PROJECT LEADS: Rebecca Carter, MD, Vidya Pai, MD, Clare Pearson, RN, CNL
EXECUTIVE SPONSORS: James Anderson, MD, Director of Neonatology, UCSF Benioff Children’s Hospital Oakland, Leslie Lusk, MD, Medical Director, ECMO Co-Medical Director, UCSF Benioff Children’s Hospital Oakland
ABSTRACT: Mother’s own milk (MOM) is the optimal nutrition source for critically ill infants. Provision of MOM is associated with reductions in many short- and long-term neonatal morbidities. Use of MOM is associated with both direct and indirect cost savings through reduction in subsequent healthcare utilization and improved neurodevelopmental outcomes. Benioff Children’s Hospital (BCH) Oakland neonatal intensive care unit (NICU) discharges fewer infants on MOM than other safety net NICUs in California. Without regular lactation support from a dedicated NICU International Board-Certified Lactation Consultant (IBCLC), our NICU has struggled to increase rates of breastfeeding and MOM use. We propose the introduction of regular lactation support to help mothers establish and maintain milk supply, and the initiation of an oral milk drops procedure to provide MOM to all infants on day-of-life 3 until ready for oral feeding. Through this intervention, we will increase the rates of breastfeeding and MOM use at time of NICU discharge and reduce length of NICU hospitalization by ≥1 day in at least 30% of NICU admissions. Based on a variable direct cost of $3,154/day, and an average of 393 yearly admissions from 2022-2024, we estimate a direct cost savings of $369,018 for FY2026. Because the benefits of MOM feedings far exceed these measurable direct cost benefits, we expect the financial savings to the healthcare system to greatly exceed this estimate. Additional benefits include cost savings from reducing donor human milk and formula use; decrease in short- and long-term neonatal morbidities; reduction in rehospitalization rates and pediatric subspecialty visits; and improved patient and family experience through enhanced bonding. This intervention aligns with the True North Pillars of improving clinical outcomes, improving financial performance, and creating exceptional patient experiences.
TEAM: Rebecca Carter, MD, Project Lead; Vidya Pai, MD, MS Epi, Project Lead; Clare Pearson, RN, CNL, Nursing Project Lead; Manchen Hao, MPH, PMP, Quality Improvement Advisor; Taranae Mahmoodi, Neonatology Service Line Director; Phuong Huynh, RD; Vanessa Kobza, RD; Leslie Lusk, MD, Medical Director, Neonatology, UCSF Benioff Children’s Hospital Oakland
PROBLEM: Mother’s own milk (MOM) is the optimal nutrition source for critically ill and premature infants. When provided during a critical exposure period in the NICU hospitalization, MOM is associated with a reduction in many short-term neonatal morbidities including late onset sepsis, necrotizing enterocolitis, chronic lung disease, and retinopathy of prematurity.1,2 Dose-dependent effects of human milk feeding have been demonstrated to improve cognitive and language development,4 and reduce healthcare utilization through fewer hospitalizations, pediatric subspecialty visits, and specialized therapy supports after NICU discharge.5 Estimated costs of these prematurity-related complications that may be avoided with MOM use range from $27,890 for late-onset sepsis to $46,103 for necrotizing enterocolitis (in 2016 US dollars).6
Lactation consultants are essential resources for hospitalized newborns and their mothers. Dedicated NICU lactation support is associated with increased rates of breastfeeding and MOM use during hospitalization and at time of discharge.7-9 Lactation support also provides direct cost savings through reduction in donor milk and formula use in addition to the previously described indirect cost savings through improved health outcomes.
The proportion of infants receiving mother’s own milk (MOM) at time of discharge from the BCH Oakland NICU is lower than comparable safety net NICUs in California, particularly in our most vulnerable population of Very Low Birth Weight (VLBW) infants. From 2018-2022, only 42% of our VLBW babies were receiving MOM at NICU discharge, compared to 67% for comparable California safety net NICUs. Black VLBW infants fare particularly poorly, with less than 30% of Black infants receiving MOM at NICU discharge. Despite interventions to promote breast pumping and address barriers to MOM use by our quality improvement team, our rates of breast milk use are poorly sustained for the duration of NICU hospitalization. Based on input from our families and staff, the inability to provide regular and frequent lactation support is one of the most significant barriers to improving rates of breastfeeding and MOM use.
