associated with artificial feeding. (CA#2) b. The hospital will provide accurate information early in the pregnancy, when feeding decisions are made (TX Ten Steps)

Additional Evidence-Based Steps a. The hospital will incorporate structured breastfeeding education, taught by an IBCLC or a certified lactation counselor, in all routine prenatal classes and visits, regardless of mothers’ infant feeding decisions. (USBC) Classes and teaching materials should be selected which consider the woman’s cultural background, education and preferred language. (CA#2) Teaching materials should be tailored to age of client (CA #2) and be free of any information (including industry logos) that promotes the use of infant formula, bottles, feeding devices and other related items. b. Health care providers will provide education around the following topics:  Benefits of breastfeeding  Importance of exclusive breastfeeding for first 6 months  Non-pharmacologic pain relief methods for labor  Early initiation of breastfeeding  Early skin to skin contact  Rooming-in on a 24-hour basis  Baby led feeding  Frequency of feeding in relation to establishing a milk supply  Effective positioning and latch techniques  Manual expression of breast milk  Importance of continuing breastfeeding after the introduction of complementary foods and/or returning to work (Baby Friendly USA, Inc.) c. The hospital will inform all potential income-eligible women of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) which offers additional breastfeeding education during the prenatal and post-partum periods. d. The hospital will explore issues and concerns with women who are unsure how they will feed their babies or who have chosen not to breastfeed. Efforts will be made to address the concerns raised and she will be educated about the risks of not breastfeeding. If the mother chooses to formula feed, she will be taught safe methods of formula preparation and infant feeding. This information will be provided on an individual basis. e. Prenatal education will be documented by Physicians and/or Advanced Practice Nurses in prenatal record.

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Indiana Hospital Model Breastfeeding Policy

3 - Breastfeeding Initiation and Skin-to-Skin Contact

First Step a. Hospital maternity staff will document a woman’s desire to breastfeed in her medical record (and infant’s chart and bassinet). (ABM #7)

Important Next Steps a. Nurses, certified nurse midwives and physicians will encourage new mothers to hold their baby skin-to-skin during the first 2 hours following birth, and as much as possible thereafter, unless contraindicated. This includes the post-cesarean mother and baby, when alert and stable. (CA #5) b. The hospital will allow early breastfeeding to take place in the delivery room and/or recovery areas where possible. (NY Model Policy) c. Hospital maternity staff will transfer mother and baby from delivery to post-partum area while infant is skin-to-skin on mother’s chest. (USBC)

Additional Evidence-Based Steps a. All healthy term newborns with no evidence of respiratory compromise will be placed and remain in direct skin to skin contact with their mothers immediately after delivery until the first feeding is accomplished, unless medically contraindicated. (AAP Sample Policy) b. Mothers will be encouraged to exclusively breastfeed for 6 months unless medically contraindicated. Exclusive breastfeeding is defined as providing breast milk as the sole source of nutrition. Exclusively breastfed babies receive no other liquids or solids with the exception of oral medications prescribed by a medical care provider for the infant. (ABM #7) (Joint Commission Core Measures)

Procedure for skin to skin a. Naked infant will be dried and placed ventral-to-ventral on mother’s naked chest. May place cap on head. Place pre-warmed blankets over mother and baby, may suction if necessary. Assess and assign APGARS. Replace damp blankets as needed. (Baby-Friendly USA, Inc.) b. Skin to skin time will be documented in the medical record. c. Routine newborn procedures (weighing, measuring, and the administration of vitamin K and eye prophylaxis) are postponed until after the first breastfeeding session. d. Hospital maternity staff will inform a mother for whom breastfeeding is medically contraindicated of the specific contraindication, whether she can express breast milk during that time for her infant and what criteria need to be met before she can resume breastfeeding. (NY Model Policy) e. Newborns affected by maternal medication and primiparous mothers may require assistance for effective latch-on and initiation of breastfeeding. (AAP Sample Policy)

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Indiana Hospital Model Breastfeeding Policy

3 - Breastfeeding Initiation and Skin-to-Skin Contact (continued)

