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A Quality Improvement Project to Increase Breast Milk Expression

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A Quality Improvement Project to Increase Breast Milk Expression 2.5 A QualityContact Hours Improvement Project to Increase Breast Milk Expression Mary Ellen Connolly, DNP, CRNP and Kathleen M. Buckley, PhD, RN, IBCLC Abstract: Breast milk is recognized as the ideal nutrition for all infections, diarrheal illnesses, asthma, childhood obesity, infants especially for infants in the neonatal intensive care unit and several other disorders of childhood. The surgical (NICU). Breast milk diet for critically ill infants is associated with neonate hospitalized in the neonatal intensive care unit decreased septic events and length of stay and reduced risk (NICU) especially benefits from breast milk’sprotective of surgical necrotizing enterocolitis. Purpose: This quality improvement project focused on the devel- properties. Infants fed a breast milk diet in the postop- opment of a breast pumping program for mothers with infants in erative period show less septic events (Manzoni et al., the NICU. 2011), a decreased length of stay (Kohler, Perkins, & Methods: NICU nurse breast milk champions received education Bass, 2013), and a reduced risk of developing necrotiz- on benefits of breast milk and key factors in maintaining adequate ing enterocolitis (Gephart, McGrath, Effken, & Halpern, milk supply. Champions engaged mothers in conversations to pro- vide support and used a “Coming to Volume Assessment” tool as a 2012). Surgical teams are increasingly reliant on breast guide to assess pumping effectiveness. Champions were inter- milk for the prevention of postoperative complications viewed about the benefits, ease of use of assessment tool, and as well as the nutritional management of the surgical future directions for the pumping program. neonate. Unfortunately, infants with a history of sur- Results: Daily contact with the bedside nurse had a positive gery are more likely to be discharged on formula than effect on breast milk expression rates. Six of 14 mothers, who met with a champion greater than three times in a 2-week period, breast milk (Purdy et al., 2012). This finding may be reached goal volumes. Average maximum milk produced was related to the surgical infant’s inability to feed at the 836.6 ml (SD = 228.5 ml, 95% confidence interval [596, 1076]) breast because of concerns for airway management on infants’ eighth day of life. Champions described the program and/or feeding intolerance (Edwards & Spatz, 2010). as a positive experience for the mothers and themselves and the Nurses and providers may not view breastfeeding as a tool as easy to use. They also endorsed continued implementation of the pumping program. priority when caring for such critically ill infants. It is Conclusions: A pumping program in the NICU that incorporates estimated that only one third of NICUs in the United staff education and use of the “Coming to Volume Assessment” Stated routinely use breast milk for most infant feedings tool with frequent dialogue with mothers to evaluate effectiveness (Perrine & Scanlon, 2013). of breast milk expression can aide in the promotion of breast milk The critically ill infant hospitalized in the NICU may expression. be unable to feed at the breast for weeks to months KEY WORDS: breast milk, breast pumps, neonatal intensive care unit after birth because of a variety of reasons such as pre- maturity and respiratory or cardiovascular instability. INTRODUCTION During the interim, mothers of ill infants are encour- Breast milk is recognized as the ideal nutrition for in- aged to pump milk to ensure an adequate milk supply fants from birth to 1 year old (Section on Breastfeeding, (Philipp & Academy of Breastfeeding Medicine Protocol 2012). The Section on Breastfeeding (2012) has made Committee, 2010). Stimulation to express breast milk this recommendation based on findings of numerous shortly after birth is associated with an increased likeli- studies showing breast milk’s protective properties against hood of reaching goal milk volumes (Hill, Aldag, & Chatterton, 2001). A breast pumping program described Mary Ellen Connolly, DNP, CRNP by Spatz (2005) at the Children’s Hospital of Philadelphia Division of Pediatric Surgery, University of Maryland Medical incorporates staff and parent education and an emphasis Center. Kathleen M. Buckley, PhD, RN, IBCLC on early and frequent milk expression. Mothers were Associate Professor, University of Maryland School of Nursing, instructed to begin milk expression within 2–4hours Baltimore. after delivery with a hospital-grade simultaneous pump. The authors have declared no conflict of interest. Correspondence: Mary Ellen Connolly, DNP, CRNP. The NICU nursing staff received training in lactation E-mail: [email protected] support and educated mothers