This quality improvement study conducted in a neonatal intensive care unit aimed to increase exclusive breastfeeding rates of preterm neonates from 12.5% to 30% over 6 weeks. The team implemented comprehensive postnatal breastfeeding counseling for mothers, which focused on early and frequent milk expression. This led to improved breast milk output, with the proportion of neonates receiving mother's own milk increasing from 12.5% to 80%. Sustaining efforts like allocating breast pumps and celebrating successes helped maintain high exclusive breastfeeding rates of over 80% in follow up periods. The simple counseling approach improved breastfeeding outcomes without external funding or additional staffing.

1. CLINICAL BRIEF
A Quality Improvement Initiative: Improving Exclusive
Breastfeeding Rates of Preterm Neonates
Amanpreet Sethi1 & Meena Joshi1 & Anu Thukral1 & Jagjit
Singh Dalal1 &
Ashok Kumar Deorari1
Received: 7 October 2016 /Accepted: 31 January 2017
/Published online: 24 February 2017
# Dr. K C Chaudhuri Foundation 2017
Abstract This study is a single center quality improve-
ment (QI) initiative in a tertiary care neonatal intensive
care unit which was done with an objective to increase
the proportion of neonates receiving mother’s own milk
(at postnatal age of 7 d) from the current rate of 12.5%
to 30% over a period of six weeks. Additional objec-
tives were to evaluate the proportion of mothers’ ex-
pressing breast milk within 3 h of birth, on day one
and three and the amount of expressed breast milk
(EBM) on day one and day seven. A team was formu-
lated to evaluate the reasons for inadequate breast milk
expression and to plan the steps for promoting the
same. Comprehensive postnatal breast feeding counsel-
ing (CPNC) to promote early breast milk expression
was initiated soon after the birth of a preterm neonate.
CPNC was done for next fifteen mothers and their
breast feeding support was streamlined. The effect of
CPNC and teamwork was discussed amongst the team
members every day and adjustments incorporated (Plan-

2. Do-Study-Act cycle). The proportion of neonates receiv-
ing mother’s only milk (MOM) on day 7 increased to
80% (12/15) after 4 wk of QI. Thus, a simple and
feasible CPNC package lead to improved breast milk
output in mothers.
Keywords Breast milk . Neonate . Quality improvement
Introduction
Exclusive breastfeeding for six months is the most effective
preventive strategy for under-five mortality [1]. Host resis-
tance factors are abundant in fresh breast milk and when prop-
erly collected and stored, it provides the highest quality of
anti-infective properties. [2, 3] However, for various reasons,
mothers of these neonates face multiple challenges in estab-
lishing and maintaining an adequate supply of milk, this phe-
nomenon being more common in preterm neonates [4, 5]. The
gap in current evidence based implementation is the strategy
to reduce the time to first milk expression and to increase
frequency of expression and night time expression of milk in
these mothers. It is also known that mothers of extremely
preterm neonates should be taught early and effective milk
expression techniques [6].
The authors identified problem of delayed breast milk ex-
pression by mothers of preterm neonates whose babies were
admitted in the neonatal intensive care unit (NICU). The fre-
quency of milk expression in these mothers was limited to two
to three times in the entire day leading to most neonates re-
ceiving predominant formula feed for the first one week.
In view of the existing evidence and the identified problem,
the authors formulated an aim to increase the proportion of
breast milk intake in the admitted preterm neonates on day 7
from a current baseline rate of 12.5% to 30% over a period of

3. six weeks by comprehensive postnatal breast feeding counsel-
ing (CPNC) of mothers soon after the birth of the preterm
neonate.
Material and Methods
This quality improvement initiative was conducted in a Level-
3 NICU of a tertiary care hospital from 15th August through
* Ashok Kumar Deorari
[email protected]
1 Division of Neonatology, Department of Pediatrics, All India
Institute of Medical Sciences, New Delhi 110029, India
Indian J Pediatr (April 2017) 84(4):322–325
DOI 10.1007/s12098-017-2306-4
http://crossmark.crossref.org/dialog/?doi=10.1007/s12098-017-
2306-4&domain=pdf
30th September 2015 to improve the exclusive breastfeeding
rates in preterm neonates.
Mother-newborn dyads who were likely to stay for more
than 7 d in the unit were included. Critically sick mothers
admitted in obstetrics intensive care unit, retro-positive
mothers who declined breastfeeding and mothers with
neonates having major congenital malformations requir-
ing surgical intervention and hence, non establishment
of exclusive breast feeding in the initial one week were
excluded from the study.
A team comprising of one faculty incharge, two resident
physicians, one nurse educator and two senior staff nurses was
formulated to evaluate the reasons for poor breast milk expres-

