1. The University Hospital Limerick implemented a quality improvement project to increase breast milk exposure for extremely low birth weight infants from below 20% to 100% in order to eliminate cases of necrotizing enterocolitis (NEC). 2. Through staff education, parental involvement, and policy changes, the hospital was able to achieve 100% breast milk exposure for ELBW infants and zero cases of NEC, saving over €250,000. 3. The success of this project received international acclaim, with Dr. Philip receiving an award for best educational project at a world congress on excellence in pediatrics.

1. Quality and Child HealthQuality and Child Health
‘Milky way’- a Limerick model‘Milky way’- a Limerick model
Dr. Roy K Philip
Consultant Paediatrician & Neonatologist
University Hospital Limerick
Limerick, Ireland
roy.philip@hse.ie
@roykphilip

2. Jupiter, king of the Gods, tried covertly to have his son Hercules take a
few sips of divine breast milk from his stepmother, Juno (queen of
the gods), but startled, she awoke and milk shot from her breasts into the
heavens thus forming the Milky Way galaxy.
The Origin of the Milky Way, about 1575, oil on canvas. National Gallery, London

4. Breastfed children have at
least six times greater
chance of survival in the
early months than non-
breastfed children.
Breastfeeding drastically
reduces deaths from acute
respiratory infection and
diarrhoea, two major child
killers, as well as from other
infectious diseases (WHO-
Lancet 2000).

6. Survival of ELBW and VLBW neonates over 5 decades

7. • Causes and Timing of Death in Extremely Premature
Infants from 2000 through 2011
• Ravi M. Patel, M.D.
• N Engl J Med 2015; 372:331-340 January 22, 2015
• Analyzed prospectively collected data on 6075 deaths among 22,248
live births, with gestational ages of 22 0/7 to 28 6/7 weeks, among infants
born in study hospitals within the National Institute of Child Health and
Human Development Neonatal Research Network.
• We found that from 2000 through 2011, overall mortality declined among
extremely premature infants. Deaths related to pulmonary causes,
immaturity, infection, and central nervous system injury decreased, while
necrotizing enterocolitis–related deaths

8. NECROTIZING ENTEROCOLITIS (NEC) is the most common
acquired gastrointestinal emergency in the preterm low birth weight
newborn.

9. Breastfeed Med. 2011 Jun 30.
Costs of Necrotizing Enterocolitis and Cost-
Effectiveness of Exclusively Human Milk-Based
Products in Feeding Extremely Premature Infants.
Ganapathy V, Hay JW, Kim JH.
•Nationally, the total economic benefit from avoided direct and
mortality costs would be a $1.8-2.1 billion per year savings.
65% decrease in the incidence of NEC and an 8 fold reduction in
the odds of needing surgery in the group getting the fully human milk
based diet compared with the group getting the standard diet which includes
bovine-based components.

10. IRELAND
In 2013, 55.8%55.8% of mothers were breastfeeding on discharge from
hospital, 46.6% exclusively.
Figures for 2012 showed that five out of every 10 babies born in Ireland
were being breastfed on leaving hospital.
This compares with eight out of every 10 in the UK.
Across Europe on average nine out of every 10 babies born are breastfed,
with almost all babies born in
Norway, Denmark and Sweden being breastfed.
Less than 10% at 6 months of age.

11. University Hospitals Limerick
(UHL)
University Maternity
Hospital Limerick
Model 4
Population served 375,000
Stand-alone maternity hospital
In-house births 4,600 per year
Regional NICU

12. QIP
• Aim statement
• Aim checklist
• Driver diagram
• Test of change
• Primary drivers
• Secondary drivers

13. 100 % exposure to breast milk for ELBW
(from below 20%)
Zero NEC
(from 12 - 20%)

19. How to achieve 100% breast milkHow to achieve 100% breast milk
uptake by ELBWuptake by ELBW
• 1. Nutrition of premature neonates & routes of nutrition (policy)
• 2. Choice of nutritional products (policy)
• 3. Advantages of breast milk for premature infants
• 4. Barriers to breastfeeding & psychology of mother
(Father, grand mother)
• 5. Maternal involvement in the ‘care team’ / ‘Peer support’
• 6. ‘Senior’ discussion with mother & father on day one*
• 7. Challenges & changes; Reinforce
• 8. Cultural aspects & history
• 9. Coach, cultivate and convert – key message
• 10. Staff belief, empowerment – create BF
advocates & champions
Bring to sustainability and pride (still keep an eye)

20. Potential other contributors to aPotential other contributors to a
‘NEC free NICU’‘NEC free NICU’
• Hand hygiene
• Antibiotic stewardship
• Central lines
• SaO2 monitoring
• Maternal management
• Antenatal steroids
• PDA management
• Blood transfusion
• Ventilation
• Improved formula / volume
• (Probiotics)
• KMC / KFC

21. Breastmilk exposure and NEC:ELBWexperience UMHL
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Years2000 - 2013
NumberofELBW
Numbero ELBW
EBM exposure number
Number of NEC

22. ‘‘NEC free NICU’NEC free NICU’
• Breast milk for premature babies.
• From below 20% to 100%
• ZeroZero Necrotising enterocolitis (NECNEC) at UMHL.
• Maintenance of success for 3 years
• Saving of over €250,000
• Through QIP, buy-in, parent in the treating
team.
• International black spot to hot spot in
breastfeeding.
• International acclaim – awards & publications.

23. Excellence in Pediatrics (EiP) – world congress.Excellence in Pediatrics (EiP) – world congress.
Best educational project award – 70 countries and over 2000 participants.Best educational project award – 70 countries and over 2000 participants.

24. • A 'NEC free NICU' throughA 'NEC free NICU' through
breastfeeding quality improvementbreastfeeding quality improvement
project (QIP)project (QIP)
• RK Philip, A Ismail, C Quinn, M Dunworth,
A Hannigan, M O'Leary
• Pediatrics 2015; 135:Supplement 1
135S1; doi:10.1542/peds.2014-330W
• Extract Full Text Full Text (PDF)

25. Breast milkBreast milk
• A prebiotic
• A probiotic
• A synbiotic
• An antibiotic
• A lovebiotic
@roykphilip

26. Breast milk: the best lovebioticlovebiotic
• Crealey MR, Ludusan E, Philip RK.
• J Perinatol. 2015 Aug;35(8):665. PMID: 26219700

27. Generally speaking, the number of people an
organization needs to train in process improvementtrain in process improvement
is the square root of the total number of personnel.
Rule of ThumbRule of Thumb
Thomas H Lee, MD, chief medical officer at Press Ganey Associates.
Engaging doctors in the health care revolution ...
HRB 2010
Turning Doctors into Leaders
Thomas H. Lee, MD

28. 1.India: 3, 519 1001.India: 3, 519 100
The 10 countries with the greatest number of preterm births

29. In summary…..In summary…..
• Initiating change
• Effective clinical leadership
• Clinical innovation
• Value in healthcare
• Adapt, Articulate, Buy-in
• Collective mission
• Goal – feel proud
• Break it down - process
Dr Roy Philip Clinical Leaders Summit
26th May 2016

31. Mahatma Gandhi once said,
“Be the change that you wish to see in the world.” and
"Your beliefs become your thoughts,
Your thoughts become your words,
Your words become your actions,
Your actions become your habits, Your habits become your values,
Your values become your destiny.”

32. roy.philip@hse.ie
@roykphilip
Breast milk: the best lovebioticBreast milk: the best lovebiotic