Breastfeeding is contraindicated in the following situations a. HIV-positive (If status is unknown, a rapid HIV test will be completed and until the results are available, the dyad can be skin to skin but not breastfeeding) b. Illicit drugs, substance abuse and/or alcohol abuse --unless specifically approved by the infant’s health care provider (ABM #21) c. Taking certain medications (i.e., radioactive isotopes, anti-metabolites, cancer chemotherapy, antiretroviral medications and a small number of other medications where the risk of morbidity outweighs the benefits of breast milk feeding). d. Active, untreated tuberculosis (mother can express her milk until she is no longer contagious) e. Active herpetic lesions on her breast(s) (breastfeeding can proceed on unaffected breast; consult Infectious Disease Dept. for problematic infectious disease issues) f. Active, untreated varicella with onset within 5 days before or up to 48 hours after delivery, until mother is no longer infectious g. HTLV1 (human T-cell leukemia virus type I or II) h. Undergoing radiation therapy i. Infant with galactosemia

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Indiana Hospital Model Breastfeeding Policy

4 - Breastfeeding Assistance and Assessment

First Steps a. Mothers and infants will be assessed for effective breastfeeding. Mothers should be offered instruction in breastfeeding as indicated. (CA #6) b. The hospital will provide mothers with assistance from someone specially trained in breastfeeding support and expressing breast milk if the baby has special needs. (IN Standards)

Important Next Steps a. At all times, there will be available at least one staff member qualified to assist and encourage mothers with breastfeeding. (NYCRR) b. The hospital will provide mothers with full information about their breastfeeding progress and how to obtain help to improve their breastfeeding skills. (BMBR)

Additional Evidence-Based Steps a. Hospital maternity staff will observe mothers several times per day and provide additional support, if needed, to ensure successful breastfeeding. (ABM #7) b. The hospital will not routinely provide nipple creams, ointments, or other topical preparations, unless indicated for a dermatologic problem; or nipple shields or bottle nipples to cover a mother’s nipples, treat latch-on problems, prevent or manage sore or cracked nipples or use when a mother has flat or inverted nipples. Nipple shields will be used only in conjunction with an IBCLC consultation and after other attempts to correct the difficulty have failed. (ABM #7) c. Breastfeeding assessment, teaching, and documentation will be done on each shift and, whenever possible, with each staff contact with the mother. Each feeding will be documented, including latch, position, and any problems encountered in the infant’s medical record. For feedings not directly observed, maternal report may be used. Every shift, a direct observation of the baby’s position and latch-on during a feeding will be performed and documented. (AMB #7)

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Indiana Hospital Model Breastfeeding Policy

5 - Unrestricted Breastfeeding/Feeding on Demand

First Step Hospital maternity staff will teach mothers feeding cues and encourage mothers to feed as soon as their infant(s) display early infant feeding cues. (NY Model Policy)

Important Next Steps a. The frequency and duration of breastfeeding will be baby-led, based on infant’s early feeding cues. (ABM #7) b. If a mother and infant are separated, hospital maternity staff will take the breastfeeding infant to the mother for feeding whenever the infant displays early infant feeding cues, including but not limited to sucking noises, sucking on fist or fingers, fussiness, or moving hands toward mouth. (NY Model Policy) c. Time limits for breastfeeding on each side will be avoided. Infants can be offered both breasts at each feeding but may be interested in feeding only on one side at a feeding during the early days. (ABM #7)

Additional Evidence-Based Steps a. Nursing staff will offer each mother further assistance with breastfeeding within 6 hours of delivery. The mother should be guided to help the newborn latch onto the breast properly. During the course of her hospitalization, she shall receive instruction on and be evaluated for knowledge of:  Her infant’s hunger and satiety cues  Principles of breastfeeding on demand  Goals of positioning and latch - to reduce interference with and increase effectiveness of milk transfer and to minimize fatigue or discomfort for herself and her baby during the feeding  Signs of effective milk transfer (intake) o During a breastfeeding o By observing output, behavior, weight and other indicators of the baby’s general condition  Basics of building and sustaining a milk supply  Indications that help might be needed  How and when to access help if needed  Hand expression (TX Ten Steps)

b. Nutritional guidelines and expectations  Normalcy of weight loss (average of 7 %, not to exceed 10% in term newborns)  Normal timing to regain birth weight (by day ten)  Expected feeding volumes in first 2 days (1-2 tsp or 5-10 ml per 1-2 oz. per day for a term newborn) (AAP sample policy)

