NICU関連資料 ibclcnicu BFHINU March 2011

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T HE BFHI INITIATIVE IN

NEONATAL UNITS

PROPOSAL FROM A _N ORDIC

AND _Q UEBEC

WORKING GROUP

THREE GUIDING PRINCIPLES AND TEN STEPS _:

SUPPORTING _B REASTFEEDING AND

F ^AMILY - CENTERED CARE

DRAFT FOR THE 1 ST INTERNATIONAL

CONFERENCE AND WORKSHOP ON THE EXPANSION OF THE

BABY FRIENDLY HOSPITAL INITIATIVE

IN

NEONATAL UNITS

14

^TH

-16

^TH

S

EPTEMBER

2011

IN

U

PPSALA

, S

WEDEN

2

Members of the Nordic and Quebec working group



Norway

Anna-Pia Häggkvist, RN, MSc, IBCLC

Mette Ness Hansen, RN, Midwife, IBCLC

Sweden

Kerstin Hedberg Nyqvist, RN, PhD

Elisabeth Kylberg, nutritionist, PhD, IBCLC

Finland

Leena Hannula, RN, Midwife, MNSc, PhD

Katja Koskinen, RN, Midwife, IBCLC

Aino Ezeonodo, RN, EN, PN, NICN, HC

Denmark

Ragnhild Måstrup, RN, IBCLC, doctoral student

Annemi Lyng Frandsen, RN, IBCLC

Québec,Canada

Laura N. Haiek, MD, MSc

Contactaddressesintheendofthedocument,page52

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Table of contents

MEMBERSOFTHEWORKINGGROUP 2



TABLEOFCONTENTS: 3



THEADAPTATIONOFBFHITONEONATALUNITS 5

DEFINITIONSANDABBREVIATIONS: 10



GUIDINGPRINCIPLE1:CLINICALSTAFFATTITUDETOTHEMOTHERRELATEDTO

BREASTFEEDINGMUSTHAVEAFOCUSONTHEINDIVIDUALMOTHERANDHER

SITUATION. 11



GUIDINGPRINCIPLE2:PROVIDEFAMILYCENTEREDCAREANDENVIRONMENT.

  14



GUIDINGPRINCIPLE3:CONTINUITYOFCARE:PREǦ,PERIǦANDPOSTǦNATAL,AND

POSTǦDISCHARGECARE 17



STEP1:HAVEAWRITTENBREASTFEEDINGPOLICYTHATISROUTINELY

COMMUNICATEDTOALLHEALTHCARESTAFF 20



STEP2:EDUCATEANDTRAINALLSTAFFINTHESPECIFICKNOWLEDGEAND

SKILLSNECESSARYTOIMPLEMENTTHISPOLICY. 22



STEP3:INFORMHOSPITALIZEDPREGNANTWOMENATRISKFORPRETERM

DELIVERYORBIRTHOFANILLINFANTABOUTTHEMANAGEMENTOFLACTATION

ANDBREASTFEEDINGANDBENEFITSOFBREASTFEEDING. 25



STEP4.ENCOURAGEEARLY,CONTINUOUSANDPROLONGEDMOTHERǦINFANT

SKINǦTOǦSKINCONTACT(KANGAROOMOTHERCARE)WITHOUTUNWARRANTED

RESTRICTIONS. 2



STEP5:SHOWMOTHERSHOWTOINITIATEANDMAINTAINLACTATIONAND

ESTABLISHEARLYBREASTFEEDINGWITHINFANTSTABILITYASTHEONLY

CRITERION. 30



STEP6.GIVENEWBORNINFANTSNOFOODORDRINKOTHERTHANBREAST

MILK,UNLESSMEDICALLYINDICATED. 35



STEP7:ENABLEMOTHERSANDINFANTSTOREMAINTOGETHER24HOURSADAY

  38

4

STEP8.ENCOURAGEDEMANDFEEDINGOR,WHENNEEDED,SEMIǦDEMAND

BREASTFEEDINGASATRANSITIONALSTRATEGYFORPRETERMANDILL

INFANTS. 41



STEP9:USEALTERNATIVESTOBOTTLEFEEDINGATLEASTUNTIL

BREASTFEEDINGISWELLESTABLISHEDANDONLYUSEPACIFIERSANDNIPPLE

SHIELDSFORJUSTIFIABLEREASONS. 44



STEP10:PREPAREPARENTSFORCONTINUEDBREASTFEEDINGANDENSURE

ACCESSTOSUPPORTSERVICES/GROUPSAFTERHOSPITALDISCHARGE447



 UNICEF.THEINTERNATIONALCODEOFMARKETINGOFBREASTǦMILK

SUBSTITUTES50

CONTACTINFORMATION 52

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The adaptation of the BFHI to neonatal units

The initiation and maintenance of breast milk production is of great importance for the mother to be able to breastfeed a preterm or ill infant. Early, systematic and continuing support for mothers to initiate breast milk expression and feeding at breast as soon as the infant is stable is essential for helping them to succeed in overcoming physiological and emotional challenges related to lactation and breastfeeding (1, 2) This is the background for developing and adapting the WHO/UNICEFs Baby- Friendly Hospital Initiative (BFHI) to the neonatal units. This world-wide initiative provides since 1991 an evidence-based set of standards for the protection, promotion and support of breastfeeding in maternity units (3). Compliance with the BFHI “Ten Steps to Successful Breastfeeding” (Ten Steps) has been proven to be effective in increasing breastfeeding duration and exclusivity (4). Evidence arises from randomized control trials examining policies and practices outlined in the individual steps as well as one large study – the PROBIT trial –that measured effectiveness of the initiative as a whole(4). Furthermore, several observational studies suggest that there is a relationship between the number of steps implemented in a facility, and breastfeeding exclusivity (5-7) and duration (6, 8-12).

WHO/UNICEF has recently updated and expanded the BFHI to ensure the health care system and other relevant sectors support the recommendation of exclusive breastfeeding for six months and continued breastfeeding for up to two years of age or beyond, while providing women with the support that they require to achieve this goal, in the family, community and workplace (3).

This global effort recognizes breastfeeding as the normal way of providing young infants with the nutrients they need for healthy growth and development (13, 14), including preterm and ill newborns (15, 16). In fact, there is growing evidence that exclusive and prolonged breastfeeding improves maternal-infant health in both developing and developed countries (4, 17-19). Furthermore, breast milk is species-specific, and all substitute feeding preparations differ markedly from it, making breast milk uniquely superior for infant feeding. Breast milk-fed preterm infants receive significant benefits with respect to host protection and improved developmental outcomes compared with formula-fed preterm infants (15, 20). More specifically, the immunological components of breast milk protect premature children from infections, and in particular life threatening illness even in western countries such as neonatal sepsis and necrotizing enterocolitis (15, 21) and support the development and maturation of the infant’s own immune system, which may explain some of the long-term health benefits observed in breastfed children (17, 18).

Several countries have been expanding the BFHI to other settings that care for breastfeeding mothers and babies, such as community health centers and neonatal care units (3). In the Nordic countries, Norway and Denmark have adapted the BFHI Ten Steps to take into consideration the special context of neonatal units and the unique needs of premature and sick babies admitted to these

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units. Norway has developed a process similar to the one used for maternity units; most Norwegian neonatal units have been successfully certified as Baby-Friendly (22). Denmark has conducted an unpublished pilot study in two hospitals and developed the Ten Steps for preterm infants. In Sweden, neonatal units were evaluated and assessed as Baby-Friendly at the same time as maternity units in the same hospital.