on proper handling, DOI: 10.1097/JPS.0000000000000081 storage, and labeling of breast milk. The NICU nurse Journal of Pediatric Surgical Nursing Volume 4 • Issue 4 128 Copyright © 2015 American Pediatric Surgical Nursing Association. Unauthorized reproduction of this article is prohibited. was responsible for reviewing the pumping record (Spatz, 2005). In both programs, there is a daily review with the mother to evaluate milk supply and difficulties of a pumping diary with the mothers. The interventions with pumping. The program was associated with a total described by Spatz (2005) and Meier, Patel, et al. (2013) breast milk feeding or expression rate of approximately rely heavily on the nurse for education, assessment, and 75% in the NICU. Spatz (2005, 2012) emphasized the documentation of the pumping program. key role the bedside staff nurse plays in education and The purpose of this quality improvement project support of the breastfeeding mother in the NICU. was to implement and evaluate the utilization of a breast Pumping milk may be difficult for mothers experi- pumping program for mothers of infants hospitalized in encing anxiety related to their child’s health compounded a NICU. It was anticipated that a pumping program and with the stress associated with the NICU environment daily contact with the mothers to review the pumping (Gonzalez et al., 2003). Mothers of critically ill infants log would result in increased breast milk available for may feel unwell themselves and have difficulty initiat- infants in the NICU. ing lactation (Callen & Pinelli, 2005). Meier, Engstrom, Patel, Jegier, and Bruns (2010) found that often mothers METHODS do not receive adequate information on the benefits of Design, Setting, and Sample human milk and how to maintain milk supply. Several The setting for the project was a Level 4 NICU in a experts call for clear and direct communication with large mid-Atlantic medical center. The average census mothers about the benefits of breast milk through the in this medical center NICU was approximately 40 in- use of consistent educational “talking points” (Meier fants per day. Infants usually ranged in age from 1 day et al., 2010; Rodriguez, Miracle, & Meier, 2005). The of life through 10 months old. Most patients tended to “talking points” should focus on the need for early be African American and from lower income families and frequent milk expression with the use of an appro- relying on medical assistance for payment. priate pump, even with mothers who do not wish to later breastfeed their infants. Mothers usually do not Procedures feel coerced when information regarding the benefits The proposal was submitted to the institutional re- of human milk and expression is explained (Rodriguez view board and deemed nonhuman subjects research. et al., 2005). After nursing administration approval, an informal sur- An example of a lactation support program in the vey was conducted by the project leader, a pediatric NICU setting that incorporates staff and parent educa- surgery advanced practice nurse (APN), of the NICU tion is the “Rush Mothers’ Milk Club” at Rush University nurses during the daily pediatric surgery rounds. The in Chicago. Meier, Patel, Bigger, Rossman, and Engstrom purpose of the survey was to obtain baseline informa- (2013) reported that 98% of infants in the Rush NICU re- tion before implementation of the project on nurses’ ceived some human milk with an average of 60 ml/kg/day awareness of the mothers’ breast pumping practices of breast milk during the NICU hospitalization. The Rush and milk available for infants in their care. No identify- model relies heavily on NICU and maternity nurses and ing information was collected. The nurses were asked breastfeeding peer counselors (BPCs). The program sup- (a) if the infant assigned to their care had breast milk ports mothers in the early initiation of milk expres- available, (b) if the mother was pumping, (c) how often sion and frequent pumping with documentation in a the mother was pumping, and (d) how much milk was breastfeeding milk diary. In this program, the diary is re- expressed daily. Nursing staff were also asked to iden- viewed daily with the mother by the registered nurse or tify any tools used to document volumes of milk mothers the BPC, which serves as an opportunity for emotional being expressed and the frequency of pumping. An in- and informational support. The daily contact may occur formal assessment was also conducted to gather prelim- face-to-face or via telephone. In addition, the staff nurse inary data on the number of infants in the NICU who or BPC completes the “Coming to Volume Assessment” were being fed breast milk. tool, which helps evaluate breast milk expression and While the survey data were being collected, the guide conversations with the mothers. Frequency of NICU manager assisted
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