Breastfeeding Practices in Breastfeeding Practices in the Neonatal Intensive Care the Neonatal Intensive Care

Unit Before and After an Unit Before and After an InterventionIntervention

Roberta Roberta GittensGittens Pineda PhD OTR/LPineda PhD OTR/LFebruary 2, 2007February 2, 2007

THE NICUTHE NICU

Medically complex environmentMedically complex environmentFragile and neurologically immature Fragile and neurologically immature infantsinfantsHealth care professionals as primary Health care professionals as primary caregiverscaregiversPriority is life saving/medical interventionsPriority is life saving/medical interventions

Mothers of Infants in the NICUMothers of Infants in the NICU

Separated from the infantSeparated from the infantIncreased stress and anxietyIncreased stress and anxietyIntimidated by the environmentIntimidated by the environmentUnable to breastfeed in the traditional Unable to breastfeed in the traditional sensesense

Why are Breastfeeding and Breast Why are Breastfeeding and Breast Milk Feedings Critical in This Milk Feedings Critical in This

PopulationPopulationImportant part of mothering, despite the Important part of mothering, despite the difficult environmentdifficult environmentImmediate health benefits for the infantImmediate health benefits for the infantLong term health benefits for the infantLong term health benefits for the infantDevelopmental benefits for the infantDevelopmental benefits for the infantHealth benefits for the motherHealth benefits for the mother

Breast Milk and Benefits for Breast Milk and Benefits for Premature BabiesPremature Babies

DECREASES:DECREASES:Risk of NEC, GER, ROP, respiratory infections Risk of NEC, GER, ROP, respiratory infections ((HylanderHylander, 2001), 2001)

Risk of ARisk of A’’s and Bs and B’’s during oral feeds s during oral feeds (Chen, 2000)(Chen, 2000)

Risk of sepsis and meningitis Risk of sepsis and meningitis ((HylanderHylander, 2001), 2001)

Morbidity and mortality Morbidity and mortality ((HylanderHylander, 2001), 2001)

Blood pressure in the teenage years Blood pressure in the teenage years ((SinghalSinghal, 2001), 2001)

Length of hospitalization and health care costs Length of hospitalization and health care costs ((HarroldHarrold, 2002), 2002)

IMPROVES:IMPROVES:Gastrointestinal functioning Gastrointestinal functioning ((HylanderHylander, 2001), 2001)

Neurological maturity and IQ at 7Neurological maturity and IQ at 7--8 years of age 8 years of age (Smith, 2003; (Smith, 2003;

GomezGomez--SanchizSanchiz, 2003), 2003)

Developmental motor quotients at 18 months of age Developmental motor quotients at 18 months of age (Morley, (Morley, 1988; Gomez1988; Gomez--SanchizSanchiz, 2003), 2003)

Benefits of Breastfeeding for the Benefits of Breastfeeding for the MotherMother

Special bonding experienceSpecial bonding experience ((TorgusTorgus, 1997), 1997)

Decreased risk of breast and ovarian cancer Decreased risk of breast and ovarian cancer (Lacey, 2002)(Lacey, 2002)

Improved bone mineral density Improved bone mineral density (Chantry, 2004)(Chantry, 2004)

Faster pregnancy related weight loss Faster pregnancy related weight loss (Dewey, 1993)(Dewey, 1993) and and less postnatal weight gain less postnatal weight gain (Rooney, 2002)(Rooney, 2002)

Delayed ovulation Delayed ovulation (Rea, 2004)(Rea, 2004)

Less postpartum bleeding Less postpartum bleeding (Chua, 1994)(Chua, 1994)

Decreased risk of diabetes and rheumatoid arthritisDecreased risk of diabetes and rheumatoid arthritis (Rea, (Rea, 2004)2004)

Benefits of Breastfeeding for the Benefits of Breastfeeding for the Mother of a Hospitalized InfantMother of a Hospitalized Infant

Mother with improved sense of wellMother with improved sense of well--being: being: ““the one thing that I can do for my babythe one thing that I can do for my baby”” ((SchanlerSchanler, 1999), 1999)

Quicker discharge of the baby enables Quicker discharge of the baby enables the mom to function in her role as mother the mom to function in her role as mother more quicklymore quickly

© 2005 Medela, Inc.Used with permission of Medela Inc., McHenry, IL.