These adaptations have been supported by an increasing number of publications documenting the effectiveness of breastfeeding-related best practices in neonatal units. Three recent systematic reviews have established the importance of professional and peer-support, implementing hospital practices such as skin-to-skin, kangaroo mother care and rooming in as well as adopting effective methods to support mothers initiate and maintain milk production (1, 2, 23). Early initiation of breastfeeding, with infant stability as the only criterion is another important issue to be considered (24-26).

In addition, some studies report positive effects of implementing the Baby-Friendly standards on breastfeeding rates and exclusivity in neonatal units (27-28). To date, there is no consensus on which breastfeeding-related policies and practices should be recommended for neonatal unit nor have any study examined the effectiveness of these expanded initiative.

The main difference between maternity units and neonatal units is that most neonatal units separate the mothers from the infants, there is little or no space for the mothers and the possibility for having a chair or a bed at the infant’s bedside is not always granted. In addition mothers to a premature or ill full term infant have more need for support from the father or other family members because of the emotional stress they are in. For mothers in a neonatal unit, the transition to motherhood entails a crisis, a process which takes time (29). In this setting, lactation often has to be initiated with expression using a pump. These mothers may perceive breastfeeding as mutually pleasurable and reciprocal, or – contrarily – as task-oriented, non-reciprocal. There is a risk that hospital nutrition and feeding practices are interpreted by mothers as a message that breastfeeding is a maternal responsibility: an obligation to transfer a certain volume of milk, a norm to be fulfilled; if so, a mother’s inability to meet expectations on success in lactation and breastfeeding may lead to feelings of failure and shame (30, 31).

In Sweden, the recommendations of the Ten Steps were studied in the neonatal care setting. The results showed that mothers need more, and to some extent different breastfeeding support. The views, experiences and thoughts of the mothers resulted in a modified version of the Ten Steps (32). It is of importance to raise the awareness among health and medical professionals about mothers’ feelings around breastfeeding, to improve guidance and - of course respect - and support mothers who fail in breastfeeding or choose not to breastfeed at all. These mothers and infants specially need have to be taken in consideration when developing standards for BFHI in neonatal units.

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Who is doing the adaptation?

The Nordic working group was formed in Copenhagen, March 2009 by professionals from Sweden, Norway, Denmark, Finland and Quebec, Canada to address the expansion of the BFHI to neonatal care. The working group has developed a unified adaptation of the BFHI to Neonatal units, based on review of the evidence, expert opinion, and Nordic experiences. To remain consistent with the WHO/UNICEF’s 2009 update of the BFHI standards (i.e., the “Global Criteria”) (3), it was decided that the adaptation of the BFHI to neonatal units should closely follow the revised Ten Steps. To ensure that the recommended practices focuses on respect to mothers, a family-centered approach and a continued chain of care, the working group formulated three Guiding Principles meant to go like a thread through the Ten Steps. In agreement with the BFHI, the adaptation also includes the respect of the International Code of Marketing of Breastmilk Substitutes (Code). It must be noted that in the spirit of this adaptation, neonatal units typically covers all levels of neonatal care, including healthier infants who may require episodic or short-term monitoring or medical interventions.

Objectives of the adaptation

Aim

To expand and adapt the Ten Steps to protect, promote and support breastfeeding in the neonatal unit based on WHO/UNICEF’s BFHI (3).

Objectives

1. To examine the evidence in relation to breastfeeding promotion, protection and support in the neonatal units

2. To develop and adapt standards and criteria

3. To develop an assessment tool to evaluate if neonatal units comply with the criteria 4. To pilot the new assessment tool

5. To promote implementation of the adapted standards

6. To encourage research to assess the effectiveness of the adaptation

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References

1. Renfrew MJ, Craig D, Dyson L, et al. Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technol Assess 2009;13:1-146, iii-iv.

2. Rice SJ, Craig D, McCormick F, Renfrew MJ, Williams AF. Economic evaluation of enhanced staff contact for the promotion of breastfeeding for low birth weight infants. Int J Technol Assess Health Care 2010;26:133-40.

3. World Health Organization/UNICEF. Baby-Friendly Hospital Initiative. Revised, Updated and Expanded for Integrated Care. Section 1: Background and implementation. In. Geneva: World Health Organization/UNICEF; 2009:70.

4. Kramer MS, Chalmers B, Hodnett ED, et al. Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001;285:413-20.

5. Declercq E, Labbok MH, Sakala C, O'Hara M. Hospital practices and women's likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health 2009;99:929-35.

6. Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics 2005;116:e702-8.

7. Toronto Public Health. Breastfeeding in Toronto: Promoting Supportive Environments. In. Toronto: Toronto Public Health; 2010:109.

8. Centers for Disease Control and Prevention. Breastfeeding-related maternity practices at hospitals and birth centers--United States, 2007. MMWR Morb Mortal Wkly Rep 2008;57:621-5.

9. DiGirolamo AM, Grummer-Strawn LM, Fein S. Maternity care practices: implications for breastfeeding. Birth 2001;28:94-100.

10. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics 2008;122 Suppl 2:S43-9.

11. Murray E. Hospital practices that increase breastfeeding-duration: results from a population based study. Birth 2006;34:202-10.

12. Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ, Crivelli-Kovach A. Impact of hospital policies on breastfeeding outcomes. Breastfeed Med 2008;3:110-6.

13. World Health Organization. Global Strategy for Infant and Young Child Feeding. In. Genève: World Health Organization; 2003:30.

14. Breastfeeding. World Health Organization, 2010. (Accessed May 17, 2010, 2010, at http://www.who.int/topics/breastfeeding/en/.)

15. Karen E, Rajiv B. Optimal feeding of low-birth-weight infants. Technical review. In. Geneva: World Health Organization; 2006:121.

16. The Value of Human Milk. HMBANA Position Paper on Donor Milk Banking. (Accessed December 15, 2009, at http://www.hmbana.org/downloads/position-paper-donor-milk.pdf.) 17. Horta B, Bahl R, Martinés J, Victora C. Evidence on the long-term effects of breastfeeding.

Systematic reviews and meta-analysis. In. Geneva: World Health Organization; 2007:52.

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18. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153. AHRQ Publication No. 07-E007. In: Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries Evidence Report/Technology Assessment No 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No 290-02-0022) AHRQ Publication No 07-E007. Rockville, MD: Agency for Healthcare Research and Quality; 2007:186

19. Leon-Cava N, Lutter C, Ross J, Martin L. Quantifying the benefits of breastfeeding: A summary of the evidence. In. Washington DC: Pan American Health Organization; 2002:168.

20. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics 2005;115:496-506.

21. Ronnestad A, Abrahamsen TG, Medbo S, et al. Late-onset septicemia in a Norwegian national cohort of extremely premature infants receiving very early full human milk feeding. Pediatrics 2005;115:e269-76.

22. The Baby Friendly Hospital Initiative in Norwegian neonatal units. Norwegian Resource Centre for Breastfeeding, 2011. (Accessed April 1st, 2011, at http://www.oslo- universitetssykehus.no/omoss/avdelinger/nasjonalt-kompetansesenter-for-

amming/Sider/enhet.aspx.)

