The Role of Pediatrician in BFHI Hezekiah Beardsley CT PowerPoint Presentation

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The Role of Pediatrician in the Baby-Friendly Hospital Initiative Lori Feldman-Winter, MD, MPH Professor of Pediatrics Cooper Medical School of Rowan University Teleconference April 24, 2012 !2:00-1:15 PM

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Disclosure I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. 2

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Objectives Understand that breastfeeding matters Identify the evidence that physicians need education and describe how to become educated Explain why physicians are necessary in implementation of the BFHI Describe promising strategies 3

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“By failing to prepare, you are preparing to fail.” Benjamin Franklin 4

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Importance of Breastfeeding “Dose Dependent” Infant Outcomes Obesity Excl. BF vs. None Type 1 Diabetes Mellitus BF > 3 months Type 2 Diabetes Mellitus any BF vs. None Cancer: ALL BF > 6 months AML BF > 6 months Sudden Infant Death any BF vs. None Syndrome S. Ip, et al. AHRQ Review 2007 36% 20% 15% 40% 30% 34% 5

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Breastfeeding Leads to Self-Regulation Exclusive breastfeeding at breast Expressed breast milk in bottle Combination breastfeeding Formula feeding, Breast/bottle All formula in a bottle How often does your infant empty the bottle/cup after 7 months of age? 27% 47% 56% 68% Source: Pediatrics. 2010 Jun;125(6):e1386-93. 2010. 6

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Breastfeeding Protective Factors for Mothers Type 2 Diabetes Mellitus for each year of breastfeeding for women Pre-menopausal Breast Cancer for each year of breastfeeding Ovarian Cancer for any vs. no breastfeeding and dose response Post-partum Depression for short breastfeeding vs. no breastfeeding Source: S. Ip, et al. AHRQ 2007 ` 12% 28% 21% 7

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Who can Breastfeed? Almost All! 8

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Physicians Need Education Historical Perspective Hollen BK Freed GL Schanler RJ Graph data from the Mother’s Survey, Ross Products Division of Abbott 9

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Sometimes it is what we don’t say or are “too vague” in saying Sometimes it’s not what we say… but what we do give out formula company literature and portray bottle feeding as the norm in the office setting Recommend formula supplementation when it is not indicated Knowledge and Attitudes 10

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Encouragement from health care providers is associated with breastfeeding initiation Lu MC, Lange L, Slusser W, Hamilton J, Halfon N. Provider encouragement of breast-feeding: evidence from a national survey. Obstet Gynecol.2001; 97 :290 –295 …and continuation Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics.2003; 112 :108 –115 Why Physicians matter? 11

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Taveras E. et al. 2004. Pediatrics. 113(4):e283-e290 Influence of Pediatricians on Weaning   AOR CI p Recommend formula supplementation if infant is not gaining enough weight 3.2 (1.04–9.7) .04  Advice to mothers… duration is not very important 2.2 (1.2–3.9) .01  Does not recommend exclusive breastfeeding during the first month of life 2.1 (0.95–4.7) .07 12

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Why Physicians Matter? Labarere J. et al. Pediatrics. Feb 2005;115(2):e139-e146 13

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AAP Breastfeeding Promotion in Physician Office Practices (BPPOP) III-funded by MCHB: Residency Curriculum Included three major sections: Advocacy Clinical Management Delivering Culturally Competent Breastfeeding Care Pilot tested June 2006- June 2007 7 test sites; 7 comparison sites With additional funding from the CDC Development of a Residency Curriculum through the AAP 14

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Traditional vs. Competency-based Education Frenk J. et. al. Lancet 2010. 15

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Health System needs Need to improve physician knowledge, skills and attitudes to support exclusive breastfeeding Competencies Skills in taking history, doing assessments and counseling Outcomes Increased Exclusive Breastfeeding Assessment of Outcomes measure rates Assessment of Competencies Tools Direct observation, OSCE Develop curriculum Competency-based Education 16

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Intended for a multispecialty audience Pediatrics Ob/GYN Family Medicine Flexible for 1-year implementation Organized by ACGME Core Competencies Patient Care, Medical Knowledge, Practice-based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, Systems-based Practice  Evaluation Tools designed to facilitate residency program director review and tracking of residents’ progress AAP Breastfeeding Curriculum 17