Current RecommendationsCurrent Recommendations

AAP: AAP: --Exclusive breastfeeding for 6 monthsExclusive breastfeeding for 6 months--Continued breastfeeding until the Continued breastfeeding until the infant is at least 12 monthsinfant is at least 12 months

WHO:WHO:--Breastfeeding until the infant is at least Breastfeeding until the infant is at least 2 years of age2 years of age

Predictive Factors of BreastfeedingPredictive Factors of Breastfeeding

Socioeconomic status Socioeconomic status ((MitraMitra, 2004), 2004)

Previous children but smaller family size Previous children but smaller family size ((MitraMitra, 2004), 2004)

Race Race ((MitraMitra, 2004), 2004)

Maternal age Maternal age ((BuenoBueno, 2003), 2003)

Maternal education Maternal education ((BuenoBueno, 2003), 2003)

Birth weight Birth weight (Hwang, 2006)(Hwang, 2006)

PerinatalPerinatal medical condition medical condition (Espy, 2003)(Espy, 2003)

Admission into the NICU Admission into the NICU (Scott, 2006)(Scott, 2006)

Barriers to Breastfeeding Barriers to Breastfeeding

Perceived lack of family support Perceived lack of family support (Scott, 2006)(Scott, 2006)

Early supplementation or first feeding of formula Early supplementation or first feeding of formula (Wheeler, 2000)(Wheeler, 2000)

Social withdrawal and isolation Social withdrawal and isolation (Stewart(Stewart--Knox, 2003)Knox, 2003)

Functional problems Functional problems (Bick, 1998)(Bick, 1998)

Perceived inadequacy of the milk supply Perceived inadequacy of the milk supply ((AroraArora, , 2000)2000)

Intent to return to work Intent to return to work ((AroraArora, 2000), 2000)

Maternal illness Maternal illness ((RiskinRiskin, 2003), 2003)

Perceived inconvenience Perceived inconvenience (Zimmerman, 2001)(Zimmerman, 2001)

Barriers to BreastfeedingBarriers to Breastfeedingin the NICUin the NICU

Stress and anxiety Stress and anxiety (Docherty, 2002) (Docherty, 2002)

Lack of ad lib feedings and normal motherLack of ad lib feedings and normal mother-- infant contact infant contact (Black, 2000)(Black, 2000)

Complex environment and medical interventions Complex environment and medical interventions (Wheeler, (Wheeler, 2000) 2000)

Lack of a calm, comfortable and private environment Lack of a calm, comfortable and private environment (Wheeler, 1999) (Wheeler, 1999)

Oral motor/mechanical problems Oral motor/mechanical problems (Hill, 1994)(Hill, 1994)

Diminished milk supply Diminished milk supply ((AroraArora, 2000; Colin, 2002; , 2000; Colin, 2002; CallenCallen, 2005), 2005)

Support of health care professionals in the NICU Support of health care professionals in the NICU ((BerensBerens, , 2001; Spicer, 2001; Swanson, 2005) 2001; Spicer, 2001; Swanson, 2005)

Health Care Professionals Health Care Professionals Can Disable or Enable the Can Disable or Enable the

Breastfeeding Process in the NICUBreastfeeding Process in the NICUMothers receive conflicting advice Mothers receive conflicting advice (Jaeger, 1997).(Jaeger, 1997).

HCPsHCPs lack education about lactationlack education about lactation ((BerensBerens, , 2001; 2001; PantaziPantazi, 1998; Register, 2000), 1998; Register, 2000)

Education can affect attitudes and Education can affect attitudes and knowledge knowledge ((BernaixBernaix, 2000; , 2000; SiddellSiddell, 2003; Swanson, 2005), 2003; Swanson, 2005)

HCPsHCPs can support or can support or damage breastfeeding damage breastfeeding in the NICU in the NICU ((EkstromEkstrom, 2005), 2005)

Need for ResearchNeed for Research

No studies investigating breastfeeding No studies investigating breastfeeding outcomes following an educational outcomes following an educational initiative targeted at health care initiative targeted at health care professionalsprofessionals

© 2005 Medela, Inc.Used with permission of Medela Inc., McHenry, IL.

Breastfeeding Interventions Must Breastfeeding Interventions Must be Specific to the NICU Infantbe Specific to the NICU Infant

Must be individualizedMust be individualizedBased on current literatureBased on current literatureBe realistic, given the environmentBe realistic, given the environmentHave minimal or no riskHave minimal or no risk

HypothesisHypothesis

A three pronged intervention will positively A three pronged intervention will positively affect breastfeeding practices in very low affect breastfeeding practices in very low birth weight infants admitted to the birth weight infants admitted to the neonatal intensive care unitneonatal intensive care unit

Specific AimSpecific Aim

The overall goal was to attempt to develop The overall goal was to attempt to develop an effective intervention that would enable an effective intervention that would enable health care professionals to instruct and health care professionals to instruct and assist motherassist mother--infant dyads in the complex infant dyads in the complex NICU environment NICU environment The purpose of this study was to test the The purpose of this study was to test the efficacy of a 3efficacy of a 3--part intervention on part intervention on improving breastfeeding practices in the improving breastfeeding practices in the NICUNICU

