Upload
others
View
4
Download
0
Embed Size (px)
Citation preview
Improving Exclusive Breastfeeding in an Urban Academic HospitalLaura P. Ward, MD, IBCLC, a Susan Williamson, RN, BSN, IBCLC, b Stephanie Burke, MS, RD, LD, IBCLC, b Ruby Crawford-Hemphill, RNC, BSN, MSA, c Amy M. Thompson, MDd
aPerinatal Institute, Division of Neonatology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, Ohio; bWomen’s Health Services and cUCMC Patient Care
Services, University of Cincinnati Medical Center, Cincinnati,
Ohio; and dDepartment of Obstetrics & Gynecology,
University of Cincinnati College of Medicine, Cincinnati, Ohio
Dr Ward was the pediatrics physician champion,
developed the pediatric education modules,
oversaw the analysis and interpretation of the
data, drafted the initial manuscript, and revised the
manuscript; Ms Williamson was the Baby-Friendly
Task Force Chair, developed and implemented
nursing education and the practice plan, supervised
data collection, and collaborated in manuscript
revisions; Ms Burke developed the nursing and staff
education modules, developed and implemented
the practice plan, coordinated and supervised
data collection, participated in data analysis,
and collaborated in manuscript revisions; Ms
Crawford-Hemphill was the administration team
leader, helped develop and implement the practice
plan, and collaborated in manuscript revisions; Dr
Thompson was the obstetrics physician champion,
developed the obstetrician education modules,
developed and implemented the practice plan, and
revised the manuscript. All authors approved the
fi nal manuscript as submitted.
DOI: 10.1542/peds.2016-0344
Accepted for publication Jul 25, 2016
Address correspondence to Laura P. Ward, MD,
IBCLC, Cincinnati Children’s Hospital Medical Center,
Division of Neonatology, 3333 Burnet Ave, MLC 7009,
Cincinnati, OH 45229. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2017 by the American Academy of
Pediatrics
Breast milk is the optimal source of
nutrition for newborns, conferring
many health benefits to mothers and
infants. Breastfed infants have a lower
risk of infant mortality and childhood
illnesses, including respiratory and
gastrointestinal infections, otitis
media, and childhood leukemias. 1 – 4
Breastfed infants are also less likely
to develop diabetes and obesity.1, 5
Maternal benefits include lower risk
of postpartum hemorrhage, breast
and ovarian cancers, and type 2
diabetes. 1, 6
Despite these benefits, national
breastfeeding rates are below the
goals set by Healthy People 2020. 7
Ohio’s exclusive breastfeeding (EBF)
rates are in the lowest quartile
nationally. 8 In addition, racial and
socioeconomic disparities exist. 9, 10
Antenatal education and hospital
practices that support breastfeeding
significantly affect breastfeeding
success, exclusivity, and duration,
regardless of socioeconomic status.11
In addition, the number of practices a
mother experiences is associated with
improved breastfeeding duration and
exclusivity. 12
University of Cincinnati Medical
Center (UCMC) has long-standing
low rates of EBF, and in June 2012
we began participation in Best
Fed Beginnings (BFB), a quality
improvement collaborative targeting
abstractBACKGROUND AND OBJECTIVE: Breastfeeding has many well-established health
benefits for infants and mothers. There is greater risk reduction in health
outcomes with exclusive breastfeeding (EBF). Our urban academic
facility has had long-standing low EBF rates, serving a population with
breastfeeding disparities. We sought to improve EBF rates through a
Learning Collaborative model by participating in the Best Fed Beginnings
project.
METHODS: Formal improvement science methods were used, including the
development of a key driver diagram and plan–do–study–act cycles.
Improvement activities followed the Ten Steps to Successful Breastfeeding.
RESULTS: We demonstrated significant improvement in the median adherence
to 2 process measures, rooming in and skin-to-skin after delivery.
