NEONATAL BREASTFEEDING OUTREACH CAMPAIGN

Patricia L. Bilyk, RN, MSN, MPH, IBCLC

in collaboration with Women, Infants and Children Services Branch

and Healthy Mothers Healthy Babies Coalition of Hawaii

Premature births have risen over the last 2 decades in the USA. In 1980 the rate was 9.5%. In 2000 it had risen to 11.6%¹ and in 2002 it was 12%. In Hawaii, the statistic was 11%². Premature birth is defined in terms of gestational age, 37 weeks or younger, and weight of infant, under 2500 grams or 5 pounds 8 ounces.

The causes of prematurity are controversial among health professionals and researchers. Some of the causes identified in the literature are related to: 1) genetics, 2) infections 3) illicit drug use, 4) in vitro fertilization (accounting for 18% of total rate)³, and 5) long term chronic malnutrition and poor health care.

"Low birthweight and prematurity are the most important determinants of neonatal mortality as well as infant and childhood morbidities⁴." Preterm and low birth weight infants are particularly vulnerable throughout their lives. Optimal nutrition is a key element to their long-term health and prevention of diseases. According to Dr. A. Lucas, "nutrition during critical periods in early life may permanently affect the structure and/or function of organs and tissues⁵."

The goals of premature infant nutrition are to:

1. achieve standard short term growth,
2. prevent feeding related morbidities, and
3. optimize long-term outcomes⁶.

The excellent benefits of breastmilk for the premature (and term) infant have been well documented in the literature⁷. Some of the key benefits of breastmilk for the premature infant are: 1) stimulating gastrointestinal growth, motility and maturation; 2) less costly and fewer hospital days; 3) higher fat content and calories with hind milk vs. premature formulas;

4) reduced incidence of necrotizing enterocolitis (NEC), bacteremia and sepsis; and 5) improved visual development⁸.

At the time of a premature delivery, the health team and parents may be focusing primarily on the immediate health of the premature infant. Especially with a very low birth weight infant, parents cannot envision the feasibility of breastfeeding. Yet research has shown that mothers will provide breastmilk for their infant and eventually breastfeed post discharge if the health professional cites the benefits to the infant at this very critical time in his life⁹.

Further, health professionals in the hospital can assist the breastfeeding mother of a premature infant by ensuring she does the following:

1. pumps her breasts with double attachments and an electric breastpump,
2. pumps by 6 hours postpartum and every 3 hours round the clock thereafter,

1. holds her infant skin to skin, and
2. breastfeeds infant when showing feeding cues.

These activities create a more abundant milk supply and establish a closer relationship with her infant.

After discharge, if the mother continues the above activities (visits infant daily, pumps at infant’s bedside and continues to put infant to breast depending on feeding cues), she will have a higher chance of breastfeeding success post discharge. The availability of supportive health professionals, specifically lactation consultant services will further support the mother-infant dyad toward a successful outcome for breastfeeding¹⁰.

Healthy Mothers Healthy Babies Coalition of Hawaii was awarded a grant from the Women, Infants and Children (WIC) Services Branch of the Hawaii State Department of Health in April 2004 to help families of premature and high risk newborns receive excellent, standardized information on breastfeeding. First, a statewide survey of 338 Hawaii health professionals was conducted to identify attitudes and knowledge of breastfeeding and the premature infant (Attachment 1 - Survey). Second, specific educational presentations to perinatal and pediatric physicians, mother-baby staff nurses and Maternal Child Health community health professionals were given throughout the state (Attachment 2 - Presentation List). Third, the video or CD, "A Premie Needs His Mother" was distributed to 40 hospitals, WIC agencies and other community organizations (Attachment 3 - Distribution List).

A standardized 11 question survey, obtained from the California Perinatal Quality Care Collaborative 2004, was conducted statewide over a 3-month period (May-July). A final number of 338 completed surveys were obtained. The demographics of the survey showed a wide variety of health professionals participated, including civilian (private and government) and military. Specifically the health professionals were: 1) Attending MD (39), 2) Resident MDs (20), 3) RNs Midwives (3), 4) RNs (137), 5) LPNs (13), 6) Dietitians (13), 7) Ward Secretaries (10), 8) "Others" (54), and 9) No Response (49). The speciality areas represented were:

1) Physicians-OB/GYN, Perinatology, Family Practice, Pediatrics and Neonatology; 2) Nutritionists; 3) Lactation Consultants/WIC LAs; 4) Nurses/LPNs-Nursery, Mother-Baby Unit, Nursery, Labor and Delivery, and NICU; and 5) Government and Community Agency Personnel. Eighty-eight percent of the respondents were female while 12% were male. The range of birth years was 1941 to 1983, with the highest number of respondents born in the 1950’s and 1960’s.