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Indiana Hospital Model Breastfeeding Policy

6 - Rooming-In

First Steps a. Mothers and infants will be encouraged to remain together during the hospital stay. b. The hospital will establish and implement the option of rooming-in for each patient unless medically contraindicated or the hospital does not have sufficient facilities to accommodate all such requests. (NYCRR)

Important Next Step Hospital maternity staff will perform routine medical procedures for baby in the mother’s room for medically stable mothers and infants. (NY Model Policy)

Additional Evidence-Based Steps a. Hospital maternity staff will not separate healthy mothers and infants during the entire hospital stay, including during nights and transitions. (NY Model Policy) b. Medically stable mothers and infants will room-in together, minimally 23 hours per day, regardless of feeding method. (Baby-Friendly USA, Inc.) c. When a mother requests that her infant be cared for in the nursery, the staff should explore reasons for the request. Staff should encourage and educate the mother about the advantages of having her infant(s) stay with her in the same room continuously throughout the hospital period. This education will be documented in the medical record. (Baby-Friendly USA, Inc.) d. If after education of the benefits of rooming in, the mother requests that her infant be cared for in the nursery, the infant will be brought to the mother’s room for feedings each time the infant shows feeding cues. Document reason, location and length of interruption of rooming in in medical record (Baby-Friendly USA, Inc.) e. Parents will be encouraged to hold their infant in skin to skin contact. If the infant is placed in a bassinet, the bassinet will be positioned within arm’s reach of the mother so that the mother can easily see, reach and respond to her baby. (TX Ten Steps)

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Indiana Hospital Model Breastfeeding Policy

7 - Separation of Mother and Baby

First Step If direct nursing is not possible, mothers will be encouraged and helped to begin pumping in order to provide their expressed breast milk for their baby.

Important Next Steps a. The hospital will allow mothers to breastfeed their babies in the neonatal intensive care unit unless medically contraindicated. (BMBR) b. If a mother or baby is re-hospitalized in a maternal care facility after the initial delivery stay, the hospital will make every effort to continue to support breastfeeding, to provide hospital grade electric pumps and rooming-in facilities. (BMBR)

Additional Evidence-Based Steps a. Hospital maternity staff will instruct mothers of infants in the NICU on how to hand express their milk and use a hospital-grade breast pump until their infant is ready to nurse. (ABM #7) b. Hospital maternity staff will teach mothers proper handling, storage and labeling of human milk. (ABM #7) c. Infants will be fed mother’s expressed milk, if available, until the medical condition allows the infant to breastfeed. (USBC) d. Every effort will be made to obtain Pasteurized Human Donor Milk (PHDM) if mother and infant are separated and the mother is not able to express a sufficient amount of milk for the infant. (USBC, AAP) e. The hospital will provide medical orders for a hospital grade electric breast pump or referral to insurance provider for rental, purchase, and reimbursement information for mothers who require extended pumping. (NY Model Policy)

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Indiana Hospital Model Breastfeeding Policy

8 - Formula Supplementation and Bottle Feeding

First Step Sterile water, glucose water, and artificial milk (infant formula) will not be given to a breastfeeding infant without the mother’s informed consent and/or physician’s specific order. (CA #8)

Important Next Steps a. The hospital will restrict supplemental feedings to those indicated by the medical condition of the newborn or mother. (NYCRR) b. Hospital maternity staff will not place formula bottles, pacifiers or artificial nipples in a breastfeeding infant’s room or bassinet. (ABM #7) c. Hospital maternity staff will provide a specific medical order when formula is provided to a breastfeeding baby and document the reason(s) for the provision of formula, the route (i.e. spoon, cup, syringe, supplemental nursing system etc.), the form of supplement, and the amount given in the infant’s medical chart. (adapted USBC) d. When supplemental feedings are given, the feeding volume will not exceed the physiologic capacity of the newborn stomach (under 20cc in the first few days of life). (TX Ten Steps)

