PQCNC Human Milk NCCC Track LS 1 Crucial Conversations

8/8/2019 PQCNC Human Milk NCCC Track LS 1 Crucial Conversations

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Crucial ConversationsCrucial ConversationsPQCNC NCCCPQCNC NCCC

Human Milk Initiative Focus 2Human Milk Initiative Focus 2


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Encouraging Mother to ProvideEncouraging Mother to Provide

Milk for her InfantMilk for her Infant Despite well documented benefits of human milkDespite well documented benefits of human milkobstetricians, pediatricians, and nurses may beobstetricians, pediatricians, and nurses may bereluctant to encourage mothers to express milkreluctant to encourage mothers to express milk

Common concerns:Common concerns: Does it really make a clinically significant difference?Does it really make a clinically significant difference? Increase maternal anxietyIncrease maternal anxiety Influence on maternal decisionInfluence on maternal decision CoerciveCoercive

Mothers health/living situationMothers health/living situation Personal choicePersonal choice Time consuming/expensiveTime consuming/expensive UnethicalUnethical

Meier PP. Clinics in Perinatology. 2010;37:217-245


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Lactation Counseling for Mothers of VeryLactation Counseling for Mothers of VeryLow Birth Weight Infants: Effect on MaternalLow Birth Weight Infants: Effect on Maternal

Anxiety and Infant Intake of Human Milk.Anxiety and Infant Intake of Human Milk.

Enrolled 196 mothers of VLBWEnrolled 196 mothers of VLBW

infantsinfants 81 planned to formula feed81 planned to formula feed

115 planned to breast feed115 planned to breast feed

Anxiety inventory administeredAnxiety inventory administeredbefore and after counselingbefore and after counselingand every 2 weeks until infantand every 2 weeks until infantdischargedischarge

Sisk et al. Pediatrics. 2006;117:e67Sisk et al. Pediatrics. 2006;117:e67


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Counseling ScriptCounseling Script

Benefits of human milk for VLBWBenefits of human milk for VLBWinfantinfant Focused on short term benefitsFocused on short term benefits

Protection from infection/NECProtection from infection/NEC Better feeding toleranceBetter feeding tolerance Better stooling patternBetter stooling pattern

Common myths:Common myths: MedicationsMedications SmokingSmoking Transporting milk to the hospitalTransporting milk to the hospital NutritionNutrition PainPain Combination feedingCombination feeding

Procedure for collection andProcedure for collection andstorage of milkstorage of milk

Preterm alternative if decide not toPreterm alternative if decide not topumppump

www.medela.com


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ResultsResults

State Anxiety scoresState Anxiety scoressignificantly lower for bothsignificantly lower for bothgroups after counseling thangroups after counseling thanbeforebefore

No difference in anxietyNo difference in anxietybetween groupsbetween groups

Similar decrease in anxietySimilar decrease in anxietyover timeover time

Mothers stated that theyMothers stated that they

appreciated the information,appreciated the information,assistance, andassistance, andencouragement they receivedencouragement they receivedabout providing breast milkabout providing breast milk

10

20

30

40

50

60

Before State After State 2 Wks State 4 Wks State

Breast

Formula


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Breast Milk Expression Before andBreast Milk Expression Before and

After CounselingAfter Counseling

0%

10%20%

30%

40%

50%

60%70%

80%

90%

100%

Be e C nse ing A e C nse ing

a (I G)

B eas (IBG)

Sisk, et al Pediatrics 2006;117:67Sisk, et al Pediatrics 2006;117:67


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Co ri ht 2006 American Academ of Pediatrics

Sisk, PM et al. Pediatrics 2006;117:e67-e75

FIGURE 1 Proportion of enteral feeding that was breast milk during the first 4 weeks and

during the total hospitalization

* Significantly different: P< .05.


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ConclusionsConclusions

Maternal anxiety notMaternal anxiety notheightenedheightened

Mothers were willing to initiateMothers were willing to initiatepumpingpumping

Infants received clinicallyInfants received clinicallyimportant volumes of humanimportant volumes of humanmilkmilk

lower incidence of NEClower incidence of NEC

shorter time to full enteralshorter time to full enteralfeedingsfeedings

Counseling was worth the effortCounseling was worth the effort


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Influence on Maternal Decision?Influence on Maternal Decision?

ProviderE

ncouragementProviderE

ncouragement Several studiesSeveral studies

Mothers of full termsMothers of full termsinfantsinfants

More likely to initiateMore likely to initiatelactation when alactation when aphysician or nursephysician or nursehas introduced thehas introduced the

topic and providedtopic and providedindividualizedindividualizedinformation andinformation andanswers to questionsanswers to questions

Lu MC, et al. Obstet Gynecol.2001;97:290-297Britton C et al. Cochrane Database Syst Rev. 2007;ICD001141.