23. McInnes RJ, Chambers J. Infants admitted to neonatal units--interventions to improve breastfeeding outcomes: a systematic review 1990-2007. Matern Child Nutr 2008;4:235-63. 24. Nyqvist KH, Sjoden PO, Ewald U. The development of preterm infants' breastfeeding behavior.

Early Hum Dev 1999;55:247-64.

25. Nyqvist KH, Farnstrand C, Eeg-Olofsson KE, Ewald U. Early oral behaviour in preterm infants during breastfeeding: an electromyographic study. Acta Paediatr 2001;90:658-63.

26. Nyqvist KH. Early attainment of breastfeeding competence in very preterm infants. Acta Paediatr 2008;97:776-81.

27. Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. Breastfeeding promotion in neonatal intensive care unit: impact of a new program toward a BFHI for high-risk infants. Acta Paediatr 2007;96:1626-31.

28. Merewood A, Philipp BL, Chawla N, Cimo S. The baby-friendly hospital initiative increases breastfeeding rates in a US neonatal intensive care unit. J Hum Lact 2003;19:166-71.

29. Shin H, White-Traut R. The conceptual structure of transition to motherhood in the neonatal intensive care unit. J Adv Nurs 2007;58:90-8.

30. Flacking R, Ewald U, Nyqvist KH, Starrin B. Trustful bonds: a key to "becoming a mother" and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Soc Sci Med 2006;62:70-80.

31. Flacking R, Ewald U, Starrin B. "I wanted to do a good job": experiences of 'becoming a mother' and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Soc Sci Med 2007;64:2405-16.

32. Nyqvist KH, Kylberg E. Application of the baby friendly hospital initiative to neonatal care: suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008;24:252-62.

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Definitions and Abbreviations:

Abbreviations:

NICU Neonatal intensive care unit 24 h/7d 24 hours a week

24 h/d 24 hours a day

PMA Postmenstrual Age (corresponds to gestational age after birth)

Definitionsinthisdocument:

Neonatal unit Neonatal unit covers all levels of neonatal care (levels I-III) MORE WORDS and pediatric units, including infants in maternity/postpartum units who require some kind of monitoring or medical and nursing interventions. “Baby in Special Care” is used in the original BFHI document

Father Includes partner or significant other person

Family Includes significant others and is defined by the parents.

Infant or baby “Infant” or “baby” refers to preterm and/or ill infants/babies. Otherwise infant or baby be described as healthy and/or fullterm.

Stable infant Stable infants: Infants regarding whom there is sufficient evidence of safety and positive effects of Kangaroo Mother Care: infants born at a gestational age of at least 28 weeks without severe physiological instability.

Clinical staff Staff in all levels of care including out-patient care Head/director of

nursing services

The professional who has the main responsibility for nursing care in the ward

Tactile stimulation Therapeutic intervention provided to the infant using touch by containment/”hand swaddling”, stroking, massage, holding etc. Nursing

supplementer

A method for supplementation by using a feeding tube device with a bag/bottle to hold milk, connected to fine tubing taped to the mother’s nipple, delivering supplementation to the baby at the same as he/she suckles the breast.

Pacifier Also called dummy or soother

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Guiding principle 1: Staff attitude to the mother related

to breastfeeding must have a focus on the individual

mother and her situation.

Mothers with infants in a neonatal ward may experience a delayed development of a maternal identity (1). They may give birth before they have passed all phases in the process of becoming a mother, experienced by mothers who give birth at term (2). For mothers in a neonatal ward, the transition to motherhood entails a crisis, a process which takes time (1). Their feelings can swing between shock, sorrow, emotional exhaustion, and hope; they can feel as if they are hovering around the edge of mothering (3). Preterm birth is a traumatic experience which may lead to maternal posttraumatic stress, non-balanced attachment representations, with long term consequences for the mother-infant relationship (4, 5). This requires early support, especially if the mother reports negative birth experiences.

These mothers may perceive breastfeeding as mutually pleasurable and reciprocal, or – contrarily - as task-oriented, non-reciprocal. There is a risk that hospital nutrition and feeding practices are

interpreted by mothers as a message that breastfeeding is a maternal responsibility: an obligation to transfer a certain volume of milk, a norm to be fulfilled; if so, a mother’s inability to meet expectations on success in lactation and breastfeeding may lead to feelings of failure and shame (6,7).

Mothers of preterm infants have described their milk as a connection between themselves and the infant, an integral part of their construction of motherhood (8), and may not feel as mothers until they can initiate breastfeeding (9). This makes the mother’s own milk highly valued, at the same time as it can places pressure on her to produce milk. When the mother considers breastfeeding a marker of

‘good motherhood’, her inability to produce enough milk can result in feelings of inadequacy and guilt (6, 7). This gives causes for concern, as maternal depressive symptoms and mothers’ early feeding behavior can have negative impact on the development of her maternal role. Mothers’ lack of confidence in feeding has been associated with maternal perceptions of the infant as vulnerable and parenting stress (10). In order to help mothers in attaining motivation for establishment of lactation and breastfeeding, support should be offered with empathy, in a psychologically and culturally appropriate way (11, 12).

Therefore, the mother must be met as a person, not only as a producer of breast milk and a care-giver who participates in the infant’s care by feeding the infant at the breast or by other feeding methods. She should be supported in making and implementing informed decisions about milk production, breastfeeding and infant feeding, according to her wishes.

All mothers of preterm infants and ill newborn infants must be recognized as “vulnerable” mothers. In addition, special attention should be paid to “particularly vulnerable” mothers (families): mothers who are first time mothers, mothers with previous breastfeeding difficulties, multiparous mothers with a long interval since the last birth, mothers with low socio-economic status (SES), smokers, mothers with substance abuse, and mothers belonging to groups with low breastfeeding incidence and duration. Regarding risk factors for not breastfeeding, epidemiological studies have consistently found less likelihood of breastfeeding in mothers of preterm infants, who are young, have a low level of education, and are smokers (13).

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Standards

 



1 a Treat every mother with sensitivity (meaning being responsive to what the mother communicates), empathy and respect for her maternal role.

1 b Give special attention to particularly “vulnerable” mothers (families) with respect to milk production, breastfeeding and infant feeding.

1 c Show respect to mothers who decide or are advised not to breastfeed, or do not succeed in reaching their breastfeeding goal.

CriteriaGP1a(questionsmothers)

x

At least 80 % of mothers rate the care they received from the clinical staff in the ward as 7 or more on a VAS scale measuring sensitivity.

x

At least 80 % of mothers rate the care they received from the clinical staff in the ward as 7 or more on a VAS scale measuring empathy.

x

At least 80 % of mothers rate the care they received from the clinical staff in the ward as 7 or more on a VAS scale measuring respect for her maternal role.

x

At least 80 % of mothers rate the care they received from the clinical staff in the ward as 7 or more on a VAS scale measuring her role as a primary caregiver.

CriterionGP1a(questionsmothers)

x

At least 80 % of mothers rate the support they received from the clinical staff in the ward in making their own decisions about milk production as 7 or more on a VAS scale.

x

At least 80 % of mothers rate the support they received from the clinical staff in the ward in making their own decisions about breastfeeding as 7 or more on a VAS scale.

x

At least 80 % of mothers rate the support they received from the clinical staff in the ward in making their own decisions about infant feeding before the infant’s discharge from hospital as 7 or more on a VAS scale.