Subsequently, the proportion of infants exclusively breastfed at hospital
discharge in our facility increased from 37% to 59%. We demonstrated an
increase in sustained breastfeeding in a subset of patients at a postpartum
follow-up visit. These improvements led to Baby-Friendly designation at our
facility.
CONCLUSIONS: This quality improvement initiative resulted in a higher number
of infants exclusively breastfed in our patient population at “high risk
not to breastfeed.” Other hospitals can use these described methods and
techniques to improve their EBF rates.
QUALITY REPORTPEDIATRICS Volume 139 , number 2 , February 2017 :e 20160344
To cite: Ward LP, Williamson S, Burke S, et al.
Improving Exclusive Breastfeeding in an Urban
Academic Hospital. Pediatrics. 2017;139(2):
e20160344
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
WARD et al
facilities serving populations at
highest risk not to breastfeed. BFB
was led by the National Institute
for Children’s Health Quality in
partnership with the Centers for
Disease Control and Prevention
and Baby-Friendly USA (BFUSA).
Through BFB, we received coaching,
technical assistance, and guidance
from breastfeeding and quality
improvement experts and access to
shared knowledge.
Our objective was to incorporate
evidence-based hospital practices to
improve EBF rates to 90% by August
2014 and to achieve Baby-Friendly
designation by September 2014.
We used the Learning Collaborative
model where representatives from
similar health care organizations
share their experiences while
individually implementing best
practices. 13 Group learning sessions
alternate with local action cycles.
Learning sessions are led by national
content experts. We chose this
model because of its success in other
national health care collaboratives,
such as improving end-of-life care,
decreasing appointment wait times,
and reducing adverse events. Here,
we share our improvement methods,
experiences, and outcomes to assist
hospitals intending to make similar
improvements.
METHODS
Setting
UCMC is a large, urban academic
medical center that trains obstetric
and pediatric residents and serves
southwestern Ohio, northern
Kentucky, and southeastern
Indiana. Fifty-five percent of women
delivering at UCMC receive prenatal
care at the Center for Women’s
Health (CWH), a hospital-based
resident and midlevel provider
practice; the remainder receive
care at community health centers,
local health departments, and the
academic physicians’ office, all
staffed by UCMC faculty. In fiscal
year 2011 (the year of application
to BFB), there were 2352 deliveries;
30% of patients were white, 51%
black, and 7% Hispanic; 82% had
Medicaid coverage, and 15% were
privately insured. Because of these
characteristics, our interventions
needed to engage trainees, faculty,
staff, and hospital leadership. Our
hospital’s 7-year plan included
an initiative to pursue national
certification and recognition that
coincided with Ohio’s campaign to
lower the infant mortality rate.
Improvement Team
In July 2012, we assembled a
multidisciplinary team that included
an administrative leader, obstetrics
and pediatrics physicians, a mother–
infant nurse manager, labor and
delivery and postpartum staff nurses,
and lactation consultants. The team
evolved to include a Women, Infants,
and Children administrator and
peer. 14 The team developed a key
driver diagram ( Fig 1) and identified
improvement activities and plan–
do–study–act cycles to meet the
aims. 15 The UCMC Office of Research
Compliance determined that our
project was a quality improvement
initiative and not human subjects
research.
The team attended 3 BFB
Collaborative Learning sessions,
participated in regular webinars,
reported monthly data, implemented
and tested changes, and shared
resources with other hospital teams.
The desired BFB outcome was
Baby-Friendly designation of all
participating hospitals by September
2014. BFB surveyors conducted a
mock site visit to evaluate readiness
for a BFUSA assessment. They
reviewed infant feeding policies,
compliance with BFUSA guidelines,
and interviewed providers and
patients. Visit findings provided
opportunities to correct deficiencies
before the actual BFUSA assessment.
Improvement Activities
Our improvement activities
followed the Ten Steps to Successful
Breastfeeding, 16 endorsed
by the American Academy of
Pediatrics (AAP), the World Health
Organization, and other health care
organizations. A dose-dependent
relationship exists between
breastfeeding duration, exclusivity,
and the number of these steps a
mother experiences during the
delivery hospitalization. 12, 17
Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff.