Familiarity with the World Health Organization/United Nations Children’s Fund Baby Friendly Hospital Initiative were: 1) Very Familiar 14%, 2) Somewhat familiar 31%, 3) Not at all familiar 50%, and 4) No Response 5%.

Personal/partner breastfeeding experience was as follows: 1) No experience 31%, 2) <2 months 6%, 3) 2-6 months 17%, 4) 7-12 months 18%, 5) >12 months 23%, and 6) No response 5%. It is interesting to note that 59% of the respondents had no experience or under six (6) months experience with breastfeeding.

Analysis of the 11 questions provide some interesting findings.

The first question was "Breastmilk and formula are equally acceptable for preterm and ill infants." A weakness was identified with the wording of this question. It could be interpreted as breastmilk and formula are the same, or breastmilk and formula are different, depending on your point of view on the issue. Possibly the question did not discriminate enough the respondents true feeling as to the importance of breastmilk for the premature infant. Still, 62% disagreed or strongly disagreed that the liquids were not the same especially for this population. Of the remaining respondents 29% agreed or strongly disagreed and 9% neither/unsure/no response category.

The second question "Physicians should actively encourage breastfeeding" drew a 96% agreed/strongly agreed. Both American College of Obstetricians and Gynecologists and American Academy of Pediatrics have gone on record to encourage the expansion of knowledge for the physician on breastfeeding management. Medical schools throughout the country are integrating breastfeeding management into their curricula in the Pediatric, Obstetric, Neonatology and Family Practice specialities¹¹.

The third question reflected on the importance of the obstetrician’s role in the woman’s decision to breastfeed. Eighty-six percent of the respondents agreed or strongly agreed in this early valuable role. A Centers for Disease Control and Prevention research study concurred the importance of the obstetrician’s role, stating that if a physician has a strong positive opinion regarding the value of breastfeeding and breastmilk, the woman had higher breastfeeding rates at 6 weeks postpartum¹².

The fourth question was "Healthcare professionals should not stress breastfeeding, because it might make mothers feel guilty." This was a "loaded" question. Research in the past has identified that making a woman feel guilty about her feeding choice is something health professionals wanted to avoid vs. stressing the evidence of healthy benefits of breastfeeding. Seventy-eight percent of the health professionals’ disagreed/strongly disagreed, thereby stating ‘making mother feel guilty’ was not the issue. Fourteen percent agreed/strongly agreed and 8% were unsure/neither.

The influence of the formula companies in the United States has been very powerful and health professionals have been highly influenced by them in the past. The fifth question attempts to survey their view of having formula company items available and specifically wearing such items in the presence of clients. The question was "Wearing formula lanyards and badge holders, tell mothers I endorse that formula." The responses were split with 50% agreed or strongly agreed, 28% disagreed or strongly disagreed and 22% neither/unsure/no response. These responses demonstrated a conflict of loyalties for health professionals and the continued need for educational assistance with this issue.

The sixth question looked at health professionals’ thoughts on their role in promoting successful breastfeeding. The question reads "Almost all mothers can be successful at breastfeeding if they are supported and encouraged." Ninety-three percent of the health professionals agreed or strongly agreed with this statement, with 6% disagreeing or strongly disagreeing, and 1% neither or unsure.

The seventh question talked about their view on the sterility of human milk. In truth, human milk is sterile in the body, but once it leaves the body it accumulates free-floating pathogens in the air and therefore is no longer sterile. The respondents felt as follows: 1) 60% agreed or strongly agreed, 2) 23% disagreed or strongly disagreed, and 3) 17% unsure/neither.

The protective benefit against pathogens that may cause preterm and term infants difficulties is well documented in the scientific literature. Question number 8 states "Premature infants fed human milk have less NEC and sepsis." Most of the health professionals got this correct in agreeing or strongly agreeing 79% to the statement. It is interesting to note that 18% of the health professionals chose "unsure" or "neither", and 3% disagreed or strongly disagreed.

Another opportunity for additional education and information presented itself in question number 9. "In the long run, formula fed babies are just as healthy as breastfed ones." The results were equally distributed over the choices with 51% disagreeing or strongly disagreeing, 31% agreeing or strongly agreeing, and 18% unsure/neither/no response.

Again looking at the issue of responsibility of the health professional in the breastfeeding success of the mother, the 10^th question reads "I feel responsible for helping a mother be successful at breastfeeding." Seventy five percent of the respondents agreed or strongly agreed, while 18% selected unsure/neither/no response, and 7% disagreed or strongly disagreed.