Additional Evidence-Based Steps a. If possible, breastfed infants who cannot nurse at the breast will be fed in a manner that is consistent with preserving breastfeeding (i.e. by cup, dropper, supplemental nursing system or syringe). (ABM #7) b. If the first choice (direct breastfeeding) is not possible, the order of desirable choices is:  The baby’s own mother’s milk expressed and fed to the baby by other means (cup, tube or bottle)  Pasteurized human donor milk from a milk bank  Infant formula (TX Ten Steps) c. The hospital will eliminate all advertising for formula, bottles and nipples produced by manufacturers/distributors of these products from all patient care areas. Breast milk substitutes, infant feeding bottles and artificial nipples will be purchased through hospital’s purchasing department at fair market value. (Baby-Friendly USA, Inc.) d. Hospital maternity staff will inform mothers of the risks of supplementation to establishing and sustaining breastfeeding prior to non-medically indicated supplementation and document that the mother has received this information. (ABM #7) e. The hospital will not promote or provide group instruction for the use of breast milk substitutes, feeding bottles and nipples. The hospital will provide individual instruction in formula preparation and feeding techniques for mothers who have chosen formula feeding or for whom breastfeeding is medically contraindicated. (Baby-Friendly USA, Inc.)

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Indiana Hospital Model Breastfeeding Policy

9 - Artificial Nipples and Pacifier Use

First Steps a. The hospital will respect a mother’s decision to have her baby not receive any pacifiers during hospital stay. (BMBR) b. Artificial nipples and pacifiers will be discouraged for healthy breastfeeding infants during first few weeks until breastfeeding is well established. Mothers should be encouraged to breastfeed frequently in response to hunger cues. (AAP and CA#7)

Important Next Steps a. Hospital maternity staff will not offer pacifiers or artificial nipples to healthy, full-term breastfeeding infants. (ABM #7) b. The hospital will integrate skin-to-skin contact and breastfeeding into relevant infant care protocols to promote infant soothing and pain relief. (ABM #7) c. If breastfeeding is not possible during a painful procedure, a pacifier may be used and discarded after the procedure. (TX Ten Steps) d. Mothers who are asking for pacifiers to calm a fussy infant will be assessed for effective feedings. (AAP) Parents will be taught about the ways their infant communicates with them, and other ways of comforting a baby. Mothers will be encouraged to breastfeed frequently in response to hunger cues. (TX Ten Steps)

Additional Evidence-Based Steps a. Educate on pacifier use when placing an infant down to sleep, once breastfeeding is well established (after four to six weeks) because of possible risk reduction for sudden infant death syndrome. Use of pacifiers is not indicated with babies who are awake. (AAP) b. The hospital will not accept free or low-cost pacifiers. (Baby-Friendly USA, Inc.) c. Hospital staff will use pacifiers only when clinically indicated and only after informed consent has been obtained from mother. (TX Ten Steps)

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Indiana Hospital Model Breastfeeding Policy

10 - Discharge Support

First Steps a. The hospital will provide mothers with information (names and phone numbers) about breastfeeding resources in their community, including information on availability of WIC, breastfeeding consultants, support groups and breast pumps. (BMBR) b. The hospital will provide mothers with information to help them choose a medical provider for their baby and understand the importance of a follow-up appointment. (BMBR)

Important Next Steps a. The hospital will provide written information to and require that all breastfeeding mothers are able to do the following prior to discharge. An educational checklist is recommended.  Position the baby correctly at the breast with no pain during the feeding  Latch the baby to breast properly  State when the baby is swallowing milk  State that the baby should be nursed a minimum of eight to 12 times a day until satiety, with some infants needing to be fed more frequently  State age-appropriate elimination patterns (at least six urinations per day and three to four stools per day by the fourth day of life)  List indications for calling a healthcare professional  Manually express milk from their breasts (ABM #7) b. The hospital will schedule a follow-up visit for all infants within a timeframe consistent with current AAP recommendations (3-5 days of life, or within 24-72 hours). The newborn should be assessed for jaundice, adequate hydration, and age-appropriate elimination patterns. (AAP)

Additional Evidence-Based Steps a. The hospital will provide home visiting referrals to support continuation of breastfeeding. (NY Model Policy) b. The hospital will facilitate mother-to-mother and/or health care worker-to-mother support groups. (Baby-Friendly USA, Inc.) c. If a newborn is not latching on or feeding well by the time of discharge, the feeding/pumping/supplementation plan will be reviewed and arrangements made for follow-up within 24 to 72 hours of discharge. Prior to discharge, arrangements will be made to secure an appropriate pump for home use, if needed. (AAP)