⚬ Policy written and implemented
(online Supplemental file).
Step 2: Train all health care staff in the skills necessary to implement this policy.
⚬ Nursing education (for which
staff was compensated): online
breastfeeding modules (15
hours), skill laboratory (4
hours), breastfeeding policy
in-service (1 hour).
⚬ Pediatric providers: 2 hour
lectures for residents and
fellows, AAP slide sets
distributed with posttest 18 (3
hours).
⚬ Obstetric providers: American
College of Obstetrics and
Gynecology publications 19, 20
and breastfeeding videos
(taped neonatal grand rounds
and Stanford University
breastfeeding/hand
expression) 21 with posttest (4
hours).
⚬ New employees complete
training within 6 months of hire.
Step 3: Inform all pregnant women about the benefits and management of breastfeeding.
⚬ CWH staff education: Lactation
consultant lecture (3 hours).
⚬ Community (non-CWH)
nurse case managers: online
e2 by guest on August 24, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 2 , February 2017
breastfeeding modules (20
hours), training by lactation
consultant (3 hours).
⚬ Policy written and implemented
outlining prenatal breastfeeding
education topics.
⚬ Prenatal education checklist
generated in electronic medical
record (EMR) to facilitate
efficient documentation.
⚬ Pocket scripts developed
for breastfeeding education
reflecting policy (Supplemental
Information A).
Step 4: Help mothers initiate breastfeeding within 1 hour of birth.
⚬ Skin-to-Skin (STS) Task Force
created.
⚬ Infant nurse role developed to
facilitate STS for all medically
appropriate deliveries regardless
of feeding plan.
Step 5: Show mothers how to breastfeed and maintain lactation, even if they are separated from their infants.
⚬ Initiate timely pumping within
6 hours of delivery if couplet
separated. Extra pumps and
hands-free pumping bras
obtained.
Step 6: Give infants no food or drink other than breast milk, unless medically indicated.
⚬ Developed acknowledgment
form for families, explaining the
risks of non–medically indicated
supplementation (Supplemental
Information B).
⚬ Created physician order for
supplementation and smart
phrase documentation in EMR
(Supplemental Information C).
Step 7: Practice rooming-in: allow mothers and infants to remain together 24 hours a day.
⚬ Nursery was staffed only
for procedures and was
subsequently named the
Newborn Observation Unit to
minimize separation, optimize
family recognition of feeding
cues, and prevent delayed
feedings.
⚬ Computer workstations on
wheels obtained for family-
centered rounds.
⚬ Infant location documented in
EMR.
e3
FIGURE 1Key driver diagram.
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
WARD et al
Step 8: Encourage breastfeeding on demand.
⚬ Infant-led feedings encouraged
for breastfed and formula-fed
infants.
⚬ Nursing personnel, including
labor and delivery staff, trained
in latching techniques and
positions.
Step 9: Give no pacifiers or artificial nipples to breastfeeding infants.
⚬ Pacifiers eliminated from the
postpartum unit, except for
medical indications. Scripts
developed to respond to
maternal requests for pacifiers;
smart phrases developed in
the EMR for documentation
of counseling (Supplemental
Information C).
⚬ Alternative feeding methods
introduced (syringe, cup, and
supplemental nursing system).
⚬ Case managers counseled
patients in prenatal visits
regarding risk of early pacifier
use.
Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.
⚬ A Women, Infants, and Children–
funded peer provided part-time
counseling.
⚬ Outpatient lactation visits
promoted.
⚬ Telephone support system
(warm-line) provided to patients
upon discharge.
⚬ Hospital-based breastfeeding
support group developed.
Study Population
There were 4181 total deliveries
during the study period. The study
population included all infants cared
for on the postpartum unit at UCMC
from July 2012 through December
2014. Infants were excluded for NICU
transfer or maternal contraindication
to breastfeeding (Supplemental
Information D).