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Effect of prenatal consultation with neonatologistEffect of prenatal consultation with neonatologiston human milk feeding in VLBW infantson human milk feeding in VLBW infants

Objective:Objective: effect of prenatal consultation (PC) with aeffect of prenatal consultation (PC) with aneonatologist on the incidence and duration of humanneonatologist on the incidence and duration of humanmilk feeding in preterm infants.milk feeding in preterm infants.

Methods:Methods: Retrospective matched caseRetrospective matched case--control studycontrol study Performed at a perinatal centrePerformed at a perinatal centre PC infants gestational agesPC infants gestational ages -- 2323--35 wk whose35 wk whose

mothers received counseling regarding importance ofmothers received counseling regarding importance ofhuman milkhuman milk Control infants were matched by birth weight,Control infants were matched by birth weight,

gestational age and multiplicitygestational age and multiplicity

Friedman S, et al Acta Paediatr. 2004;93:775-8


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Effect of prenatal consultation with neonatologistEffect of prenatal consultation with neonatologiston human milk feeding in VLBW infantson human milk feeding in VLBW infants

Results: PC infants received human milkResults: PC infants received human milksignificantly longersignificantly longer Hospital: PC 37 +/Hospital: PC 37 +/-- 34 d vs. control 15 +/34 d vs. control 15 +/-- 19 d, p =19 d, p =

0.0010.001 Discharge: PC 60 +/Discharge: PC 60 +/-- 57 d vs. control 21 +/57 d vs. control 21 +/-- 32 d; p =32 d; p =

0.0001)0.0001) No significant difference in neonatal morbidityNo significant difference in neonatal morbidity

between the groupsbetween the groups

Conclusions: PC is associated with significantlyConclusions: PC is associated with significantlylonger human milk feeding in preterm infants,longer human milk feeding in preterm infants,both in hospital and after dischargeboth in hospital and after discharge


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Mothers decisions to change from formulaMothers decisions to change from formulato mothers milk for VLBW infantsto mothers milk for VLBW infants

Qualitative study, semiQualitative study, semi--structured interviews, attitudesstructured interviews, attitudesassessedassessed

21 mothers (76% African American, 62% low income)21 mothers (76% African American, 62% low income)

Planned formula feeding, decided to provide breast milkPlanned formula feeding, decided to provide breast milkafter provider encouragementafter provider encouragement

All provided breast milkAll provided breast milk >>30 d, 19 breast fed30 d, 19 breast fed

Reasons originally cited for planning to formula feed:Reasons originally cited for planning to formula feed: Didnt know anyone who had ever breastfedDidnt know anyone who had ever breastfed

Felt lactation would involve discomfort and lifestyle changesFelt lactation would involve discomfort and lifestyle changes Identified rewards for themselves and infantsIdentified rewards for themselves and infants

Denied feeling pressured or coercedDenied feeling pressured or coerced

Miracle et al. J Obstet Gynecol Neonatal Nurs. 2004;33:392-703


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Economic ImplicationsEconomic Implications

Reduction in NEC may have a profound effectReduction in NEC may have a profound effecton cost of health careon cost of health care

One case of medically treated NEC increasesOne case of medically treated NEC increases

the cost of hospitalization by $73,700the cost of hospitalization by $73,700 4% incidence of NEC w/ human milk4% incidence of NEC w/ human milk vs.vs. 10% w/10% w/

formulaformula

22402240 vs.vs. 5600 infants/year might be affected in5600 infants/year might be affected in

the United States with a cost savings of of $2.5the United States with a cost savings of of $2.5millionmillion

Data from 1992Data from 1992--19941994

Bisquera JA, Cooper TR, Berseth CL. Pediatrics 2002;109:423Bisquera JA, Cooper TR, Berseth CL. Pediatrics 2002;109:423428428

Arias E, et al. Pediatrics 2003;112:1215Arias E, et al. Pediatrics 2003;112:121512301230Caicedo RA, SchanlerRJ, Neu J. PediatrRes 2005;58:625Caicedo RA, SchanlerRJ, Neu J. PediatrRes 2005;58:625


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Ethical?Ethical?