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Indiana Hospital Model Breastfeeding Policy

11 - Formula Discharge Packs

First Step The hospital will not provide mothers with discharge packs containing infant formula or formula coupons unless these items are available at the hospital and are ordered by their baby’s health care provider or specifically requested by the mother. (BMBR)

Important Next Step The hospital will not [accept or] provide any mother with discharge packs containing infant formula or formula coupons. (NY Model Policy)

Additional Evidence-Based Steps a. If a hospital provides discharge packs, they will design their own commercial free bags and provide materials that are also non-proprietary. (NY Model Policy) b. The hospital will not [accept or] provide discharge packs that contain infant formula, coupons for formula, logos of formula companies, and/or literature supplied or sponsored by formula companies or their affiliates. (ABM #7)

IPN would like to thank Chris Lundberg for her time and effort in creating this document and for her continued efforts on behalf of new mothers, their infants and their families.

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Indiana Hospital Model Breastfeeding Policy

References

American Academy of Pediatrics Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics, Volume 115, Number 2, 2005, pp. 496-506 (doi:10.1542/peds.2004-2491).

Academy of Breastfeeding Medicine Clinical Protocol #2 (ABM #2): (2007 Revision): Guidelines for Hospital Discharge of the Breastfeeding Term Newborn and Mother: “The Going Home Protocol”. Breastfeeding Medicine, Volume 2, Number 3, 2007.

Academy of Breastfeeding Medicine Clinical Protocol #3 (ABM #3): Hospital Guidelines for the Use of supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2009. Breastfeeding Medicine, Volume 4, Number 3, 2009.

Academy of Breastfeeding Medicine Clinical Protocol #5 (ABM #5): Peripartum Breastfeeding Management for Healthy Mother and Infant at Term Revision, June 2008. Breastfeeding Medicine, Volume 3, Number 2, 2008.

Academy of Breastfeeding Medicine Clinical Protocol #7 (ABM #7): Model Breastfeeding Policy (Revision 2010). Breastfeeding Medicine, Volume 5, Number 4, 2010. http://www.bfmed.org/Resources/Protocols.aspx

NY Codes Rules and Regulations, Title 10,405.21 Perinatal Services. (NYCRR) http://www.health.state.ny.us/nysdoh/phforum/nycrr10.htm

NY Public Health Law, Article 25, Title 1, § 2505-a (2009) - Breastfeeding Mothers’ Bill of Rights (BMBR) http://www.health.ny.gov/publications/2028/

New York State Model Hospital Breastfeeding Policy http://www.health.ny.gov/community/pregnancy/breastfeeding/docs/model_hospital_breastfeeding_policy.pdf

Overcoming Barriers to Implementing the Ten Steps to Successful Breastfeeding: Final Report, Baby-Friendly USA, Inc. http://www.babyfriendlyusa.org/eng/docs/BFUSAreport_complete.pdf

United States Breastfeeding Committee (USBC). Implementing The Joint Commission Perinatal Care core measure on exclusive breast milk feeding. Revised. Washington, DC: United States Breastfeeding Committee; 2010. http://www.usbreastfeeding.org/HealthCareSystem/HospitalMaternityCenterPractices/ToolkitImplementingTJCCo reMeasure/tabid/184/Default.aspx

World Health Organization (WHO)/UNICEF. Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. World Health Organization, UNICEF, 2009. http://www.unicef.org/newsline/tenstps.htm

JCAHO Perinatal Core Measure Exclusive Breast Milk Feeding http://manual.jointcommission.org/releases/TJC2013B/MIF0170.html

California Breastfeeding Hospital Policy Recommendations On-Line Toolkit (CA) http://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/MainPageofBreastfeedingToolkit.aspx

Texas Ten Step Star Achiever Training Toolkit (TX Ten Steps) http://texastenstep.org/starachiever-texastenstep/Star_Achiever_Ten_Step_Modules/resources-and- tools/docs/Texas%20Ten%20Step%20Star%20Achiever%20Training%20ToolKit_Entire%20Toolkit.pdf

Indiana Perinatal Hospital Standards (IN Standards) http://www.in.gov/laboroflove/files/Perinatal_Hospital_Standards_2015.pdf

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