Outcome Measures
The primary outcome measure was
the percentage of infants exclusively
fed breastmilk. Infants were excluded
from this measure if the mother
exclusively formula fed from birth,
after being informed of the benefits
of breastfeeding. If supplements were
medically indicated, breastfeeding
was considered exclusive. A secondary
outcome measure was the percentage
of mothers reporting breastfeeding at
a CWH postpartum visit.
We identified 2 process measures.
Rooming-in was the percentage of
infants separated from their mothers
for ≤1 hour per day; STS was the
percentage of infants placed STS with
their mothers within 5 minutes of
birth, until the first breastfeed or 1
hour of life.
Data Collection
From July 2011 to June 2012, we
reviewed 30 charts per month to
establish a baseline EBF rate for
the year preceding BFB. From July
2012 to October 2012 we selected
every fourth medical record from
monthly delivery reports (n =
50). Starting in November 2012,
30 infant charts were reviewed,
per BFB project guidelines. 22
We extracted the following data
from the infant hospital charts:
breastfeeding assistance, exclusivity,
supplementation, rooming-in,
feeding on cue education, and
discharge lactation support referral.
Maternal charts were reviewed
to assess breastfeeding intent,
prenatal breastfeeding education,
and STS compliance at delivery.
We performed an EMR query for
sustained lactation success. This
included charts of CWH patients
seen postpartum with a documented
feeding plan from November 2012 to
December 2014. The data collection
periods for inpatient and outpatient
were different because of the 6-week
postpartum period and coincidental
implementation of an EMR system at
our hospital.
Data Analysis
Statistical process control charts and
run charts evaluated the impact of
interventions on the outcomes over
time. These tools can evaluate the
effectiveness of change over time and
distinguish common cause variation
(causes that are random in the process
over time) from special cause variation
(causes that are not part of the process
but arise due to the process). 23
Observed changes in the mean and
median line are considered statistically
significant when the line shifts on a
chart by 8 points in either direction,
6 consecutive points either increase
or decrease, or 14 consecutive points
alternate above or below the line.
RESULTS
Our initial efforts focused on 2 key
hospital practices changes: STS and
rooming-in. Before BFB, STS after
delivery was rarely practiced. The
STS Task Force, made up of key
stakeholders, established weekly
meetings to discuss small tests
of change. The STS Task Force
acknowledged challenges voiced
by delivery personnel and adapted
practices to satisfy STS goals
and provider concerns. Although
improvement in STS was achieved
quickly with vaginal deliveries, we
observed slower progress in cesarean
deliveries. Mock drills demonstrated
the complex documentation,
monitoring, and supportive role of the
circulator nurse at cesarean delivery;
a dedicated infant nurse allowed for
STS in the operating room without
compromising patient safety. Since
STS was instituted for all infants, staff
and families shared their observations
of innate newborn behaviors, and
consequently several patients changed
their feeding plans from formula
to breastfeeding. This unexpected
consequence, along with data from
e4 by guest on August 24, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 2 , February 2017
plan–do–study–act cycles, increased
acceptance of STS benefits. With these
measures implemented by 8 months,
the median STS rate was 24.5%; by 15
months, STS increased to 59% for all
modes of delivery ( Fig 2).
Before project initiation, infants
rarely roomed in with their mothers,
and causes and duration of couplet
separation were not documented in
the EMR. During early discussions,
provider-cited reasons for separation
included newborn teaching rounds,
newborn assessments, circumcision,
and the perception that mothers
preferred uninterrupted rest.
Additionally, providers referenced
the nursery as a place to care for
multiple infants whose mothers
lacked family support. A pediatrician
tested newborn teaching rounds in
patient rooms and reported back
to the physician group to address
concerns. We obtained portable
equipment to facilitate performance
of newborn assessments. Our
obstetrician champion engaged the
postpartum team to adopt a patient-
centered rather than provider-
centered approach to circumcisions.