CriterionGP1b(review)

x

The breastfeeding policy defines which mothers (families) should be regarded as particularly

“vulnerable” and be given special attention with respect to milk production, breastfeeding and feeding.

CriterionGP1c(questionmothers)

x

At least 80 % of mothers who decided not to breastfeed, or who do not breastfeed because of failure in the establishment of breastfeeding, rate the respect shown to them regarding being a non-breastfeeding mother as 7 or more on a VAS scale.

References

1. Shin H, White-Traut R. The conceptional structure of transition to motherhood in the neonatal intensive care unit. Journal of Advanced Nursing 2007; 58(1):90-98

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2. Bruschweiler-Stern. Early emotional care for mothers and infants. Pediatrics 1998;102(5):1278- 81

3. Lau R, Morse CA. Stress experiences of parents with premature infants in a special care nursery. Stress and Health 2003;19:69-78

4. Forcada-Guex M, Borghini A, Pierrehumbert B, Ansermet F, Muller-Nix C. Prematurity, maternal posttraumatic stress and consequences on the mother-infant relationship. Early Human Development 2001;87:21-26

5. Meijssen D, Wolf M-J, van Bakel H, Koldewijn K, Kok J, van Baar A. Maternal attachment representations after very preterm birth and the effect of early intervention. Infant Behavior and Development 2010, doi.10.1016/j.infbeh.2010.09.009

6. Flacking R, Ewald U, Hedberg Nyqvist K, Starrin B. Trustful bonds: A key to “becoming a mother” and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit. Social Science & Medicine 2006;62:70-80

7. Flacking R, Ewald U, Starrin U. ‘I wanted to do a good job”: Experiences of ‘becoming a

mother’ and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit. Social Science & Medicine 2007;2405-16

8. Sweet L. Expressed milk as ‘connection’ and its influence on the construction of ‘motherhood’ for mothers of preterm infants: a qualitative study. International Breastfeeding Journal 2008;3:30. 9. Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care:

Suggestions by Swedish mothers of very preterm infants. Journal of Human Lactation 2008; 24(3):252-62

10. Teti DM, Hess CR, O’Connell M. Parental perceptions of infant vulnerability in a preterm sample: Prediction from maternal adaptation to parenthood during the neonatal period. Developmental and Behavioral Pediatrics 2005;26:283-92

11. Lee R-Y, L T-T, Kuo S-H. The experience of mothers in breastfeeding their very low birth weight infants. Journal of Advanced Nursing 2009;65(129:2523-3

12. Ekström A, Matthiesen AS, Widström AM, Nissen E. Breastfeeding attitudes among counselling health professionals. Scand J Public Health. 2005;33(5):353-9

13. Zachariassen G, Faerk J, Grytter C, Exberg BH, Juvonen P, Halken S. Factors associated with successful establishment of breastfeeding in very preterm infants. Acta Paediatrica 2010;Feb 11. E-pub ahead of print.

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Guiding principle 2: Provide family centered care and

environment.

The ward should respect the rights, responsibilities, and duties of parents to provide appropriate direction and guidance for their infant according to article 5 in the UN Convention on the Rights of the Child (1).

A family-centered individualized developmentally supportive environment is characterized by the attitude that parents are the most important persons in their infant’s life and act as the infant’s primary caregivers (as far as this is possible considering the infant’s medical condition and treatment). Core concepts of patient- and family-centered care are dignity and respect, information sharing,

participation, and collaboration (2).

Family-centered care is a concept that must be integrated into the culture and functioning of a neonatal unit. An environment that supports the presence and involvement of families may enhance family- centered care. A high level of collaboration with the families is more dependent on the attitudes of the staff and the relationships that the staff established with the families of infants in the ward than on the physical facilities (3).

Optimal support of parents as primary caregivers is achieved by offering parents freedom of choice regarding performance of tasks and advancement of taking over care (4). Mothers want a family- centered and supportive physical environment, support of the father’s presence, and early transfer of infants’ care to the parents (5). The parents must be seen as a whole, but also as individuals, mothers’ and fathers’ needs may not be the same. The father is not only the mother’s supporter. Fathers of preterm infants who experience support, security, and happiness, feel that they are in control and able to handle the situation (6). Fathers suggest that they could be included in the process of breastfeeding, by providing a favourable environment for the mother and baby and be present during breastfeeding (7).

Training in family-centered care should be arranged on a regular basis and be included in the education of all new staff members (4).

The design of the ward accommodates parents’ presence as far as possible (8, 9). Stimuli such as levels of illumination, sound and activity are modified according to the individual infant’s and parent’s needs (5), and measures are taken for safeguarding privacy for the family. Providing the mother in the neonatal ward with a comfortable chair enables the mother to support the preterm infant’s behaviour during breastfeeding (10).

Individualized developmental care (NIDCAP) promotes autonomic and motoric stability, better developed state regulation and improved attentional functioning, and infants showed significantly shorter stays on tube feeding. (11)

When the Neonatal individual developmental care assessment program (NIDCAP) principles are used during breastfeeding it can support the infant’s breastfeeding behaviour (10).

Few countries support parents’ presence 24 hours seven days a week (24h/7d) also during “doctor’s rounds”, but this is a possible practice and should be supported (11).

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Standards

 



2 a Encourage the presence of the father/family without unjustified restrictions as the mother´s supporter and the infant’s care-giver.

2 b The ward transfers the infant’s care gradually to the parents, commencing as soon as possible after birth, with support by professionals.

2 c The ward provides practical possibilities, such as a place to rest and eat, for mothers/parents to be able to stay with their baby as long as they want.

2 d The ward provides individualized developmentally supportive surroundings that are appropriate for the infant and the parents and facilitates breastfeeding.

CriterionGP2a(review,observations)

x The breastfeeding policy states and observation confirms that the father/family member or significant others are allowed in the ward.

Levels: *** without restrictions 24h/7d, * until 2 hours of restriction/24 hours

CriteriaGP2b(review,interviewwithmothers)

x Ward policy states early transfer of the infant’s care after the birth to the parents.

x At least 80 % of mothers report that they began participating in the infant’s care within the first 24 hours after the birth, unless justified by the mother’s condition and care.

x At least 80 % of mothers report that the infant’s father began participating in the infant’s care within the first 24 hours after the birth.

x At least 80 % of mothers report that both parents are participating in infant care as much as they want.

CriteriaGP2c(observations,interviewwithmothers)

x Observation confirms that all mothers of infants in the neonatal ward have access to a bed/comfortable arm chair - recliner/chair without arms at the infant’s bedside.

x At least 80% of the mothers report that they had a bed/ comfortable arm chair - recliner /chair without arms at the infant’s bedside.

Levels: ***bed ** comfortable arm chair - recliner *chair without arms at the infant’s bedside. x At least 80% of the mothers report that they were able to eat in the ward/ close to the ward

(max 5 min walking distance)/ not far from the ward (max 10 min walking distance) Levels: *** eat in the ward, ** close to the ward (max 5 min walking distance), *not far from the

ward (max 10 min walking distance)

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CriteriaGP2d(observations,interviewwithmothers) 

x Observations confirm that preterm infants’ eyes are not exposed to direct light

x At least 80 % of mothers report that the level of illumination is comfortable and adequate for their needs.

x At least 80 % of mothers report that the level of sound and activity in the nursery is comfortable.

x At least 80 % of mothers report that arrangements for her and the family’s privacy are adequate.