Human milk confers unique health benefits to both infantHuman milk confers unique health benefits to both infantand mother:and mother: VLBW infantVLBW infant covered previouslycovered previously MotherMother many have pregnancy related illnessesmany have pregnancy related illnesses

Benefits for mothersBenefits for mothers lower risk of cancer (breast and ovarian) and gestational diabetes,lower risk of cancer (breast and ovarian) and gestational diabetes,sooner return to presooner return to pre--pregnancy weight, mood improvement andpregnancy weight, mood improvement andpossible lower risk of postpartum depression, no known harmpossible lower risk of postpartum depression, no known harm

Health care providers have an ethical obligation toHealth care providers have an ethical obligation todiscuss human milk feedingdiscuss human milk feeding

Mother is not able to exercise her right to autonomy andMother is not able to exercise her right to autonomy andselfself--determination if she does not have relevantdetermination if she does not have relevantinformationinformation

Informed consent is a shared decisionInformed consent is a shared decision--making processmaking process


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Mothers Need forEvidence BasedMothers Need forEvidence Based

InformationInformation Most mothers who plan to formula feed knowMost mothers who plan to formula feed know

breast milk is better but also believe formula isbreast milk is better but also believe formula isadequateadequate

May not think breastfeeding is compatible withMay not think breastfeeding is compatible withtheir lifestyle and obligationstheir lifestyle and obligations

Need specific information regarding benefits forNeed specific information regarding benefits fortheir infanttheir infant

milk as medicinemilk as medicine special nutritional and immunological needs of infant,special nutritional and immunological needs of infant,

i.e. difficulty digesting fat and immature immunei.e. difficulty digesting fat and immature immunesystemsystem

Miracle et al. J Obstet Gynecol Neonatal Nurs. 2004:33:692-703


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Content of Informed ConsentContent of Informed Consent

DiscussionDiscussion PresentPresent

Potential benefits and potential harms ofPotential benefits and potential harms ofinfant feeding methodsinfant feeding methods

Preventive health strategyPreventive health strategy

Distinguish providing breast milk fromDistinguish providing breast milk frombreastfeedingbreastfeeding

Translate evidence into message that isTranslate evidence into message that iseasily and consistently deliveredeasily and consistently delivered


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Content of Informed ConsentContent of Informed Consent

DiscussionDiscussion Emphasize there is noEmphasize there is no

right way to provide milkright way to provide milk

Reassure women theyReassure women theycan discontinue milkcan discontinue milkexpression at any timeexpression at any time

Avoid focusing onAvoid focusing onbonding or closenessbonding or closeness

Avoid value ladenAvoid value ladenconversationconversation

www.Medela.com

Rodriguez N, et al. JOGNN. 2004;34:109-119


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How Should Providing Milk beHow Should Providing Milk be

Introduced?Introduced? Educate about perceived discomfort and lifestyleEducate about perceived discomfort and lifestyle

changeschanges

Breast and nipple painBreast and nipple pain

Dietary restrictionsDietary restrictions

Prescription medicationsPrescription medications

Maternal employmentMaternal employment

Living a distance from the hospitalLiving a distance from the hospital

Concern about returning to work or schoolConcern about returning to work or school

Reassure that decisions about this are weeks awayReassure that decisions about this are weeks awayand there are many optionsand there are many options

Rodriguez N, et al. JOGNN. 2004;34:109-119


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Helping Mothers Get StartedHelping Mothers Get Started

If they discontinue prior to infant dischargeIf they discontinue prior to infant dischargereassure mothersreassure mothers ReassureReassure -- they provided breast milk duringthey provided breast milk during

their infants most important phases of growththeir infants most important phases of growthand developmentand development

Put into perspectivePut into perspective only a minority of termonly a minority of terminfants receive exclusive mother milk for 30infants receive exclusive mother milk for 30--

60 days in the US60 days in the US PraisePraise -- especially since providing milk wasespecially since providing milk was

not her initial intentnot her initial intent


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ConclusionConclusion

Does human milk really make a clinically significantDoes human milk really make a clinically significantdifference? Yesdifference? Yes

Increase maternal anxietyIncrease maternal anxiety -- NoNo Do health care providers have an influence onDo health care providers have an influence on

maternal feeding decisionsmaternal feeding decisions -- YesYes Is encouragement perceived as coerciveIs encouragement perceived as coercive -- NoNo Is the mothers health or living situation conduciveIs the mothers health or living situation conducive

For her to decide after information providedFor her to decide after information provided Her personal choiceHer personal choice --Yes, for her to decideYes, for her to decide Counseling is time consuming/expensiveCounseling is time consuming/expensive Yes andYes and

NoNo UnethicalUnethical -- NoNo

PQCNC Human Milk NCCC Track LS 1 Crucial Conversations

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