Specifically, this approach included
individualized timing rather than
provider-convenient, designated
times for circumcisions. Nurses
performed bedside postcircumcision
checks rather than using the
Newborn Observation Unit.
Acknowledging that hospital staff
frequently interrupt mothers’
sleep, we instituted daily quiet
times to promote maternal rest. We
explained that rooming-in empowers
mothers to care for their infants and
encourages maternal recognition
of feeding cues, without affecting
maternal sleep. 24 – 26 Through these
initiatives, we improved rooming-in
to a median rate of 70% at 7 months
and 98% at 15 months ( Fig 3).
In the year preceding BFB, the baseline
rate of EBF was 37%, and within 6
months of the project, EBF increased
to 59% ( Fig 4). After observing an
unexplained deviation in March
2014, we subsequently audited all
newborn charts to ensure validity and
eliminate sampling error. We found a
small but significant improvement in
our secondary outcome of sustained
breastfeeding in women with prenatal
care at CWH. The median number of
women reporting breastfeeding at an
outpatient visit rose from 42% to 50%
in 18 months ( Fig 5).
DISCUSSION
Before our initiative, the cultural norm
did not include EBF, rooming-in, or STS
after delivery. Through participation in
the BFB Learning Collaborative model,
we successfully implemented evidence-
based hospital practices and increased
breastfeeding rates measured at
hospital discharge and a postpartum
visit. These changes provided
the foundation for Baby-Friendly
designation at our urban academic
health center in December 2014.
By June 2015, only 31 of 89 Learning
Collaborative hospitals achieved
Baby-Friendly designation. 22 We
e5
FIGURE 2Percentage of infants placed skin-to-skin after delivery.
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
WARD et al e6
FIGURE 3Percentage of infants who room in.
FIGURE 4Percentage of infants who are exclusively breastfed.
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 2 , February 2017
believe our organizational leadership
and concurrent, mutually beneficial
initiatives were key factors in our
success. We strategically associated
this department quality improvement
project with the hospital mission
to provide life-changing, patient-
centered care. Our participation in
BFB aligned our practices with the
Joint Commission Perinatal Core
Measures on EBF, 27 a publicly reported
accountability measure. The timing
of this project coincided with public
health efforts to lower the infant
mortality rate in Hamilton County and
Ohio, which our leadership champion
used to solidify the hospital’s financial
commitment and justify the increased
budget for maternity and neonatal
services. Practically, this required the
Purchasing Department to negotiate a
fair market price for formula, purchase
online modules, and cover payroll costs
for nursing education time.
The obstetrics and pediatrics
departments absorbed physician
training expenses.
Before BFB, many individuals
supported breastfeeding mothers
but functioned in silos. We
encountered numerous challenges
in our efforts to implement practice
changes. The didactic and clinical
skill sessions across multiple units
involved considerable time and
labor. Maintaining documentation
compliance required unremitting
vigilance and accountability. No
additional personnel were hired for
these activities, so workloads shifted
to maintain clinical coverage while
accommodating the extended duties of
data collection and education required
for the project. The intrinsic motivation
of many individuals was a critical, but
difficult to measure, key to our success.
For salaried members of the STS
Task Force and staff, including
pediatric and obstetrics residents,
no additional time was allotted for
meetings and training. We believe
critical buy-in was gained from
these groups, given the public health
benefits of breastfeeding and the
evolving demographics of resident
physicians. Six obstetric residents
became parents during our project.
Nationally, more residents become
parents during residency than
ever before, 28 and similar personal
motivation is probably shared by
other residency training hospitals.
A residency training hospital
supportive of breastfeeding for its
patients indirectly supports the
breastfeeding of resident trainees
and their future patients.
It is worth noting the increase in
our EBF rates was significant but
not as large as improvements we
experienced with STS and rooming
in, and we did not meet our goal of
90%. Our experience mirrored that
of other collaborative hospitals,
because the average increase in
EBF rates across all BFB facilities
was only 27%. 22 We found that
families continue to request
non–medically indicated formula
e7
FIGURE 5Percentage of CWH patients breastfeeding at an outpatient postpartum visit. WIC, Women, Infants, and Children.