Intervention Plan Intervention Plan Educational Initiative for Educational Initiative for HCPsHCPsModifications to the individualized care Modifications to the individualized care plan: Breastfeeding pathwayplan: Breastfeeding pathwayEducational booklet: NICU mothersEducational booklet: NICU mothers

Proposed InterventionsProposed Interventions

Early and consistent pumpingEarly and consistent pumpingFirst feeding at the breast First feeding at the breast Attempts at breastfeeding when infant not Attempts at breastfeeding when infant not demonstrating physiological demonstrating physiological sequelaesequelae(usually around 30 EGA)(usually around 30 EGA)Monitoring of infant responsesMonitoring of infant responsesIncreasing attempts when Increasing attempts when benefit is greater than riskbenefit is greater than risk

Research QuestionsResearch QuestionsIs there a significant difference in breast milk Is there a significant difference in breast milk feeding initiation in VLBW infants before and feeding initiation in VLBW infants before and after implementation of the intervention?after implementation of the intervention?

Is there a significant difference in the rate of Is there a significant difference in the rate of breastfeeding in the hospital among VLBW breastfeeding in the hospital among VLBW infants before and after the implementation of infants before and after the implementation of the intervention?the intervention?

Is there a significant difference in breast milk Is there a significant difference in breast milk feedings at discharge in VLBW infants before feedings at discharge in VLBW infants before and after the implementation of the and after the implementation of the intervention?intervention?

ParticipantsParticipants

VLBW (<1500 grams) infantsVLBW (<1500 grams) infantsAdmitted to the NICU for 7Admitted to the NICU for 7--120 days120 daysAchieved full gastric feedingsAchieved full gastric feedingsNo breastfeeding contraindicationsNo breastfeeding contraindications82 in each group needed82 in each group needed

DesignDesign

QuasiQuasi--experimentalexperimentalMatching through cohort controlsMatching through cohort controlsPrePre--intervention group compared to postintervention group compared to post--intervention groupintervention group

Independent VariableIndependent Variable

The 3 pronged interventionThe 3 pronged intervention

Dependent VariablesDependent Variables

Breast Milk Feeding Initiation RateBreast Milk Feeding Initiation RateBreastfeeding RateBreastfeeding RateBreast Milk Feeding At Discharge RateBreast Milk Feeding At Discharge Rate

ProceduresProcedures

6 week educational initiative: 6 week educational initiative: March 1, 2005March 1, 2005--April 15, 2005April 15, 2005““A MotherA Mother’’s Gifts Gift”” issued to new admissions issued to new admissions starting March 1, 2005starting March 1, 2005The modified ICP used in new charts The modified ICP used in new charts starting on March 1, 2005starting on March 1, 2005

Data CollectionData CollectionSubjects recruited via hospital data baseSubjects recruited via hospital data base

Retrospective chart reviewRetrospective chart review

PrePre--intervention groupintervention group--81 participants from April 15, 81 participants from April 15, 2004 to December 7, 20042004 to December 7, 2004

Intervention: March 1, 2005 Intervention: March 1, 2005 --April 14, 2005April 14, 2005

PostPost--intervention groupintervention group--54 participants from April 15, 54 participants from April 15, 2005 to November 29, 20052005 to November 29, 2005

Further Data Collection HaltedFurther Data Collection Halted

Long period of time had passed since the Long period of time had passed since the interventionsinterventionsAdditional interventions to be implementedAdditional interventions to be implementedNew power analysisNew power analysis

Group ComparisonsGroup Comparisons

ANOVA for continuous variables ANOVA for continuous variables NonparametricsNonparametrics if assumptions violatedif assumptions violatedChiChi--square for dichotomous variablessquare for dichotomous variablesRanked Ranked BonferroniBonferroni adjustmentadjustment

ResultsResults

88 (63%) of health care professionals 88 (63%) of health care professionals participated in the educational initiativeparticipated in the educational initiativeICPICP--Implementation problems/lack of use Implementation problems/lack of use First feeding at the breast First feeding at the breast ““A MotherA Mother’’s Gifts Gift””--admission paperworkadmission paperworkNursing administratorNursing administrator’’s observationss observations

DemographicsDemographics

Low SES

Race (Black)

Maternal Age

Marital Status (not married)

Transferred Instead of DC Home

LOS BirthWeight

Gestational Age

Number of Siblings

Pre-Intervention Group

.78 .46 25.46 .56 .43 50 1074 28.6 1.01

Post-InterventionGroup

.70 .56 25.62 .57 .33 54 1114 28.7 .86

p Value to Investigate Selection Differences

.34 .26 .89 .86 .23 .53 .37 .76 .30

Results Per Research QuestionResults Per Research Question

Is there a significant difference in Is there a significant difference in breast milk feeding initiation in VLBW breast milk feeding initiation in VLBW infants before and after infants before and after implementation of the intervention implementation of the intervention plan?plan?