References

1. Office of the United Nations High Commissioner for Human Rights. Convention on the rights of the child: http://www2.ohchr.org/english/law/crc.htm (downloaded 3rd February 2011)

2. http://www.familycenteredcare.org/faq.html

3. Saunders RP, Abraham MR, Crosby MJ, Thomas K, Edwards H. Evaluation and development of potentially better practices for improving family-centered care in neonatal intensive care units. Pediatrics 2003;111(4):e437-49

4. Nyqvist KH, Engvall G. Parents as their infant's primary caregivers in a neonatal intensive care unit. J Pediatr Nurs. 2009 Apr; 24(2):153-63.PMID: 19268237

5. Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care: Suggestions by Swedish mothers of very preterm infants. Journal of Human Lactation 2008; 24(3):252-62

6. Lundqvist P, Jakobsson L. Swedish men's experiences of becoming fathers to their preterm infants Neonatal Netw. 2003 Nov-Dec; 22(6):25-31.

7. Pontes CM, Osório MM, Alexandrino AC. Building a place for the father as an ally for breastfeeding. Midwifery. 2009 apr; 25(2):195-202.

8. Beck SA, Weiss J, Greisen G, Andersen M, Zoffmann V. Room for family-centered care - a qualitative evaluation of a neonatal intensive care unit remodeling project. Journal of Neonatal Nursing 2009;15(3):88-99

9. Levin A. Humane Neonatal Care Initiative. Acta Paediatr. 1999 Apr;88(4):353-5.

10. Nyqvist KH, Ewald U, Sjoden PO. Supporting a preterm infant's behaviour during breastfeeding: a case report. J Hum Lact. 1996 Sep;12(3):221-8

11. Als H, Duffy FH, McAnulty GB. Effectiveness of individualized neurodevelopmental care in the newborn intensive care unit (NICU). Acta Paediatr Suppl. 1996 Oct;416:21-30.

12. Greisen G, Mirante N, Haumont D, Pierrat V, Pallás-Alonso CR, Warren I, Smit BJ, Westrup B, Sizun J, Maraschini A, Cuttini M; ESF Network. Parents, siblings and grandparents in the Neonatal Intensive Care Unit. A survey of policies in eight European countries. Acta Paediatr. 2009 Nov; 98(11):1744-50.

17

Guiding principle 3: Ensure continuity of care: pre-, peri-

and post-natal, and post-discharge care

Continuity of care involves care delivered over time to an individual infant and his/her family (1). The time frame may vary but includes distinct time periods or phases (2):

- A prenatal care phase, when parents anticipate the arrival of an infant who will require hospital care and may be in a critical condition. This period, which is anxiety-provoking and important to parents, is the entry point for the neonatal continuum of care.

- Birth and delivery room stabilization.

- Admission to a neonatal ward in the birth hospital, or a neonatal transport before admission to a neonatal ward at another hospital.

- The phase of hospital care may include an intensive care phase and an intermediate care phase. - In case the infant was initially transferred to another hospital, the next phase involves back transfer

to a local hospital for a phase of continued care.

- A pre-discharge preparatory phase followed by discharge to the home. An alternative is early discharge for continued care of the infant at home provided by the parents, supported by staff at the hospital, a home care agency or another health care facility.

- A follow-up phase.

- In case the infant requires continued long term care (for example for treatment with additional oxygen or ventilator treatment) this means a continued phase of intensive care at home.

The phases in lactation and breastfeeding include initiation of lactation, attainment and maintenance of an adequate milk production, initiation of breastfeeding and the mother’ attainment of her breastfeeding goals (ideally exclusive breastfeeding) – combined with a transition phase using feeding methods and nutrition policies that are supportive of breastfeeding.

In moving through these stages, preterm and ill infants will be cared by several care providers who could potentially work at cross purposes (1). Continuity is achieved when providers deliver consistent care that is responsive to the infant’s and his/her family’s changing needs (1, 3, 4), with a continuity in approach (3). This necessitates shared policies and guidelines for infant care and for parents’ role, parent education programs (group activities, individual counseling or printed information) in order to achieve management continuity (1). Continuity of care of the individual infant and approach to the parents also refers to parents’ perceptions of the process of care (1, 4). On any given encounter, parents should perceive that decisions about their infant’s are based on policies which are shared by all her caregivers and to which all are willing to adhere, without any conflicting information or advice. Parents should feel confident that their caregivers know what has gone before, and that they (the parents) will not have to inform caregivers about their infant’s medical history and current care plan (3).

Regarding conflicting information and advice related to breastfeeding, mothers have described this as contradictory advice from different health professionals, frequent change of strategies, a hands-on approach in breastfeeding counseling, judgmental, critical and uncaring attitudes and minimal demonstration of empathy (5). In contrast, continuity of care by breastfeeding counselors with adequate training improves mothers’ perception of support (6)

The family-centered care approach, addressed in Guiding Principles 1 and 2, provides a framework to facilitate continuity of care (5) by, for example, promoting parents’ presence and participation as primary caregivers (6). As nurses' role transitions from caregiver to parent educator/coach, and parents take over more or nearly all components in their infants' care, they will be more informed about their infant's condition and actively participate in decisions about their care (6). This may act as a safeguard of continuity of care. Furthermore, continuity of care affects parents’ confidence in their infant’s safety and their own emotional status (7). Frequent staff changes, on the other hand, are perceived as a

18

risk for the infant’s safety and disregard of the parental role (8). Not surprisingly, continuity of care is one of the main outcomes or activities in all comprehensive global maternal-infant health initiatives (9-11). The continuity in neonatal ward physical environment (nursery environment, parent rooms and other parent/family facilities) should also be considered.

Standards

3 a Care in regards to the lactation and breastfeeding support during each stage of health care delivery (prenatal care, arrival of a “potentially” critical infant, acute/critical care phase, a stable-improving phase, a transfer-discharge phase, and a follow-up or continuing care) should be consistent.

3 b Provide a continuum of collaborative care with all relevant health care providers, institutions, and organizations involved in lactation and breastfeeding support.

CriteriaGP3a(review,questionsmothers)

x Continuity of care is addressed in the neonatal ward breastfeeding policy.

x The ward has an identified person responsible for working with continuity of care related to lactation and breastfeeding support.

x All clinical protocols or standards related to lactation and breastfeeding in preterm and ill infants are consistent in the hospital.

x At least 80 % of all mothers report that they receive consistent information regarding lactation and breastfeeding of their infant throughout the continuum of care.

CriteriaGP3b(questionsmothers,review)

x At least 80 % of the mothers report that the hospital clinical staff (medical and nursing) know what went on before with their infants and that they will not have to repeat the history of their infant’s medical condition and care, and current care plan (including current feeding and breastfeeding strategy) to different caregivers.

x Information regarding the current situation and strategy for maternal lactation and breastfeeding is included in the report provided by the neonatal unit when the infant’s care is transferred to the next phase of care.

19

References

1 Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003; 327: 1219-21.

2 Conner JM, Nelson EC. Neonatal intensive care: satisfaction measured from a parent's perspective. Pediatrics. 1999; 103: 336-49.