The last question reflected the health professionals’ knowledge of medication resources for the breastfeeding woman and infant. Question 11 reads, "The Physicians’ Desk Reference (PDR) is the best source of information on drugs and breastfeeding." The responses were equally distributed among the choices with 43% disagreed/strongly disagreed, 35% unsure/neither/no response, and 22% agreed or strongly agreed. The PDR does not give expanded information on specific drugs and breastfeeding, thereby hampering the health professional in making risk/benefit and more complete decisions regarding the use of medications in the mother’s milk.

Some specific results of this survey that were unique to the requesting hospital have already been shared with the key health professional at the hospital. Requesting hospitals were Wilcox and Kona Hospitals.

Educational sessions were done Statewide from July through September for approximately 200 health professionals. One-hour sessions were done for Mother-Baby Nurses Staff at Wilcox Hospital, Hilo Medical Center, Kona Hospital, North Hawaii Community Hospital and Maui Memorial Hospital. OB/GYN UH Faculty, Pediatric, Neonatology, OB/GYN Residents and Pediatric Resident Physicians had separate sessions provider. Specific community presentations were done on all islands with a videoconference session provided for the WIC Breastfeeding Coordinators on August 27^th and State Capitol meeting of the Perinatal Providers Network on August 13^th. Each presentation was individualized to the audience and generally included the following content areas: 1) benefits of breastmilk to the premature infant, 2) early support of premature infant’s mother to provide breastmilk and eventually breastfeed, 3) health professional printed and community breastfeeding resources, 4) results from the Statewide survey, and 5) WIC breastfeeding services available and ways to make a referral.

A general community educational session was developed on PowerPoint to be used by the WIC Services Branch for future for presentations of this material.

A total of 40 sets of the video/CD "A Premie Needs His Mother" (2 tapes or 1 CD) in English were ordered and distributed to 19 WIC agency personnel and 16 hospitals and organizations. Additionally, four WIC sites and four Hospitals received the video/CD in Spanish. Each agency, community organization or hospital received a memo regarding the funding and specifics of the Neonatal Breastfeeding Outreach Campaign Project, and instructions for use. The video tapes and CDs were labeled regarding funding source. Each organization, site or hospital returned a video/CD receipt form in order to track where all videos/CDs were distributed and who received them.

1. Conduct statewide educational meetings on importance of baby/breastfeeding friendly concepts integrated into policies and procedures at hospitals, agencies, and physicians offices.
2. Expand breastfeeding curriculum on needs of the preterm (and term) infant and their mother. This should be included in orientation sessions for agencies and hospitals who provide breastfeeding services. Regular breastfeeding updates are encouraged to maintain current level of practice.
3. Review the survey data with specialized sociometric computer program to determine more in depth correlations between type of health practitioner and their responses. This information could be used to create more targeted educational offerings to specific groups of health professionals and agency/hospital personnel.
4. Provide PowerPoint educational presentation to Guam and American Samoa via video conferencing.

The Neonatal Breastfeeding Outreach Campaign was successful in reaching a wide variety of health professionals statewide with current information geared to their specialty area. The video/CD will reinforce this information with both the health professionals and the parents. It is hoped that the results of the survey will be enlightening, and encourage discussions and policy changes at the hospitals, agencies and organizations touched by the Campaign.

BIBLIOGRAPHY

1. Jane Morton, MD, Editor, "The Role of the Pediatrician in Extending Breastfeeding of the Preterm Infant," Pediatric Annual. May, 2003. Vol. 32, No. 5.
2. State of Hawaii, 2004 Perinatal Summit, Dr. Cheryl Prince-PowerPoint presentation.
3. S.C. Tough et al, "Effects of Invitro Fertilization on Low Birth Weight, Preterm Delivery and Multiple Births," J Pediatrics, 200, 136: 618-622.
4. M.C. McCormick, "The Contribution of Low Birth Weight Infant Mortality and Childhood Morbidity," New England J Med, 1985. 312: 82-90.

1. A. Lucas, PhD. and TJ Cole, "Breastmilk and Neonatal Necrotising Enterocolitis," Lancet, 1990. 336: 1519-1523.
2. California Perinatal Quality Care Collaborative. "Nutritional Support of the Very Low Birth Weight Infant-Part 1," 2004.
3. As previous citation.
4. As previous citation.
5. See #1 citation.
6. Paula P. Meier, RN, DNSc, "Supporting Lactation in Mothers With Very Low Birth Weight Infants," Pediatric Annals, Vol 32, No. 5, May 2003, 317-325.
7. US Department of Health and Human Services, Office on Women’s Health, HHS Blueprint for Action on Breastfeeding, 2000.