Evaluation of continuous quality improvement on breastfeeding in very/extremely low birth weight infants

Abstract

Objective To implement a continuous quality improvement (QI) initiative to increase the breastfeeding rate of mother's own milk(MOM) in very low birth weight infant (VLBWI) and extremely low birth weight infant (ELBWI) in neonatal intensive care unit (NICU) and to evaluate its impact on the morbidity of these infants. Methods A retrospective analysis was performed to analyze the clinical data of VLBWIs and ELBWIs who were admitted to the Nanjing Maternity Hospital Affiliated to Nanjing Medical University from July 1, 2014 to December 31, 2017 (n=587). The QI initiative was implemented in the hospital on August 1, 2015, the effect was assessed at the end of 2016 and the QI process was adjusted from 2017 to ensure continuous quality improvement of breastfeeding, based on which the 587 infants were divided into three groups: those in pre-QI group admitted from July 1, 2014 to July 31, 2015 (n=141), post-QI group admitted from August 1, 2015 to December 31, 2016 (n=243) and continuous QI group admitted from January 1, 2017 to December 31, 2017 (n=203). Differences in breastfeeding rates of MOM, the time of first breastfeeding of MOM, duration of parenteral nutrition, time to achieve full enteral feeding, average length and costs in NICU stay and the incidence of feeding intolerance, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) were compared between the three groups. Statistical analysis was performed using analysis of variance, rank-sum test, Chi-square test and Bonferroni test. Results Compared with the pre-QI group, both the post-QI and continuous QI groups had significantly increased breastfeeding rates of MOM [0-7 d: 38.2%(0.0%-69.0%) vs 72.8%(42.6%-84.2%) and 75.5%(49.8%-87.2%); 0-14 d: 37.8%(29.9%-80.5%) vs 91.9%(79.1%-96.0%) and 92.0%(71.0%-96.8%); 0-28 d: 58.2%(30.0%-90.1%) vs 96.6%(90.3%-98.9%) and 96.4%(83.1%-98.9%); during hospitalization: 50.0%(30.0%-85.5%) vs 96.6%(89.5%-99.1%) and 96.8% (83.0%-99.3%); all P<0.05] and volume of MOM intake [0-7 d: 31 (0-397) vs 82 (0-506) and 95 (0-510) ml; 0-14 d: 198 (0-1 596) vs 622 (0-1 828) and 717 (0-1 868) ml; 0-28 d: 1 458 (0-4 960) vs 2 707 (0-7 074) and 2 893 (0-10 238) ml; during hospitalization: 2 000 (0-18 767) vs 4 071 (0-22 961) and 3 979 (0-17 260) ml] within 7, 14 and 28 d after birth and during hospitalization. Moreover, the volume of MOM intake in the continuous QI group was higher than that in the post-QI group during the first 7 d after birth (all P<0.05). The time on first MOM breastfeeding in the post-QI and continuous QI groups were earlier than that in the pre-QI group [69 (16-633) and 68 (3-456) vs 73 (8-348) h, P<0.05]. Full enteral feeding was achieved earlier in the continuous QI group than the post- and pre-QI group [14 (5-40) vs 17 (6-53) and 19 (11-56) d, P<0.05]. The length of parenteral nutrition, incidence of feeding intolerance, BPD and LOS and hospital stay in the continuous QI group, post- and pre-QI group were 13(3-38), 15(8-50) and 17(11-39) d; 31.5%(64/203), 34.2%(83/243) and 47.5%(67/141); 8.9%(18/203), 20.1%(49/243) and 36.1%(51/141); 31.5%(64/203), 35.0%(85/243) and 47.5%(67/141); 32 (1-73), 39 (10-93) and 34 (1-91) d, respectively. The length of parenteral nutrition and incidence of feeding intolerance and BPD in the continuous group were less than the pre-QI group, and the incidence of LOS and hospital stay were less than the post-QI group (all P<0.05). However, the post-QI group had longer hospital stay than the pre-QI group (P<0.05). Conclusions Continuous QI initiative improves MOM feeding rates and reduces the incidence of feeding intolerance, LOS and BPD in VLBWI and ELBWI. Key words: Breast feeding; Infant, very low birth weight; Infant, extremely low birth weight; Milk, human; Quality improvement