3 Green JM, Renfrew MJ, Curtis PA. Continuity of carer: what matters to women? A review of the evidence. Midwifery. 2000; 16: 186-96.

4 Rodriguez C, des Rivieres-Pigeon C. A literature review on integrated perinatal care. 2007/09/06 ed, 2007. p. e28. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1963469/

5 Hauck YL, Graham-Smith C, McInterney J, Kay S. Western Australian women's perception of conflicting advice around breast feeding. Midwifery, 2010, Apr 9. e-pub ahead of print

6. Ekstrom A, Widstrom A-M, Nissen E. Does continuity of care by well-trained breastfeeding conselors improve a mother's perception of support? Birth 2006;33(2):123-30

The Institute for Family-Centered Care. What is patient- and family-centered care?, .http://www.familycenteredcare.org/index.html (accessed May 21, 2010).

7 Nyqvist KH, Engvall G. Parents as their infant's primary caregivers in a neonatal intensive care unit. J Pediatr Nurs. 2009; 24: 153-63.

8 Hurst I. Mothers' strategies to meet their needs in the newborn intensive care nursery. J Perinat Neonatal Nurs. 2001; 15: 65-82.

9 Erlandsson K, Fagerberg I. Mothers' lived experiences of co-care and part-care after birth, and their strong desire to be close to their baby. Midwifery. 2005; 21: 131-8.

10 World Health Organization/UNICEF. Baby-Friendly Hospital Initiative. Revised, Updated and Expanded for Integrated Care. Section 1: Background and implementation. Geneva: World Health Organization/UNICEF, 2009. p. 70.

http://www.who.int/nutrition/publications/infantfeeding/9789241594967_s1.pdf

11 The International MotherBaby Childbirth Organization. The International MotherBaby Childbirth Initiative (IMBCI): 10 Steps to Optimal MotherBaby Maternity Services., 2010. www.imbci.org (accessed May 21, 2010).

11 World Health Organization. Making pregnancy safer. Geneva: World Health Organization, 2010. http://www.who.it/pregnancy/countries/20091007_5 (accessed May 21, 2010).

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Step 1: Have a written breastfeeding policy that is

routinely communicated to all health care staff

Hospitals with comprehensive breastfeeding policies are likely to have better breastfeeding support services and better breastfeeding outcomes (1, 2). The hospital BFHI policy increased breastfeeding rates at 2 days and 2 weeks postpartum (2). BFHI promotion increased the exclusivity and continuity of breastfeeding and decreased the risk of gastrointestinal tract infections in Belarus (1). Children born in BFHI health facility were more likely to be breastfed for a longer time, particularly if the hospital shows high compliance with UNICEF guidelines. BFHI should be extended to include monitoring for compliance, to promote the full effect of the BFHI. (3)

The implementation of a BFHI promotion program in neonatal wards had markedly positive effects on exclusive breastfeeding rates early after discharge from hospital in USA and Italy (4, 5). The impact of several recognized risk factors on exclusively breastfeeding rate was significantly reduced after the program was implemented, except for higher maternal age. Further studies are needed to adapt the Baby-Friendly Hospital Initiative (BFHI) approach to the neonatal unit setting, taking into account the characteristics of high-risk infants (5).

Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal unit (6). Having additional trained and skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Skin-to-skin contact in the kangaroo position, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital are effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone (6).Motivated staff, educational support, and clear guidelines are essential to support the implementation of BFHI in neonatal wards (7).

Standards

1 a The wards have a written breastfeeding or infant feeding policy that addresses all 10 Steps, the Guiding Principles and the standards related to Kangaroo Mother Care, unless the ward has a separate KMC policy.

1 b The policy protects breastfeeding by adhering to the International Code of Marketing of Breastmilk Substitutes. The Policy requires that ALL mothers, regardless of their feeding method, get feeding support they need. Mothers who do not breastfeed, HIV or for other reasons, receive counselling on infant feeding and guidance on selecting options likely to be suitable for their situations. The policy should include guidance for how each of the “Ten Steps” and other components should be implemented.

1 c The policy is available so that all clinical staff members who take care of mothers and babies can refer to it. Summaries of the policy covering the Ten Steps, the Guiding Principles, KMC standards, the Code and subsequent WHA Resolutions, and support for HIV-positive mothers, are visibly posted or available as written/picture information in all areas of the health care facility which serve pregnant women, mothers, infants, and/or children. These areas include the labour and delivery area, antenatal care in- patient wards and clinic/consultation rooms, post partum wards and rooms, all infant care areas, including well baby observation areas (if there are any) and neonatal wards. The summaries are displayed in the language(s) and written with wording most

commonly understood by mothers and clinical staff.

21

Criteriastep1a(question,review,observation)

x

The head/director of nursing services of neonatal/paediatric services reports that the ward has a written breastfeeding/infant feeding policy.

x

The policy can be reviewed by the evaluators

x

A copy of the summary of the policy is posted in various areas of the facility

Criterionstep1b(observation)

x

Observation confirms that there are no violations to the code

Criteriastep1c(questionmothers,observation)

x

At least 70% of the mothers are aware of the policy

x

Observation confirms that summaries of the policy are visibly posted/available in the wards.

References

1. Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP, Vanilovich I, Mezen I, Ducruet T, Shishko G, Zubovich V, Mknuik D, Gluchanina E, Dombrovskiy V, Ustinovitch A, Kot T, Bogdanovich N, Ovchinikova L, Helsing E; PROBIT Study Group (Promotion of Breastfeeding Intervention Trial). Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 2001; 24- 31;285(4):413-420.

2. Rosenberg KD, Stull JD, Adler MR, Kasehagen LJ, Crivelli-Kovach A. Impact of hospital

policies on breastfeeding outcomes. Breastfeeding Medicine 2008; 3(2):110-116.

3. Merten S, Dratva J, Ackermann-Liebrich U. Do baby-friendly hospitals influence breastfeeding duration on a national level? Pediatrics 2005; 116(5):e702-708.

4. Merewood A, Philipp BL, Chawla N, Cimo S. The baby-friendly hospital initiative

increases breastfeeding rates in a US neonatal intensive care unit. Journal of Human

Lactation 2003; 19(2):166-71.

5. Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. Breastfeeding promotion in neonatal intensive care unit: impact of a new program toward a BFHI for high-risk infants. Acta Pediatrica 2007; 96(11):1626-31.

6. Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, Misso K, Stenhouse E,

Williams AF. Breastfeeding promotion for infants in neonatal units: a systematic review

and economic analysis. Breastfeeding promotion for infants in neonatal units: a systematic

review and economic analysis. Health Technology Assessessment 2009; (40):1-146, iii-iv.

7. Taylor C, Gribble K, Sheehan A, Schmied V, Dykes F. Staff perceptions and experiences of

implementing the Baby Friendly Initiative in neonatal intensive care units in Australia. Journal of Obstetric, Gynecologic and Neonatal Nursing 2011; 40(1):25-34. doi: 10.1111/j.1552-

6909.2010.01204.x. Epub .

22

Step 2: Educate and train all staff in the specific

knowledge and skills necessary to implement this policy.

It is self-evident that training is necessary for the implementation of a breastfeeding policy. Health workers who have not been trained in breastfeeding management cannot be expected to give mothers effective guidance and provide skilled counseling, yet the subject is frequently omitted from curricula in the basic training of, doctors and nurses.

