Lisa Marie Piwoszkin
Cincinnati Children's Hospital
Background: Breast milk improves several clinically important outcomes related to infant morbidity and mortality. Due to concerns of medical stability, developmental readiness, and physical separation from mothers, many infants admitted to the Neonatal Intensive Care Unit (NICU) are reliant on pumped breast milk and vulnerable to decreased milk availability and sustainability. Early milk expression techniques including hand expression and electric pumping for mothers during lactogenesis increase immediate and long-term milk supply. An assessment of lactation support knowledge gaps among NICU, labor and delivery (L&D), and postpartum (PP) nurses at the University of Cincinnati Medical Center (UCMC) revealed low confidence in instructing mothers how to perform hand expression. Thus, our objectives reported here are to evaluate the effect of a targeted hand expression simulation curriculum for NICU, L&D, and PP nurses on: 1) confidence in instructing mothers to perform hand expression, and 2) breast milk outcomes in the NICU.
Methods: We used an interrupted time series approach to evaluate change in outcome measures over the pre and post-intervention phases of implementing a mandated hand expression simulation curriculum with nurses from NICU, L&D, and PP units consisting of a brief didactic, demonstration, and hands-on simulated practice. For objective 1, we compared responses from pre and post-training self-assessment surveys using a non-parametric Wilcoxon signed-rank test. For objective 2, we included inborn infants directly admitted to the NICU, after excluding infants admitted from home or an outside facility, not directly admitted to the NICU, never enterally fed during hospitalization, duplicate entries, multiple gestations if not the first to be discharged home, and discharged to a non-maternal (biological) caregiver. We examined the following breastfeeding outcomes using a time series analysis approach comparing the pre and post-intervention phases, with November and December (inter-intervention phase) included in the post-intervention phase: proportion of infants that received maternal breast milk as their first enteral feeding (primary), time to mother’s first milk expression, proportion of non-orally feeding infants that receive maternal colostrum for oral care within the first 36 hours of life, proportion of infants receiving any maternal breast milk at 21 days of life or discharge.
Results: Nurse confidence ratings in instructing mothers to perform hand expression improved as a result of the targeted hand expression simulation curriculum. There was significant difference in pre-training ratings across units; NICU, L&D, PP. Of the 341 mother-infant pairs included in our study, 243 (71.2%) of mothers attempted to express milk. For our primary outcome there was a significantly increased level of change for infants receiving maternal breast milk as their first feed (MOMfirst) (p-value=0.03) after the start of the intervention. For secondary outcomes, there was no significant change in FME, EBM<6h, COC<36h, MOM21/DC, but there was a significant increase in the proportion of mothers who initiated milk expression (MOMexp) (p-value=0.02).
Conclusion: Simulated hand expression training for nurses is a technically useful and well received educational approach to improve nurse confidence with hand expression. There was an immediate increase in initiation of milk expression and infants receiving maternal breast milk as their first feed. This targeted training could be implemented to improve hand expression skills and overall attitudes related to breastfeeding support in the NICU.