Breast Milk Feeding Initiation RateBreast Milk Feeding Initiation Rate

PrePre--Intervention Group 74.1%Intervention Group 74.1%PostPost--Intervention Group 85.2%Intervention Group 85.2%PearsonPearson’’s Chis Chi--Square (p=.124)Square (p=.124)Odds Ratio 2.013Odds Ratio 2.013Odds Ratio CI .818 to 4.952 Odds Ratio CI .818 to 4.952

Why the Wide CI?Why the Wide CI?Was Breast Milk Ever Provided?

No Yes

Count 21 60

Count 8 46Post-interventiongroup

Pre-interventiongroup

Group

Is there a significant difference in the Is there a significant difference in the rate of breastfeeding in the hospital rate of breastfeeding in the hospital among women with VLBW infants among women with VLBW infants hospitalized in the NICU before and hospitalized in the NICU before and after the implementation of the after the implementation of the intervention plan? intervention plan?

Pre

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grou

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Breastfeeding RateBreastfeeding Rate

Mean in preMean in pre--intervention group was .059intervention group was .059Mean in postMean in post--intervention group was .138intervention group was .138MannMann--Whitney (p= .011)Whitney (p= .011)Significant differences across groupsSignificant differences across groups

Dichotomized Variable to Ever Dichotomized Variable to Ever BreastfedBreastfed

PrePre--intervention group 25.9%intervention group 25.9%PostPost--intervention group 44.4%intervention group 44.4%PearsonPearson’’s Chis Chi--Square (p=.025)Square (p=.025)Odds Ratio 2.286 Odds Ratio 2.286 Odds Ratio CI of 1.1 to 4.750Odds Ratio CI of 1.1 to 4.750

Is there a significant difference in Is there a significant difference in breast milk feedings at discharge in breast milk feedings at discharge in VLBW infants before and after the VLBW infants before and after the implementation of the education plan?implementation of the education plan?

Breast Milk Feeding at Discharge Breast Milk Feeding at Discharge RateRate

PrePre--Intervention Group 35.8%Intervention Group 35.8%PostPost--Intervention Group 40.7%Intervention Group 40.7%Chi Square (p=.562) Chi Square (p=.562) Odds ratio 1.233 Odds ratio 1.233 Odds ratio CI .607 to 2.502Odds ratio CI .607 to 2.502

ConclusionConclusion

Partial support of the intervention Partial support of the intervention Positive trends across variablesPositive trends across variablesEvidence of increased breastfeeding Evidence of increased breastfeeding Lack of significant change across all Lack of significant change across all variables as hypothesizedvariables as hypothesizedA multifaceted approach may be indicatedA multifaceted approach may be indicated

The Intervention Had an Effect on a The Intervention Had an Effect on a Very Important VariableVery Important Variable

Diminished milk supply is a significant Diminished milk supply is a significant barrierbarrierMaternal stressMaternal stressOxytocinOxytocinMothers given some control of careMothers given some control of care

Contributions to the LiteratureContributions to the LiteratureBreast milk feeding initiation rates (74% and 85%) comparableBreast milk feeding initiation rates (74% and 85%) comparable

64% 64% (Byrne, 1996)(Byrne, 1996)

72.9% 72.9% (Meier, 2004)(Meier, 2004)

83% 83% (Yip, 1996)(Yip, 1996)

Breast milk feeding at discharge rates (36% and 41%) comparable Breast milk feeding at discharge rates (36% and 41%) comparable 38% 38% (Yip, 1996)(Yip, 1996)

Education about lactation affects HCP knowledge and support of tEducation about lactation affects HCP knowledge and support of the he breastfeeding process breastfeeding process ((SiddellSiddell, 2003; , 2003; EkstromEkstrom, 2005), 2005)

Although HCP behavior and knowledge were not measured, this Although HCP behavior and knowledge were not measured, this research concludes that there are positive breastfeeding outcomeresearch concludes that there are positive breastfeeding outcomes s following the intervention following the intervention

Main LimitationsMain Limitations

Intervention did not have a strong enough Intervention did not have a strong enough effecteffectLack of compliance Lack of compliance Lack of formal measurement of health Lack of formal measurement of health care behavior change and implementationcare behavior change and implementation

LimitationsLimitations

Inadequate time frameInadequate time frameInability to control for other changes in the Inability to control for other changes in the environment environment Lack of participation by key decision Lack of participation by key decision makersmakersWhich intervention fostered changeWhich intervention fostered changeLack of a randomized and larger sampleLack of a randomized and larger sample

ConclusionsConclusions

Significant benefits of breast milk Significant benefits of breast milk Challenges in the NICUChallenges in the NICUPartial support of the interventionPartial support of the interventionBreastfeeding in the NICU is not simply a Breastfeeding in the NICU is not simply a ““personal decisionpersonal decision””More studies are neededMore studies are needed