The implementation of Baby-Friendly policies leading to a Baby-Friendly designation was associated with increased breastfeeding initiation and duration rates (1, 2). Breastfeeding training for NICU staff has been shown to have impact on the initiation rate and rates of breast milk feeding at discharge in a study from USA (3). Siddell et al. could show a significant increase in NICU nurses' breastfeeding knowledge after education session. Findings suggest that an educational intervention has potential for improving NICU nurses' knowledge and certain attitudes about breastfeeding (4).

The need for practical aspects of breastfeeding to be included in the training is recognized as an essential step forward, but it may be necessary to update the practices of existing staff before basic training can be effective (5, 6).

It is necessary to increase knowledge as well as to increase skills, or the knowledge may not be able to be used (7). There is also a need to change attitudes that create barriers to breastfeeding promotion. These include: the assumption that health workers know enough already; a belief that there is no important difference between breastfeeding and bottle-feeding; a reluctance to allocate staff time to breastfeeding support; and a failure to recognize the impact of inconsistent or inaccurate information. Health workers may undermine mothers’ confidence, for example by implying criticism, or doubt about a mother’s milk supply. Ekstrom et al. showed how a process-oriented training in breastfeeding of health staff can alter the attitudes to breastfeeding and to breastfeeding mothers (8).

For in-service training to be successful it must be mandatory and supported by supervisory personnel, which requires a strong policy supported by senior staff. If training is voluntary, and senior staff uncommitted, attendance is likely to be poor, and only those whose attitude is already favorable will participate (9, 10).

Renfrew et al. (2009) concluded in their review that multidisciplinary staff’s training as well as the Baby Friendly accreditation has shown to be effective. Further it has been shown that skilled support from trained staff in hospital could be potentially cost-effective from the health perspective of the infants in the neonatal ward (11).

Jones et al. showed that training of the NICU-staff in breastfeeding resulted in higher milk-production, more time spent mother-infant skin-to-skin, more cup-feeding and higher frequency of feeding at the breast (12).

The nurse in the NICU-staff has a crucial role in promoting breastfeeding among the mothers to preterm babies (13)

Standards

2 a All health care staff at the neonatal ward are familiar with the existence of the policy and have basic knowledge in breastfeeding as well as the special needs of infants and

supporting mothers to enable early initiation of breastmilk production and breastfeeding. 2 b There is a plan in place for education and training of all new staff members, irrespective of

profession, and continuing education in the field should be provided on a regular basis. 2 c All clinical staff at the neonatal ward who have contact with mothers and/or infants and

have been on the staff 6 months or more have acquired knowledge corresponding to 20

23

hours of breastfeeding education that covers all 3 guiding principles and the 10 Steps, the Code and subsequent WHA resolutions, including at least three hours of supervised clinical training. In addition to this all clinical staff at the neonatal ward should get continuing education on a regular basis.

Criteriastep2

x A copy of the curricula or course session outlines for training in breastfeeding promotion and support for various types of staff is available for review, and a training schedule for new employees is available.

x Observation that education about the policy is part of the compulsory introduction program for all new staff

x Observation that opportunities for continuing education are offered.

x Observation that there is/are (a) identified person(s) with special knowledge in

breastfeeding and lactation in the ward, who carry special responsibility for breastfeeding and lactation support.

x Observation that the documentation of training indicates that 80% or more of the clinical staff members who have contact with mothers and/or infants, have got at least three hours of supervised clinical training. Non-clinical staff members have received training that is adequate, given their roles, to provide them with the skills and knowledge needed to support mothers in successfully feeding their infants. The training should cover key topics such as: the risks and benefits of various feeding options; helping the non-breastfeeding mother choose what is acceptable, feasible, affordable, sustainable and safe (AFASS) in her circumstances; the safe and hygienic preparation, feeding and storage of breast-milk substitutes; how to teach the preparation of various feeding options, and how to minimize the likelihood that breastfeeding mothers will be influenced to use formula.



Out of the randomly selected clinical staff members:

x At least 80% confirm that they have received the described training or, if they have been working in the NICU less than 6 months, have, at minimum, received orientation on the policy and their roles in implementing it.

x At least 80 % of all staff at the NICU are able to describe all 10 steps in the policy for breastfeeding friendly neonatal care.

x At least 80 % of all staff can describe benefits with breast milk and breastfeeding for infants and mothers.

x 90 % of all health staff are able to identify at least 5 factors which are important for early initiation of milk production (early initiation (within hours after birth), regular expression (every 3 hours), breast milk expression also during the night, early instruction in hand expression, easy access to a breast pump free of charge (electrical when possible), desired privacy during milk expression), suggestions about stress reduction/relaxation in

connection with milk expression)

24

References

1. Merewood A, Philipp BL, Chawla N, Cimo S. 2003 The baby-friendly hospital initiative increases breastfeeding rates in a US neonatal intensive care unit. J Hum Lact 2003;May;19(2):166-71 2. Dall'Oglio I, Salvatori G, Bonci E, Nantini B, D'Agostino G, Dotta A. 2007 Breastfeeding

promotion in neonatal intensive care unit: impact of a new program toward a BFHI for high-risk infants. Acta Paediatr. 2007;Nov;96(11):1626-31.

3. Isaacson LJ. 2006Steps to successfully breastfeed the premature infant. Neonatal Netw 2006;Mar- Apr;25(2):77-86.

4. Siddell E, Marinelli K, Froman RD, Burke G. 2003 Evaluation of an educational intervention on breastfeeding for NICU nurses. J Hum Lact 2003;Aug;19(3):293-302

5. Cattaneo A, Davanzo R, Uxa F, Tamburlini G. 1998 Recommendations for the implementation of Kangaroo Mother Care for low birthweight infants. International Network on Kangaroo Mother Care. Acta Paediatr. 1998;Apr;87(4):440-5

6. Nyqvist KH, Kylberg E. 2008 Application of the baby friendly hospital initiative to neonatal care: suggestions by Swedish mothers of very preterm infants. J Hum Lact 2008;Aug;24(3):252-62 7. Hannula L, Kaunonen M, Tarkka MT. 2008 A systematic review of professional support

interventions for breastfeeding. J Clin Nurs. 2008;May;17(9):1132-43.

8. Ekström A,Widström AM, Nissen E. 2005 Process-oriented training in breastfeeding alters attitudes to breastfeeding in health professionals. Scand J Publ Health 2005;33(6):424-31 9. Stokamer CL. 1990 Breastfeeding promotion efforts: why some do not work. Int J Gyn Obst

1990;31(Suppl 1):61-65

10. Iker CE, Mogan J. 1992 Supplementation of breastfed infants: Does continuing education for nurses make a difference? J Hum Lact 1992;8(3):131-35

11. Renfrew M, Craig D, Dyson L, McCormick F, Rice S, King S, Misso K, Stenhouse E, Williams A. 2009 Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technol Assess 2009;Aug;13(40):1-170

12. Jones E, Jones P, Dimmock P, Spencer A. 2004 Evaluating preterm breastfeeding training.

Pract Midwife 2004;Oct;7(9):19, 21-4

13. Wheeler JL; Johnson M; Collie L; Sutherland D. 1999 Chapman C. Promoting breastfeeding in the neonatal intensive care unit. Breastfeeding Review 1999;Jul;7(2):15-8

25

Step 3: Inform hospitalized pregnant women at risk for

preterm delivery or birth of an ill infant about the

management of lactation and breastfeeding and benefits

of breastfeeding.

