Increasing Breastfeeding Rates in the NICU via Utilization of the Neonatal Transport Team

The benefits of human milk and colostrum are well recognized, specifically for an infant requiring admission to the Neonatal Intensive Care Unit (NICU). Human milk offers an optimized defense against such co-morbidities as necrotizing enterocolitis (NEC), sepsis, respiratory infections, chronic lung disease and retinopathy of prematurity (ROP). Enteral feedings are better tolerated, feeding progression enhanced and cognitive development fostered when mother’s milk is utilized. Despite the strong evidence supporting the use of human milk feeding, studies have found that infants admitted to the NICU are often not discharged to home receiving human milk due to a variety of factors. These may include but are not limited to physical separation of mother and infant shortly after birth due to clinical illness or prematurity, geographical distance/transportation challenges, maternal educational deficits, inadequate lactation support, disruption of maternal infant bonding etc. Maternal infant separation may continue to be exacerbated by these same factors throughout the NICU hospitalization.

The birth of a premature or critically ill neonate is a crisis for the family unit. The necessity of neonatal transport and subsequent transfer to a higher level NICU for care causes separation of the mother from her infant during the immediate post-partum period. As such, the time period of highest colostrum production often overlaps with the transfer of the infant to a higher level NICU.

A quality improvement study was undertaken to determine if providing direct education coupled with the offering of a colostrum kit by the neonatal transport team to mothers of infants requiring transfer to another NICU facility would increase overall breastfeeding rates along with pre-existing NICU based lactation support.

As a joint venture between the Johns Hopkins Hospital (JHH) and the University of Maryland Medical System (UMMS), a program was created to utilize the influence of the Maryland Regional Neonatal Transport Team (MRNTP). The transport team members provided direct scripted education to mothers regarding breast feeding and offered them a colostrum collection kit. The colostrum kit was housed in a washable vinyl tote and consisted of two small colostrum collection bottles, a refrigerator magnet with human milk storage instructions, educational materials regarding the benefits of colostrum including instructions for breast pumping, a reusable cold pack, and a small picture frame where they could place a photo of their baby during pumping sessions.

Funding for this project was secured through a March of Dimes Community grant for a two-year time period. The colostrum kit was given to the mother at the time that the neonatal transport team brought the infant to the mother’s room prior to departure from the referral facility. The mother had the option to decline the kit. If that occurred, the kit was left with the referral hospital staff in case the mother expressed interest in using the kit at a later point in time during her hospitalization. If the mother expressed an immediate desire to bottle feed only, the scripted education asked the mother to please consider pumping for the first one to two post-partum weeks so that the infant could at least benefit from collected colostrum.

Retrospective data was collected via medical chart review for all neonates transported (N=290) for a full calendar year prior to the start of the project. Post program data was collected for all neonates transported (N=307) the calendar year thereafter. The registered dietitians (RDs) completed tracking of the neonates admitted ascertaining the following data points: if first feed was maternal breast milk and if infants were discharged on breast milk feedings. A retrospective analysis of the data was completed for both the pre-protocol and post protocol period.

As cited above, a total of 290 infants were eligible for baseline pre-protocol analysis, and 307 infants were eligible for post-protocol analysis. The retrospective data showed that in the pre-protocol period; 39% (n= 112) of neonates transferred were given breast milk as their first feeds, and only 37% (n=106) were discharged home on breast milk. In the post protocol period showed that 75% (n=97) received breast milk during their admission, 67% (n=86) received maternal breast milk as their first feed and 66% (n=85) were discharged home still receiving at least half of their feeds from breast milk. When compared to those infants whose mother did not receive a colostrum kit, only 62% (n=111) received breast milk during their admission, 51 % (n= 90) received maternal breast milk as their first feed and 42% (n= 75) were discharged home still receiving at least half of their feeds from breast milk. There was a 28% increase in infants that received maternal breastmilk as their first feeding when comparing pre and post protocol data. There was a 29% increase in infants that were discharged home that were still receiving at least half of their feeds from human milk.

The objective of the quality improvement project was to determine if providing direct education and a colostrum kit to mothers of infants requiring neonatal transport to another facility would increase breastfeeding rates in the NICU; that objective was indeed met.

Preliminary findings suggest that utilizing the neonatal transport team to provide direct scripted education and the colostrum kit increases breastfeeding rates at discharge. This practice change has the potential to improve overall outcomes by reducing a myriad of co-morbidities such as NEC, respiratory infections, ROP. It also can optimize enteral feeding tolerance and uninterrupted feeding progression. Repetitive study will be needed to determine if the influence of the neonatal transport team can continue to foster breastfeeding rates for neonates requiring transport as an adjunct to NICU based lactation support while the infant is hospitalized.

Beth C. Diehl, DNP, NNP-BC, CCRN is a Neonatal Nurse Practitioner/Transport Nurse employed at Johns Hopkins Hospital in Baltimore, MD. Originally a graduate of a nursing diploma program, she completed her BSN at the University of Michigan and MS degree at the University of Maryland in maternal child health nursing/clinical specialty track. She subsequently completed her post-master’s certificate as a Neonatal NP at the University of Maryland School of Nursing and Doctorate in Nursing Practice from Johns Hopkins University. She has published extensively and lectured nationally on multiple topics related to neonatal nursing care. She has maintained an independent legal nurse consulting business for the past three decades which focuses on the review of medical negligence cases related to nursing standards of care. In addition to the medical malpractice reviews, Beth has served as an educational consultant and been involved in institutional policy and procedure development for other healthcare institutions. She is currently a nurse surveyor for the American Academy of Pediatrics NICU Verification Program.