4. sion and to plan the subsequent steps for promoting the same.
Baseline data [including time of first expression of breast
milk (EBM); daily amount of EBM from day one to seven;
exact amount and type of milk provided to the baby and time
of postnatal counseling related to breast feeding issues (if any)
given to these mothers] was collected among eight postnatal
mothers and newborn dyads over 7 d.
A fish bone analysis was done to identify the possible fac-
tors limiting breast milk expression in these mothers. Lack of
sensitization of health care providers and lack of knowledge
among mothers and family members were identified as the
Bvital few^ causes limiting breast milk expression in these
mothers.
After baseline data collection and problem analysis, a com-
prehensive postnatal counseling (CPNC) package was
planned which consisted of two main elements; one was edu-
cation and sensitization of health care providers and the sec-
ond was education and sensitization of the family members
(Table 1). These changes were tested as a part of Plan-Do-
Study-Act (PDSA) cycle (Fig. 1).
Proportion of mothers’ expressing breast milk within 3 h of
birth, on day one and three and the amount of expressed breast
milk (EBM) on day one and seven and the proportion of
neonates fed on mother’s own milk (MOM) on day 7 of life
were evaluated. One of the balancing outcomes which the
team intended to measure was an anticipated reduced sleep
time for the mothers because of frequent milk expression.
The data was entered in excel datasheet. The data was
coded and analysed statistically using STATA version 11.1
(Stata Corp, College station, Texas, US).

5. The nurse-educator and team of nurses met the on-duty
NICU nursing staff every third day to apprise them of the
situation and share the results that they were getting from
the intervention. This allowed for continuous feedback to staff
and resident doctors involved in the clinical care.
The continuous data with normal distribution was analysed
by ‘t’ test and non-normally distributed data byWilcoxon rank
sum test (Mann-Whitney). Categorical data was analysed
using Chi-square test or fisher’s exact test. A ‘p’ value of
<0.05 was taken as significant.
Results
In the observation phase, the time to first milk expression was
24 to 48 h. Total amount of EBMwas minimal (Table 2). Only
one out of eight mothers expressed milk on day one (12.5%).
Out of 8 neonates only one of the eligible neonates was on
exclusive MOM on day 7 of life (Table 2).
Intervention phase: CPNC was done for next fifteen
mothers and their postnatal support was streamlined
(Table 1). All these mothers expressed milk within three
hours. The proportion of mothers expressing milk on day 1
increased to 86.6%. Total amount of EBM on day 7 and pro-
portion of neonates on exclusive MOM also increased.
Sustenance phase: The authors evaluated the proportion of
mothers expressing milk on day 1 and proportion of neonates
on full EBM on day 7 after 1 y of initiating this QI project in
two epochs (Epoch 1: 15th August through 30th August 2016
and Epoch 2: 20th September 2016 through 5th October 2016)
and this was 100% (12/12 mothers in epoch 1 and 14/14
mothers in epoch 2) and more than 80% respectively (10/12
neonates in epoch 1 and 13/14 neonates in epoch 2).