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Impact of Curriculum on Residents 18

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Implementing Curriculum Raises Rates of Breastfeeding 19

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Advocacy Protection of breastfeeding, BFHI, the Code Promotion of breastfeeding using specialized counseling strategies Motivational interviewing Basic Skills Anatomy Physiology Case management Solving common problems What Did We Teach? 20

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Ways to Get Education Learn: Attend a workshops on breastfeeding management: AAP, NCE, ABM, LLL Physicians’ Seminar; Use the physicians’ handbook (AAP/ACOG/AAFP) See one do one teach one Eliminate…formula company’s influence Lunch and learns Decorate…use breastfeeding posters with images of multiple cultures 21

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Learn 22

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Improve Knowledge Self directed learning: Wellstart Modules on line Level 1 http://www.wellstart.org/Self-Study-Module.pdf www.Breastfeedingbasics.org AAP Residency Curriculum: Knowledge Stanford resources: http://newborns.stanford.edu/Breastfeeding/ University of Virginia (MOC approved) http://www.breastfeedingtraining.org/ Breastfeeding answer book 23

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See one… do one… teach one Photo courtesy of Jane Morton, MD 24

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Conduct faculty development Teach residents to improve the care of breastfeeding Spread to the medical students Participate in skills fairs Use flip charts in prenatal clinic What Can You Do in an Academic Medical Center? 25

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Skills Fairs-One Day Stations Assess breastfeeding dyad Maintain milk supply Use of pumps, shields, other tools Solve common problems Interdisciplinary Volunteers from LLLI 26

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Clinicians and staff should: Support exclusive breastfeeding for 6 months Recommend human milk for ALL infants, unless medically contraindicated Provide continued support for 1 year and beyond Provide parents with complete and current information on the benefits and techniques of breastfeeding AAP Policy Statement: Breastfeeding and the Use of Human Milk. 2012 AAP Breastfeeding Policy Recommendations: 27

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Before you begin – -Conduct a needs assessment -pediatrician can be the team leader. What is currently available for breastfeeding learning opportunities? What do pediatricians know about breastfeeding, and are they able to provide evidence based care? How well do pediatricians promote, manage, and support breastfeeding? (survey mothers, nurses, residents, and faculty, about their experiences.) Are staff at the hospital able to breastfeed or express breast milk at work? What are the areas needing special attention? 28

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mPINC Scores CT Compared to US Source: CDC mPINC 2009 18% of facilities adhere to guidelines for supplementation 21% of facilities provide discharge support 21% provide mother-infant care 4% do exams in the moms room 29

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Risk of Breastfeeding Cessation before 6 weeks by Number of Steps in Place Source: DiGirolamo et al. 2008 30

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Hospital Practices and The Effect on Breastfeeding at 8 Weeks Source: NJ PRAMS data 2010 31

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What can you do to help Implement the BFHI? Step 1: Know your policy and where it is located Step 2: Get educated and develop skills Step 4: Support immediate skin to skin for 1 hour and continuous thereafter Step 5: Show mothers how to breastfeed and help them maintain breastfeeding if the baby needs to be separated (within 3-6 hours); educated formula feeding mother individually 32

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What can you do to help Implement the BFHI? Step 6: Only order (recommend) formula if it is medically necessary Step 7: Keep babies together rooming-in, do your exams in the mother/infant room (request needed supplies) Step 8: Support cue-based feeding (no time limits on feed or intervals) 33

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“Neonatal Observation Unit” The best nursery is empty 34

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What can you do to help Implement the BFHI? Step 9: Don’t provide pacifiers and recommend against their use until breastfeeding is established Step 10: Schedule follow-up visit within 2 days 35

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Best Care Least Often Percent of facilities providing care in NJ Source: CDC mPINC 2009 36

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Newborn Hospital Follow Up Periodic Survey data (AAP survey of Fellows)- 38% of pediatricians do F/U within 5 days of life (<48 hours after discharge) NJ PRAMS indicate that this varies according to insurance status Feldman-Winter L. 2008 Dec;162(12):1142-9. 37

