Neonatal Nurse Practitioner CHOP Newborn Care at Pennsylvania Hospital Swarthmore, Pennsylvania, United States
Background: Feeding clinically stable preterm infants in the first 24 hours of life can improve infant outcomes without associated risk for necrotizing enterocolitis. However, over half of such infants were fed >24 hours after birth at our center. This quality improvement project aimed to streamline the process of feed initiation in stable preterm infants. Objective: We aimed to increase the proportion of preterm infants administered enteral feeds within the first 24 hours of life from 49% to 75% in 6 months. Design/Methods: Quality improvement study of inborn Infants born at a single center at < 35 weeks gestation and < 2 kg birthweight. We excluded infants who required inotrope support or remained admitted for < 24 hours after birth. Primary outcome was time to first feed (TTFF) defined as the time from birth to first enteral feed. The balancing measure was the proportion of infants administered human donor milk (DHM) as their first feed vs. those fed mothers' own milk (MOM). Race, ethnicity, language, first feed type (MOM vs. DHM), and central line days were tracked. We assessed existing processes around first feeding with a multidisciplinary team. We identified the availability of MOM as a major barrier to early feed initiation and the lack of antepartum lactation education and access to pumps in the delivery room as a barrier to MOM availability (Figure 1). Using PDSA cycles, we initiated routine antepartum lactation consults, made pumps available in the delivery room, and provided clinician education. We also standardized feeding regimens for preterm infants. Results: Proportion of infants with TTFF < 24 hours increased from 49% to 81% exceeding our goal of 75% (Figure 2). Central line days were not different in the two periods. Overall, the type of first feed remained unchanged (Table 1). However, among infants with TTFF < 24 hours, the proportion of infants receiving DHM increased from 26.3% to 50.1%., p < 0.001. Compared to the baseline period, the increase in DHM as first feed in post-implementation period was more prominent in Black dyads (50% to 63%, p 0.2) and Asian dyads (60% to 88%, p 0.16) than among White dyads (43% to 44%, p >0.99).
Conclusion(s): Process changes and multidisciplinary teamwork allowed our birth center to improve the TTFF. However, the increase in DHM use for Black and Asian dyads is a reminder of the inequities in breastfeeding rates across different communities. Enhancing a diverse representation among lactation consultants and postpartum nursing and providing targeted support before birth and after discharge may be avenues to support breastfeeding equitably across all communities. PAS_TTFF_Figure_1.jpeg