”Common sense suggests that it must be important to talk to all pregnant women about infant feeding, to prepare them for this aspect of motherhood” (1).

Families need to be involved in decisions regarding feeding of their infant. It is extremely helpful if the discussion can take place prior to delivery, when the mother’s attention is not compromised by the condition of her infant (2). Suggestions from mothers of very preterm infants regarding modification of Baby-Friendly Hospital Initiative (BFHI) 10 Steps to Successful Breastfeeding emphasize the importance of early basic information about lactation and breastfeeding. Antenatal classes should cover breast milk benefits, breastfeeding techniques and possible problems, establishment of lactation by using a breast pump, and the fact that it may take some time before breastfeeding is possible (3). Prenatal consultation which includes information on the benefits and importance of breast milk feeding and also practical information regarding the support systems for breast milk expression and storage in the neonatal ward is associated with significantly longer breast milk feeding in preterm infants, both in hospital and after discharge. This effect suggest that hours and days immediately before preterm delivery may be of critical importance in influencing maternal planning regarding the feeding of her soon-to-be-born tiny infant (4).

A systematic review of professional support interventions for breastfeeding conclude that interventions expanding from pregnancy to the intra-partum period and throughout the postnatal period were more effective than interventions concentrating on a shorter period (5).

Standards

3 a Clinical staff from the neonatal intensive care unit visit pregnant women who are hospitalized in those cases where it is expected that the infant will be transferred to the neonatal intensive care ward after birth.

3 b Pregnant women/parents are informed about parents’ access to the unit and the importance of the parents’ presence for the infant’s wellbeing.

3 c

Pregnant women/parents are offered a discussion about breastfeeding and how

breastfeeding/breast milk feeding may be established, depending on the infant’s condition. The discussion reflects the needs of the family and might include the following:

x The significance of early stimulation of milk production and receive practical, specific information about how one goes about this.

x The particular benefits with breastfeeding/breast milk feeding for these infants and mothers.

x The importance of skin-to-skin contact with the baby after birth, as soon as possible, and the importance of letting the baby come to the breast early.

x The baby’s competence to feed and the expected condition of the baby.

Information must be given, taking into consideration the individual woman’s knowledge and whatever previous experience she may have with breastfeeding.

26

3 d Written information about breast milk, breastfeeding, including hand expression and pumping, is available.

3e There is a written summary of the breastfeeding information the pregnant women should receive. Provision of information is documented.

Criterionstep3a(questionsstaff)

x The Head/ director of Nursing Services can confirm that employees from the neonatal intensive care unit visit pregnant women who are hospitalized in those cases where it is expected that the baby will be transferred to the neonatal intensive care unit after birth.

Criterionstep3b(questionsmothers)

x At least 70 % of all mothers who were hospitalized more than 24 hours before the delivery confirm that a clinical staff member has talked with them a about parents’ access to the ward and their importance for their infant’s wellbeing.

Criteriastep3c(questionshead/directorandstaff)

x The Head/director of Nursing Services can show/refer to a written policy/check list covering the breastfeeding information the pregnant women get

x At least 80 % of all nursing clinical staff describe the breastfeeding information given to the pregnant women correctly.

Criterionstep3d(observations) 

x Written information about breast milk, breastfeeding, including hand expression and pumping is available.

Criterionstep3e(review) 

x There is a written summary of the breastfeeding information the pregnant women should receive. Provision of information is documented.

References

1. Evidence for the ten steps to successful breastfeeding. WHO/CHD/98.9. Geneva: World Health Organization, Division of child health and development, 1998. http://www.who.int (30.10.09). 2. Jones Liz. Principles to promote the initiation and establishment of lactation in the mother of a

preterm or sick infant. North Staffordshire Hospital 2008. http://www.babyfriendly.org.uk/pdfs/Liz_Jones_article_full.pdf

3. Hedberg Nyqvist K, Kylberg E. Application of the Baby Friendly Hospital Initiative to Neonatal Care: Suggestions by Swedish Mothers of Very Preterm Infants. J Hum Lact 2008; 24(3): 252- 262

4. Friedman S, Flidel-Rimon O, Lavie E et al. The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants. Acta Paediatr 2004; 93:775-778

5. Hannula L, Kaunonen M, Tarkka M-T. A systematic review of professional support interventions for breastfeeding. J Clin Nurs 2008; 17 (3): 1132–1143

27

Step 4. Encourage early, continuous and prolonged

mother-infant skin-to-skin contact (Kangaroo Mother

Care) without unwarranted restrictions.

Mother-infant skin-to-skin contact promotes breastfeeding (1-8). The core concepts in Kangaroo Mother Care (KMC) are: warmth, breast milk and love (1). The KMC method is defined as: early (as soon as possible after birth), continuous (ideally 24 hours/day, 7 days/week) and prolonged

(continuing during the infant’s whole hospital stay or for as long as needed for prevention of hypothermia usually to about term age or beyond) skin-to-skin contact between the mother and her low birth weight infant (<2.500 g.) in hospital and after discharge, with exclusive breastfeeding (ideally), early discharge and adequate follow-up. KMC also applies to ill full term infants (2

)

. In addition to the mother, the father and significant others can also participate as KMC providers. The kangaroo position means that the infant is cared for skin-to-skin in an upright prone position on the mother’s chest, with flexed arms and legs and the head turned sideways, supported by the mother’s clothing.

Tactile contact enhances the development of maternal identity after preterm birth (3). Increased milk production was demonstrated in mothers of infants in an neonatal ward who had daily skin-to-skin contact with their infants for a mean of 4 times/week during a mean of one hour (4). A review of 310 studies identified skin-to-skin as one of the pre- and post-discharge interventions that improved breastfeeding outcomes and weight gain among preterm infants (5). A multicenter study found that exclusive breastfeeding was more common at discharge in infants treated with KMC (6). Mothers who held their preterm infants (gestational age 32-36 weeks) skin-to-skin in hospital breastfed longer (5 months vs. 2 months) than a control group without skin-to-skin contact (7). Better growth and a higher rate of exclusive breastfeeding in infants who received KMC were noted at three months of age in an Indian randomized controlled trial (8).

In 2003, the World Health Organization (WHO) issued a Practical Guide for KMC (9). In settings with optimal health and medical care resources, initiation of KMC is recommended for stable infants from 28 postmenstrual weeks, from a birth weight of 600 g. Clinical guidelines for KMC have been published by the Kangaroo Foundation in Bogotá (10). Because of the massive evidence of benefits with KMC, including enhanced establishment of lactation and breastfeeding, experts have

recommended universal promotion of the method (11), and agreed on recommendations for implementation of the method in a high-tech environment (12). Training in the World Health Organization Essential Newborn Care (ENC) course, which includes KMC as one among several components, resulted in a decrease in perinatal and neonatal mortality (13).

Standards

4 a Assure opportunities for mothers to commence provision of KMC as early as possible, ideally from birth, without unjustified delay.

4 b Assure opportunities for mothers to provide KMC for as long periods per day as possible, without unwarranted restrictions.

4 c Mothers who room in 24 h/d with their infants are encouraged and supported in the provision of continuous KMC.