Our Baby Friendly Journey…. From Baby Steps to Giant Steps

Grace Doolittle RNC, IBCLC Kathy Eide PNP, IBCLC Pamela Heggie MD, IBCLC Anne Lippin MD, CLE Nichole Sandberg RNC, IBCLC University of Minnesota Amplatz Children’s Hospital October 29, 2012 Minnesota Breastfeeding Coalition Annual Conference

What Is the Baby Friendly Hospital Initiative?

International hospital designation in maternity care

Clinical excellence in breastfeeding support

Developed by UNICEF and WHO in 1991

What is Baby Friendly? Hospital practices (evidence based) known to

improve breastfeeding rates

“10 Steps to Successful Breastfeeding”

Certification process includes an on-site visit to document compliance with the “10 Steps”

The Ten Steps 1. Written

Breastfeeding Policy

2. Train all Healthcare Staff

3. Inform all Pregnant Women

of Benefits

4. Help Mothers Initiate BF within

One Hour

5. Show Mothers How to BF and

Maintain Lactation

6. Give Newborn Infants Only Breastmilk

7. Practice Rooming In

8. Encourage BF on Demand

9. Give No Pacifiers or Artificial Nipples

to Breastfeeding Infants

10. Foster the Establishment of

BF Support Groups

Baby Friendly: Global and Local 20,000 hospitals worldwide are

certified Baby Friendly Less than 5% of the hospitals in the

United States are certified Baby Friendly 129/3000 birth hospitals in the U.S (2/2012)

In Minnesota 2/106 birth hospitals are Baby Friendly certified Mayo-Austin Medical Center

Jan 2011

U of MN Amplatz Children’s Hospital Feb 2012

How we got started (

How we got started

Moms and babies needing breastfeeding support

Coffee shop gathering – no more baby steps

Grassroots effort – Let’s go for Baby Friendly

Met with CEO of Fairview

Met with CNO of Fairview Riverside Hospital

(now U of M Amplatz Children’s Hospital)

Next Steps for Baby Friendly Certificate of intent , Jan 2010 BFHI Task Force established at Amplatz, Jan 2010

MDs – Peds, FP, OBS Midwives Staff Nurses Lactation Consultants Childbirth Educator Administrative lead- Birth and Family Education Nurse managers

Data collection Data and documentation drive change!

Breastfeeding rates (initiation , exclusive and partial)

Time to first breastfeeding

Rooming in times and time in nursery and reason

Formula medical indication - documentation

NICU moms- time to first pumping and pumping log use

Long term BF rates after discharge- 3, 6, 12 months

Baby Friendly Hospital Initiative MYTHS “You’re going to make moms pay for formula?”

“Formula fed families will be discriminated against”

“It is a cost cutting measure to get rid of the nursery”

“You are leaving out the moms- what about being Mother

Friendly?”

“…the moms are so exhausted, how can you MAKE them

take care of their baby and not use the nursery?”

BABY FRIENDLY HOSPITAL INITIATIVE: Baby Friendly, Mother Friendly, Family Friendly ...helping ALL families reach their infant feeding goals

The Baby Friendly Hospital Initiative….. is about

providing clinically excellent care to moms and babies.

It is maternity care that emphasizes best practice in infant feeding ...... breastfeeding support for mothers

who choose to breastfeed and instruction about safe

formula feeding for mothers who choose formula for

their babies.

From Baby Steps to Giant Steps

BFHI Task Force started Jan 2010

Fast implementation of Ten Steps - “10 in 2010”

Epic starting – March 2011

U of M Amplatz Children’s Hospital –new hospital opening in spring 2011

Baby Friendly Task Force: Work Teams

Prenatal Team Labor and Delivery Team Postpartum Team Supplies/ Formula /Supplementation Pumping/ NICU Team Community Resources / Patient Education Professional Education (provider and nurse)

BFHI Mini Go- Live Timeline - 2010 _________________________________________________________________

August 1 – Skin to skin and first breastfeeding within first hour August 15 – NICU moms pumping initiation and documentation pumping August 30- Prenatal education tool kit August 30 – Delay 1st bath/bath teaching in postpartum /no midnight wts September 30 – Postpartum teaching tool kit September 30 – all nursing staff complete 15 hr training October 15 – Formula management and documentation process November 1 - Pacifier protocol November 15– Rooming-in and Nursery name change to NeMOU