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Newborn Follow-up Source: NJ PRAMS 2010 38

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Requirements of BFHI Staff (ALL need some training) “Nursing staff with primary responsibility for helping mothers initiate breastfeeding should have, at minimum…” 20 hours 5 hours of clinical mentoring Physicians and APRN’s 3 hours May be grand rounds Covers at least 8 of 10 steps But physicians need to know same content as nurses!! 39

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Understand - Positioning Watch how the mother positions the baby for feeding and look Maternal Comfort How the infant is positioned Infant brought to the breast, not the breast to the infant Avoid pushing on the back of the infant’s head 40

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Facilitate – Latch-on Watch how the baby is latched to the breast and look: Infant-led self-attachment Use of the C-hold to make a sandwich for the baby to latch on Acknowledgement of the rooting reflex Middle of infant’s lip stroked with nipple Infant opens his mouth wide Mother quickly draws the infant to her breast Infant takes in an adequate amount of the breast, not just nipple 41

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Anatomy of Breast, Baby's Mouth, Latch and Suckling 42

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Identify – Milk Transfer Watch the baby as she sucks and swallows and milk is transferred. Look and listen for: Audible swallowing Sucking that begins with rapid bursts to stimulate milk let-down A rhythm of sucking, swallowing, and pauses following establishment of milk flow Becomes slower and more rhythmic Approximately 1 suckle/swallow per second 43

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Prevention, Prevention, Prevention Prevention is the most effective way to deal with the management of low milk supply (real or perceived), sore nipples, and poor weight gain Understanding and being able to explain to mothers how normal breastfeeding is established is the key to prevention Protect mother’s milk supply! All mothers taught to hand express (use video) Photo © Jane Morton, MD, FAAP 44

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Lactogenesis is the transition in the mammary gland from pregnancy to lactation Lactogenesis I and II Lactogenesis II: the onset of copious milk secretion associated with parturition 45

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Myo-epithelial Cells Surround Lactating Alveolus for MER Oxytocin causes milk to be ejected into the duct system (“let down”) Photo Credit: M. Neville 46

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Average infant weight loss: 4.9% (range 0.00%-9.9%) Weight loss >7% 20% (23/118) Weight loss >8% 7% (8/118) Weight loss >10% 0 infants Appreciate Normal Weight Loss Patterns Grossman X, Feldman-Winter L, Merewood A. J Am Diet Assoc. March 2012. 47

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Over-feeding in early life Exclusive breastfeeding: 15-30cc day 1 30-150cc day 2 Exclusive formula feeding: 60-90 cc every 2 to 3 hours each day; approx 24 ounces (720cc) ≠ 48

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Results Results by Feeding Percent Weight Loss Infant weight loss nadir was significantly associated with feeding category (p=0.00) Grossman X, Feldman-Winter L, Merewood A. J Am Diet Assoc. March 2012. 49

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58.5% reached weight loss nadir by 2 days after birth Grossman X, Feldman-Winter L, Merewood A. J Am Diet Assoc. March 2012. 50

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On-Site Assessment Quantitative and Qualitative Interviews with: CEO Senior nursing administrator Purchasing agent Nurse manager, Prenatal Service Unit manager, Maternity & NICU/SCU Training coordinator Baby-Friendly project coordination team 52

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Assessment Interviews, cont. Randomly selected key informants: 5+ physicians with privileges on maternity 10+ nursing staff (day and evening shifts) 10+ prenatal woman >32 wks gest 10+ mothers of vaginal delivery 5+ mothers of cesarean delivery 5+ mothers of babies in NICU/SCU 53

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Assessment Activities Random observations are made throughout the survey of: staff competency with breastfeeding teaching birth practices location of babies on the unit mothers’ feeding competency visible messages about infant feeding 54

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Conclusions Pediatricians are necessary for the BFHI Interdisciplinary care model works Need physician champions Make education fun an innovative, case-based, clinically relevant Mock Site Visits, analogous to simulated Joint Commissions inspections 55

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“Well done is better than well said.” – Benjamin Franklin 56