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Strategies helped California hospitals improve breast milk feeding rates for preemies, researcher says

- By Erin Digitale

Paul Sharek

Premature babies benefit from consuming breast milk, but their chance of receiving it has been strongly influenced by the hospital where they spend their early days. Now, researchers at the Stanford University School of Medicine and several collaborating institutions have helped 11 California hospitals significantly improve their rates of breast milk feeding for premature infants, a strategy that carries larger implications for helping hospitals adopt underused evidence-based practices.

“There was a sixfold difference between the lowest- and highest-performing sites in California in rates of breast milk feeding for premature infants at the time of hospital discharge,” said Paul Sharek, MD, the senior author of the new research, which appeared online Nov. 5 in Pediatrics. “We saw a great opportunity there.”

Sharek is an associate professor of pediatrics at Stanford, chief clinical patient safety officer at Lucile Packard Children’s Hospital and the director of quality for the California Perinatal Quality Care Collaborative, a Stanford-based organization that tracks and seeks to improve the performance of neonatal intensive care units throughout the state. Packard Children’s was not among the hospitals participating in the study.

Over the 12-month study and subsequent six-month follow-up period, the 11 participating hospitals increased their rates of breast milk feeding for NICU babies at discharge from 55 percent to 64 percent, bringing these hospitals up to the average rates for the state. (Some participating hospitals had above-average rates before the study began, and enrolled to both learn and share their expertise with other institutions, Sharek noted.) Participating hospitals also reduced the rate of a serious complication of prematurity — the bowel disease known as necrotizing enterocolitis — by two-thirds, from 7 percent to about 2 percent of all infants in their NICUs.

The fact that the hospitals continued to sustain, and even improve on, their gains after the 12-month intervention ended is “a really important quality statement,” said Sharek, who is also the medical director of the Center for Quality and Clinical Effectiveness at Packard Children’s. “In many quality-improvement projects, improvements decrease after the hospitals’ attention is transitioned to another project. Something about our approach, and the changes made at the participating hospitals, resulted in a lasting improvement.”

After agreeing to participate in the study, each hospital received an information package detailing 10 best practices for encouraging breast milk feeding in babies in the NICU. The babies included in the study were premature, and all weighed less than 3.3 pounds at birth. The best practices were culled from scientific evidence on methods that have been used to encourage breast milk feeding in NICU settings. Hospital teams were encouraged to implement the best practices in any order they wished, and were supported in making the changes via a structured process that the CPQCC has used to modify hospital practices in the past.

Two important changes hospitals made were increasing babies’ skin-to-skin time with their mothers and improving the education of NICU staff about breast milk feeding.

“Providing staff with the skill set to support breast milk feeding in very low birth weight infants makes a big difference, because a lot of nurses and parents are initially scared to do this,” Sharek said. “These babies are so small, and people are understandably worried that they’re fragile. It’s a big barrier for families and even at times for staff.”

Before the study began, four of 11 hospitals reported that their staff had a comprehensive knowledge base and skill set in breast milk nutrition. After the study, the number rose to 10 of 11 hospitals.

The number of hospitals providing daily skin-to-skin time for moms and babies increased from six to 11 during the study. “Even the sites that said they were doing it before the study really accelerated their work on this best practice,” Sharek said.

The payoffs associated with increased breast milk feeding in premature babies are potentially wide-ranging, Sharek said. For instance, based on the drop in necrotizing enterocolitis rates observed over the course of the study, the researchers estimate that about 30 infants were prevented from developing the disease, which can permanently destroy large sections of an infant’s bowel. Breast milk is also less expensive for families and has several well-documented, long-term benefits for children’s health.

Beyond the specific benefits of breast milk, the study has important take-home messages for improving hospital performance, Sharek said. First, the researchers targeted an area that had room for improvement, as shown by the large initial difference in breast milk feeding between high- and low-performing hospitals. Second, the metric used (breast milk feeding at the time the infant was discharged) has been considered at the state level as a possible pay-for-performance metric, so hospitals are motivated to improve it. Third, evidence-based best practices for improving breast milk feeding had been identified before the study began, thus hospitals could move forward quickly rather than spend time determining how to improve this outcome.

Sharek collaborated on the research with scientists from the California Perinatal Quality Care Collaborative; the University of California-San Francisco; Rady Children’s Hospital in San Diego; the Sharp Mary Birch Hospital for Women and Infants in San Diego; the California Department of Health Care Services; Sutter Medical Center in Sacramento; Sharp HealthCare in San Diego; and Health Information Solutions in Rocklin.

The research was funded by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of Medicine, Stanford Health Care (formerly Stanford Hospital & Clinics), and Lucile Packard Children's Hospital Stanford. For more information, please visit the Office of Communication & Public Affairs site at

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