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
WARD et al
despite our counseling, and many
have the prenatal intention of both
breastfeeding and formula feeding.
We suspect there are broader
cultural and generational biases to
be addressed well before pregnancy,
delivery, and even conception.
We must acknowledge certain
limitations to our results. The
data sampling measures may not
accurately reflect the EBF rate.
Our outpatient data suggest that
sustained breastfeeding increased, as
other authors in the literature have
described, 29 although this outcome
was measured only in a subgroup of
patients receiving prenatal care in
our clinic. In addition, this measure
is based on maternal report and does
not describe exclusivity. Although
exact timing of the postpartum
visit was not available, most visits
occurred within 6 weeks. Because
of practical constraints, the baseline
for this outcome was generated with
EMR implementation rather than
project initiation. It is possible the
baseline could be lower, resulting
in greater improvement; given
the preexisting culture, we do not
suspect the baseline would be higher.
Some barriers we faced implementing
the Ten Steps 16 were unique to urban
or academic health facilities. Our
demographics and hospital dynamics
may not generalize to all facilities,
especially those already serving
populations with high breastfeeding
rates. 30 In fact, our own evolving
demographics may provide false
reassurance of sustainability. By 2014,
our deliveries increased by 7.8%,
which included a greater percentage
of privately insured patients. We
cannot rule out the possibility that
these changes factored into the
improvements we experienced.
Despite these demographic changes,
added complexity remains in caring
for underserved populations in the
context of an academic medical
center with many faculty and resident
physicians transitioning monthly.
Another noteworthy challenge
has been reconciling AAP
recommendations to consider
pacifier use to prevent unexplained
infant death 31 while promoting step
9. Although the AAP recommends
delaying pacifier use until 1 month
for breastfed infants, 31 we have found
that this recommendation might
represent a mixed message with
regional infant mortality reduction
efforts for parents, families, nurses,
physicians, and public health officials.
Nevertheless, we are dedicated to
collaborating with all stakeholders,
and we strive for a unified approach
as we move forward.
Baby-Friendly designation marks
not the end of a journey but rather
an ongoing pathway for which
sustainability has distinct barriers.
Overall, we are gratified by the
changed attitudes and diminished
biases among our staff, physicians,
and families. This project fostered
standardized communications
with patients and families and
collaborative interaction between
providers. As an added benefit, we
found the educational processes
required for Baby-Friendly
designation improved staff retention,
helped recruit nurses, and promoted
resident physician well-care.
CONCLUSIONS
This initiative represents a
multitiered approach to improve
the health of our community and
to address existing disparities.
Although challenging, Baby-Friendly
designation is achievable, and it
sets the standard for breastfeeding
support and mother–infant care. It is
particularly important for academic
centers training future health care
providers to adopt best maternity
practices to improve health outcomes
for mothers and infants.
e8
ABBREVIATIONS
AAP: American Academy of
Pediatrics
BFB: Best Fed Beginnings
BFUSA: Baby-Friendly USA
CWH: Center for Women’s
Health
EBF: exclusive breastfeeding
EMR: electronic medical record
STS: skin-to-skin
UCMC: University of Cincinnati
Medical Center
FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.
FUNDING: Best Fed Beginnings was supported by the Centers for Disease Control through the National Institute for Children’s Health Quality.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.
REFERENCES
1. Ip S, Chung M, Raman G, Trikalinos TA,
Lau J. A summary of the Agency for
Healthcare Research and Quality’s
evidence report on breastfeeding in
developed countries.Breastfeed Med.
2009;4(suppl 1):S17–S30
2. Bowatte G, Tham R, Allen KJ, et al.
Breastfeeding and childhood acute
otitis media: a systematic review
and meta-analysis. Acta Paediatr.