Critically ill infants experience many invasive oral procedures, such as suctioning, taping, feeding tube insertion, intubation, and mask ventilation. These repetitive experiences can negatively impact oral function and the subsequent progression of oral feeding skills.9 Delayed oral feeding competence is a primary driver of prolonged NICU hospitalization, and mitigation of negative oral experiences during the period of critical infant brain development is essential to promoting feeding proficiency.9,10 O’Rourke et al utilized lactation support to provide positive oral experiences through the provision of oral milk drops in infants unable to orally feed. They found that this low-cost intervention led to a 4-day reduction in hospital length of stay and an estimated cost savings of over $600,000, in addition to enhanced parental understanding of oral feeding and improved bonding.10
TARGET: Our goal is to establish regular lactation support for families in the BCH Oakland NICU. With the support of a dedicated IBCLC, we will provide early, regular, and frequent lactation support for breast pumping. We will partner with a local lactation service that currently supports the UCSF Mission Bay ICN and the BLOOM: Black Love Opportunity and Outcome Improvement in Medicine Clinic, to provide racially concordant lactation support to Black race-identifying families. We will provide education to staff and family on the benefits of human milk feedings and standardize and support the transition to non-nutritive breastfeeding (NNBF) and nutritive breastfeeding (NBF). For infants unable to feed orally, we will establish a procedure for families and staff to provide oral milk drops. We will utilize the electronic health record to automate interventions and track outcomes.
GAPS
Gap | Specific driver | Interventions |
Educational | Lack of knowledge on benefits of human milk, pumping, positive oral stimulation on feeding outcomes | -Educational sessions for physicians and nurses -Monthly newsletter to nursing staff -Educational handouts to families |
Systems | Mother-infant separation | Transport team brings educational materials to referring hospital |
Systems | Lack of IBCLC support | Recruit IBCLC |
Technological | Lack of standardized pathway for introducing NNBF and NBF | Clinical guideline dissemination |
INTERVENTION
Intervention | Description | Rationale |
Education | -“Milk Matters” newsletter -Staff education sessions, nursing skills day -Educational handouts brought to referral hospital by transport team -Education outreach to referral hospital staff | Lack of knowledge of MOM benefits |
Colostrum collection kit delivered to referring hospital | Families will receive a cooler bag with syringes and oral swabs for colostrum collection, and educational handouts | Mothers often remain hospitalized for days after infant transfer |
Lactation supply cart | Create and maintain lactation supply cart with pumping kits, pumping logs, nipple shields, galactagogues, educational materials | Ensure availability of pumping equipment at bedside |
Community partners | Partner with Alameda Women Infants and Children (WIC) to obtain loaner pumps | Ensure pump available for home |
Weekly lactation rounds | -Discuss maternal milk supply, barriers to MOM provision weekly at ID rounds -Review eligibility for NNBF, NBF | Multidisciplinary involvement |
Clinical pathway | -Clinical procedure for oral milk drops -Standardize eligibility for NNBF, NBF | Reduce practice variability |
Order modification | -Automate orders: milk drops, IBCLC consult, NNBF and NBF | Reduce practice variability |
Collaboration | Partner with MB ICN, review cross-bay outcome measures and share high-impact interventions. | Share successes and challenges |
Audit | Create dashboard to track outcome measures and stratify by birth weight, gestational age, race/ethnicity: - IBCLC consultation rates - % infants receiving oral milk drops - % infants breastfeeding at NICU discharge - % infants receiving MOM at NICU discharge | Provide feedback on impact of improvement efforts |
Urgency: The American Academy of Pediatrics proposed standards for levels of neonatal care in 2023, indicating that an IBCLC be available on-site for weekday consultation and be accessible by phone 24/7.12With no dedicated NICU IBCLC, the BCH Oakland NICU does not meet this standard of care.
Barriers: Implementing an IBCLC and providing oral milk drops will require creation of new workflows, in addition to education and training of nursing staff. We aim to mitigate these challenges through educational sessions and in-unit training.
Possible adverse outcomes: Breast milk administration error rates will continue to be tracked and reviewed.
Plan to measure and close equity gaps: Rates of lactation consultation, expressed milk volumes, direct breastfeeding, and MOM use at discharge will be measured for all patients and further stratified by race and ethnicity. Any identified inequities will be communicated to clinicians, and efforts to close potential gaps will be incorporated into the interventions.
PROPOSED EHR MODIFICATIONS: APeX order sets will be revised to automate orders for IBCLC consultation, oral milk drops, and eligibility criteria for NNBF. A dashboard will be created to track outcome measures and review data with key stakeholders.
RETURN ON INVESTMENT (ROI): For FY24, the cost components for BCH Oakland NICU bed days (variable direct costs only) were $3,154 per day. The average number of NICU admissions from 2022-2024 was 393 infants. Based on a conservative estimate of length of stay reduction of 1 day in at least 30% of NICU admissions in FY2026, we estimate a direct cost savings of $3,154/day x (393 x 30%) = $369,018 for FY2026.
SUSTAINABILITY: These interventions will be sustained by the BCH Oakland NICU quality improvement team led by Drs. Pai and Carter, Clare Pearson, Phuong Huynh, and Vanessa Kobza. Outcome measures will be reviewed monthly to ensure continuous quality improvement. If the introduction of a dedicated NICU IBCLC proves to be a high-impact intervention, we will advocate to establish a permanent partnership with our local lactation services.
BUDGET: See attachment