6. Discussion
The present study suggests that a simple and feasible CPNC
package can lead to improved milk output in mothers of pre-
term neonates admitted in NICU. Another welcome change
noted in authors’ unit was the decrease in the requirement of
formula milk by almost 50% after the first week of interven-
tion phase.
Similar QI initiatives to increase early milk expression in
mothers of preterm or very low birth weight (VLBW) infants
have been published previously. However, these studies were
Fig. 1 Plan-Do-Study-Act Cycle
Indian J Pediatr (April 2017) 84(4):322–325 323
either externally funded and/or also required additional work-
force [7–10].
The present study is a single centre small quality improve-
ment initiative utilising the existing caregivers (including ma-
ternity unit health care professionals) and no extra external
funding of manpower which suggests the importance of a
simple and feasible CPNC package implementation using
team approach.
The problem of reduced sleep time for mothers was man-
aged by expression of milk from both breasts simultaneously
and managing the timing of milk expression so that she gets at
least four hours of continuous sleep in the night. This is the
first reported QI project related to promotion of expression of
breast milk in NICU without the requirement of any external
support or funding and carried out by the actual caregivers of

7. the unit.
For sustenance; an extra breast pump from the NICU was
given to the maternity ward to ensure breast milk expression
within the maternity ward. In addition, the results of this in-
tervention (run chart) were put up in the unit and shared with
new mothers and newly joined staff nurses and finally the
authors celebrated each success and have been acknowledging
nurse champions every month till date.
Conclusions
A simple quality improvement approach using CPNC
package with team of physicians and nurses helped to
increase exclusive MOM feeding among the NICU ad-
mitted preterm neonates.
Table 1 Elements of comprehensive post-natal counseling
(CPNC) package
S. No. Description Various actions taken Staff involved
1. Education and sensitization of health care providers (HCP) 1.
Teaching and training of HCP by showing webinars
and videos regarding its importance
2. Making sister-incharge of the unit as the team leader
3. Early expression and 4 hourly expression of milk
included in doctor’s treatment order
4. Primary nurse was assigned responsibility of early
milk expression
5. Nurse whose neonate was on exclusive breast milk
only on Day 7 given a Bcertificate of best nurse^

8. of the month
• Faculty incharge [1]
• Resident physicians [2]
• Nurse educator [1]
• Senior staff nurses [2]
2. Education and sensitization of family members 1. Teaching
and counseling of mothers and family
by the HCP
2. Explaining the importance of early and regular
milk expression to the bedside caretaker and mother
3. Advising night expression at 20:00, 22:00, 00:00
and then at 04.30 h
4. Faculty to proactively ask the proportion of EBM
and early expression on routine rounds
5. Encouraging mother for Kangaroo mother care
• Faculty incharge [1]
• Resident physicians [2]
• Nurse educator [1]
• Senior staff nurses [2]
Table 2 Outcome variables
Outcome Observation Phase
(n = 8)
Intervention Phase
(n = 15)
P value

9. Mothers expressing milk within 3 h of birth 0 (0) 15 (100)
<0.0001
Proportion of mothers expressing milk on
day 1
1 (12.5) 13 (86.6) 0.001
Proportion of mothers expressing milk on
day 3
2 (25) 15 (100) <0.0001
EBM on day 1 (ml) 1 2 (1–4)
EBM on day 7 (ml) 100 (91–127) 360 (169–483) 0.001
Proportion of neonates on MOM on day 7
(%)
1 (10) 13 (81.3) 0.001
Data expressed as number (%), median (range)
MOM Mother’s only milk; EBM Expressed breast milk
324 Indian J Pediatr (April 2017) 84(4):322–325
Acknowledgements The authors acknowledge the contribution
by
nursing staff (Ms Kiran Singh, Ms. Veena Bahri, Ms. Geeta
George, Ms. Sneh Dixon) and Dr. Poonam Joshi (Lecturer,
Nursing College, AIIMS) without whom this study would not
have been possible.

10. Contributions AS: Primary responsibility for protocol develop-
ment, study implementation, data management and writing the
manuscript; MJ: Primary responsibility for protocol
development,
supervised implementation of the study and contributed to
writing
of the manuscript; JSD: Participated in implementation of study
and provided inputs in manuscript writing; AT and AKD:
Participated in development of the protocol, supervised
implemen-
tation of the study and contributed to writing of the manuscript.
AKD will act as guarantor for the paper.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
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A Quality Improvement Initiative: Improving Exclusive
Breastfeeding Rates of Preterm
NeonatesAbstractIntroductionMaterial and
MethodsResultsDiscussionConclusionsReferences