2015;104(467):85–95
3. Chen A, Rogan WJ. Breastfeeding and
the risk of postneonatal death in the
United States. Pediatrics. 2004;113(5).
Available at: www. pediatrics. org/ cgi/
content/ full/ 113/ 5/ e435
4. Sankar MJ, Sinha B, Chowdhury R,
et al. Optimal breastfeeding practices
and infant and child mortality: a
systematic review and meta-analysis.
Acta Paediatr. 2015;104(467):3–13
5. Horta BL, Loret de Mola C, Victora
CG. Long-term consequences of
breastfeeding on cholesterol, obesity,
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
PEDIATRICS Volume 139 , number 2 , February 2017
systolic blood pressure and type
2 diabetes: a systematic review
and meta-analysis. Acta Paediatr.
2015;104(467):30–37
6. Chowdhury R, Sinha B, Sankar MJ,
et al. Breastfeeding and maternal
health outcomes: a systematic review
and meta-analysis. Acta Paediatr.
2015;104(467):96–113
7. US Department of Health and Human
Services. Maternal, infant and child
health. Objectives. Available at: www.
healthypeople. gov/ 2020/ topics-
objectives/ topic/ maternal- infant- and-
child- health/ objectives. Accessed
October 13, 2015
8. Center for Disease Control and
Prevention. Nutrition, physical activity,
and child health. Available at: www. cdc.
gov/ breastfeeding/ data/ reportcard/
reportcard2011. htm. Accessed October
13, 2015
9. American College of Obstetricians and
Gynecologists. Committee opinion no.
570: breastfeeding in underserved
women: increasing initiation and
continuation of breastfeeding. Obstet
Gynecol. 2013;122(2 pt 1):423–428
10. Jones KM, Power ML, Queenan
JT, Schulkin J. Racial and ethnic
disparities in breastfeeding.
Breastfeed Med. 2015;10(4):186–196
11. Declercq E, Labbok MH, Sakala C,
O’Hara M. Hospital practices and
women’s likelihood of fulfi lling their
intention to exclusively breastfeed. Am
J Public Health. 2009;99(5):929–935
12. Murray EK, Ricketts S, Dellaport J.
Hospital practices that increase
breastfeeding duration: results from
a population-based study. Birth.
2007;34(3):202–211
13. Institute for Healthcare Improvement.
The Breakthrough Series: IHI’s
collaborative model for achieving
breakthrough improvement. IHI
Innovation Series white paper.
2003. Available at: www. ihi. org/
resources/ pages/ ihiwhitepapers/
thebreakthroughse riesihiscollabora
tivemodelforachie vingbreakthroughi
mprovement. aspx. Accessed June 9,
2016
14. About WIC Breastfeeding Peer
Counseling. Available at: https://
lovingsupport. fns. usda. gov/ content/
about- wic- breastfeeding- peer-
counseling. Accessed June 4, 2016
15. Langley GI, Moen RD, Nolan KM,
Nolan TW, Norman CL, Provost LP.
The Improvement Guide. 2nd ed. San
Francisco, CA: Jossey-Bass; 2009
16. Baby-Friendly USA. The ten steps to
successful breastfeeding. Available at:
www. babyfriendlyusa. org/ about- us/
baby- friendly- hospital- initiative/ the- ten-
steps. org. Accessed October 19, 2015
17. Perrine CG, Scanlon KS, Li R, Odom E,
Grummer-Strawn LM. Baby-Friendly
hospital practices and meeting
exclusive breastfeeding intention.
Pediatrics. 2012;130(1):54–60
18. American Academy of Pediatrics
Breastfeeding Residency Curriculum
Tools. Accessible at: https:// www2. aap.
org/ breastfeeding/ curriculum/ tools.
html. Accessed June 4, 2016
19. American Congress of Obstetricians
and Gynecologists. Breastfeeding your
baby (FAQ029). Available at: www. acog.
org/ Patients/ FAQs/ Breastfeeding- Your-
Baby. Accessed January 3, 2016
20. Committees on Healthcare for
Underserved Women and Obstetric
Practice. Breastfeeding: maternal
and infant aspects. ACOG Clin Rev.