The Ten Steps 1. Written

Breastfeeding Policy

2. Train all Healthcare Staff

3. Inform all Pregnant Women of

Benefits

4. Help Mothers Initiate BF within

One Hour

5. Show Mothers How to BF and

Maintain Lactation

6. Give Newborn Infants Only Breastmilk

7. Practice Rooming In

8. Encourage BF on Demand

9. Give No Pacifiers or Artificial Nipples

to Breastfeeding Infants

10. Foster the Establishment of BF

Support Groups

Breastfeeding Initiation Rates

90 % 93 %

77 % 78 %

0

10

20

30

40

50

60

70

80

90

100

2009 2011 US MN

U of M before and after BFHI US and MN 2012

U of M U of M f

Effect of Baby Friendly – U of M Time to First Breastfeeding

48 %

63 %

0102030405060708090

100

% Breastfeeding within 1 hour

2009 2011

Effect of Baby Friendly at discharge

start BFHI

after BFHI

0

10

20

30

40

50

60

70

80

90

100

2007 2008 2009 2011

excl

usiv

e B

F ra

te

Exclusive Breastfeeding Rates at discharge: before and after BFHI - U of M

Effect of Baby Friendly: long term rates

29.6

61.7

0

10

20

30

40

50

60

70

80

90

100

before BFHI after BFHI

Excl

usiv

e B

F ra

te

Exclusive Breastfeeding at 3 months – U of M

22.8

38.3

0

5

10

15

20

25

30

35

40

45

before BFHI after BFHI

Exclusive Breastfeeding at 6 mo – U of M

Effect of Baby Friendly: U of M 12 months later

BEFORE 10 steps: 15.9 %

AFTER 10 steps: 27.7% Breastfeeding at 12 mo

“You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete. “ --Richard Buckminster Fuller

Step 1: Policy Have a written breastfeeding policy that is routinely communicated to all health care staff

• Revised Breastfeeding policy to be consistent with Baby Friendly requirements

• MD order sets match policy

• Nursing protocols match policy

Step 2: Staff Training Train all staff in the skills necessary to

implement this policy

Step 2: Staff Training

Step 2: Staff Training All of the birthplace nurses completed extensive training in

lactation support - Hospital classes and Skills session

“Passport” competency assessment for nurses by LC

Grand Rounds, Residency training lectures

Email Newsletter– sent to staff (RN and MD) with key messages

On-line courses – some nurses and most of MDs Jones and Bartlett - Ten Steps (RNs) University of Virginia on-line module (free CME) - MDs

Step 3: Prenatal Education

Inform all pregnant women about the benefits and management of breastfeeding.

Prenatal “Tool Kit” for prenatal education in prenatal clinics at targeted visits (12,28,36 wks)

DVDs, including Somali video Handouts Posters for clinic

Infant Feeding Plan Prepare for hospital routines – STS, pacifier, Rooming-In

formula/bottles and milk supply

Baby is placed in skin to skin contact on mother’s chest

immediately after birth for ALL healthy babies

Baby led feeding and no “Baby Burritos”

Vit K and erythromycin ointment -delayed up to 1 hr age to allow first breastfeeding attempt and skin to skin time

C-section deliveries – Planned approach for baby STS Baby placed on mom’s chest before surgery is complete

behind drape 2nd Nurse is responsible for baby Worked with Anesthesia /CNRAs on protocol

Step 4: Help mothers initiate breastfeeding within one hour of birth.

Step 4: Delay the bath

Delay 1st bath until BF going well and

usually not in Delivery Room

Exceptions include: maternal HIV,

Hepatitis B, C

Babies stay warmer – less hypothermia

Postpartum teaching of bath in room – helps

parent confidence in baby care

Show mothers how to breastfeed and how to maintain

lactation, even if they are separated from their infants.

Direct one to one teaching by nurses on positioning and latch LC teaches breastfeeding class on unit Somali doulas work with Somali Moms Routine instruction about hand expression for all mothers

using Stanford website on patient room computer http://newborns.stanford.edu/Breastfeeding/HandExpression.html

Step 5: Teach Breastfeeding and Hand Expression

Step 5: Teach Breastfeeding

Postpartum “Tool Kit” for staff to use for patient education

Doll Breast model Baby’s 2nd night

handout DVDs –

including Somali “Talking Points”

– scripts for staff

Step 5: Pumping if separated from infant NICU moms encouraged to start pumping within

6 hours after delivery

Documentation about pumping initiation Chart Audits by NICU LC of pumping initiation Staff given feedback about pumping times to help facilitate change • video about pump assembly and use done by NICU

LC- required viewing

Step 6: Give only breastmilk

Give newborn infants no food or drink other than breastmilk, unless medically indicated

Medical indication list for formula supplementation is in doctor orders on admission order set

Treating formula like medication

All formula kept in Pyxis (med cabinet)

Nurse signs out and documents reason for formula

Eliminated free diaper bags with formula- years ago

Step 6: no routine supplementation

If parental choice to use formula, documentation in parent’s words why they are choosing formula

Chance to find out what parent goals are

Starting point for education and dialogue with families

Opportunity to encourage exclusive breastfeeding

Education about milk supply

Never “forcing” someone to breastfeed- making informed

choice

Talking Points: Mom asks for bottle

Ask WHY? …..“Tell me more about that.” Why do you want to give your baby a bottle? Why do you think your baby needs formula? Explore concerns/reasons and document them Education and respect “If you give a bottle of formula you won’t make enough milk for your baby” “ Your body knows just how much milk to make for your baby” “Babies cry for many reasons- it does not always mean they are hungry”

“Skin-to-skin contact , finger sucking helps to sooth babies who are crying” “Formula can change the baby’s gut- different bacteria start to grow and babies

can have more gas … it’s harder to digest formula.”

What about the Formula feeding babies? But isn’t Baby Friendly about breastfeeding?

___________________________________________________

It’s about ALL babies and ALL families!

Opportunity to teach about safe formula feeding and prevent overfeeding of formula fed babies

Slower flow nipples if family insists on bottle supplement for breastfed baby after education given

Allows equal “playing field” for Baby Friendly – teaching about infant feeding to all babies (BF and F)

Formula and Feeding Supplies: “Fair Market” Purchase

All formula and feeding supplies purchased

Fair Market value formula = same hospital discount as

other baby items (diapers, wipes)

Fairview “conflict of interest” policy

Formula treated like medication and other supplies

No free formula or discharge bags

Step 7: Rooming-In

Practice “rooming-in”-- allow mothers and infants to remain together 24 hours a day.

Step 7: Rooming-In

Rates of rooming in prior to BFHI approximately 25%

despite “allowing” rooming in

This was the most difficult step at our site

Talking about the hospital room as Mother-Baby room rather than baby in “mother’s room” Providers and nurses provide care at the bedside Concept of “Pair-Care” or “Couplet-care “ MDs do exams in pt rooms with “tool bucket”

Rooming-In : Step 7 Changed name of Newborn Nursery Newborn Medical Observation Unit “NeMOU” for short!! List of admission criteria for NeMOU

Medical indication (mom or baby) Social service 72 hr hold Hearing Screen Car seat trial Phototherapy (if can’t do in room) Time in and out documented

Step 7: Rooming-In Changed time of weights

No midnight weights

Weights done in room on evening shift - encourages

baby and mom together

Allows discussion with parents about weight and

reassurance or change in feeding plan for night

Improves parent confidence in baby care before

discharge

Step 7: Rooming-In Emphasize culture of doctors and nurses “coming to the bedside”

to provide care

“this is what we do here”- this is our routine and this is why….

”we do not have a well baby nursery”

“this is the family room- it is the room for mom AND baby”

Only “sick” babies go to the “Medical Observation Unit”

“Let me help you get some rest with your baby right here next to

you” (in bassinette)

“your baby will sleep better right next to you”

“You learn how to care for your baby before you go home”

Step 8: On Demand - feeding cues

Encourage breastfeeding on demand

Teaching about breastfeeding 8-12 times/day for good milk supply

Cluster feeding q 1-3 hrs , not schedule Reassure about clustering Crying is a late sign of hunger Parents are taught early feeding cues – latching

goes better when baby not frantic

Step 9: Pacifiers and Bottles Give no pacifiers or artificial nipples to

breastfeeding infants.

Pacifiers not routinely given to any baby

Parents can bring in own pacifier (BYOP) but we discourage use until 3-4 wks

Education given about impact of pacifier on milk supply and nipple confusion

Step 9: no pacifiers

Admission orders –”no pacifier for breastfed baby” Pacifiers reserved for painful procedures and medical

indications 1. Painful procedures (rare- no circumcisions done at our

hospital)

2. Withdrawal symptoms 3. Phototherapy 4. Preterm infants in NICU

Step 9 – no bottles

No bottles if formula supplement is needed- flow is too fast, latch issues if use bottle too soon

Alternative Feeding

methods for medically indicated supplements instead of bottles--cup, finger feeding, spoon, SNS

Step 10: Support Groups • Foster the establishment of breastfeeding support

groups and refer mothers to them on discharge from the hospital or clinic

WIC Breastfeeding Peer Counselors (culturally appropriate)

La Leche League Mother baby groups Lactation consultation resources UMMC Outpatient Lactation clinic Breastfeeding Medicine Clinic at Fairview Children’s

Lessons Learned