2007;12(1):1S–16S
21. Stanford Medicine Newborn Nursery
at LPCH. Available at: http:// newborns.
stanford. edu/ Breastfeeding/
HandExpression. html. Accessed
December 3, 2015
22. National Institute for Children’s Health
Quality. Best Fed Beginnings. June
30, 2015. Available at: www. nichq.
org/ sitecore/ content/ breastfeeding/
breastfeeding/ solutions/ best- fed-
beginnings. Accessed December 3,
2015
23. Benneyan JC, Lloyd RC, Plsek PE.
Statistical process control as a
tool for research and healthcare
improvement. Qual Saf Health Care.
2003;12(6):458–464
24. Keefe MR. The impact of infant
rooming-in on maternal sleep at
night. J Obstet Gynecol Neonatal Nurs.
1988;17(2):122–126
25. Waldenström U, Swenson A.
Rooming-in at night in the
postpartum ward. Midwifery.
1991;7(2):82–89
26. Ball HL, Ward-Platt MP, Heslop E,
Leech SJ, Brown KA. Randomised
trial of infant sleep location on
the postnatal ward. Arch Dis Child.
2006;91(12):1005–1010
27. The Joint Commission. Joint
Commission perinatal core measure
PC-05. Available at: https:// manual.
jointcommission. org/ releases/
TJC2013A/ MIF0170. html. Accessed June
9, 2016
28. Finch SJ. Pregnancy during residency:
a literature review. Acad Med.
2003;78(4):418–428
29. Hughes V. The Baby-Friendly Hospital
Initiative in US hospitals. Child Obes
Nutr. 2015;7(4):182–187
30. Brodribb W, Kruske S, Miller YD.
Baby-Friendly hospital accreditation,
in-hospital care practices,
and breastfeeding. Pediatrics.
2013;131(4):685–692
31. Moon RY; Task Force on Sudden
Infant Death Syndrome. SIDS and
other sleep-related infant deaths:
expansion of recommendations
for a safe infant sleeping
environment. Pediatrics.
2011;128(5):1030–1039
e9 by guest on August 24, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2016-0344 originally published online January 4, 2017; 2017;139;Pediatrics
Amy M. ThompsonLaura P. Ward, Susan Williamson, Stephanie Burke, Ruby Crawford-Hemphill and
Improving Exclusive Breastfeeding in an Urban Academic Hospital
ServicesUpdated Information &
http://pediatrics.aappublications.org/content/139/2/e20160344including high resolution figures, can be found at:
Referenceshttp://pediatrics.aappublications.org/content/139/2/e20160344#BIBLThis article cites 20 articles, 6 of which you can access for free at:
Subspecialty Collections
http://www.aappublications.org/cgi/collection/breastfeeding_subBreastfeedinghttp://www.aappublications.org/cgi/collection/nutrition_subNutritionsubhttp://www.aappublications.org/cgi/collection/quality_improvement_Quality Improvement_management_subhttp://www.aappublications.org/cgi/collection/administration:practiceAdministration/Practice Managementfollowing collection(s): This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or
Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:
by guest on August 24, 2020www.aappublications.org/newsDownloaded from
DOI: 10.1542/peds.2016-0344 originally published online January 4, 2017; 2017;139;Pediatrics
Amy M. ThompsonLaura P. Ward, Susan Williamson, Stephanie Burke, Ruby Crawford-Hemphill and
Improving Exclusive Breastfeeding in an Urban Academic Hospital
http://pediatrics.aappublications.org/content/139/2/e20160344located on the World Wide Web at:
The online version of this article, along with updated information and services, is
http://pediatrics.aappublications.org/content/suppl/2017/01/02/peds.2016-0344.DCSupplementalData Supplement at:
by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
by guest on August 24, 2020www.aappublications.org/newsDownloaded from