The document outlines a quality improvement initiative aimed at increasing expressed breast milk (EBM) intake in neonates admitted to a tertiary NICU in India. The initiative successfully increased the proportion of neonates receiving EBM from 12.5% to 83% within six weeks by enhancing maternal milk expression practices and implementing supportive measures. Lessons learned include the effectiveness of a structured approach and the ability to sustain improvements over a year, benefiting both infant care and reducing formula costs.

1. Making NICUs breastfeeding-friendly
Lessons from India
Quality improvement initiative
“Improving expressed breast milk intake in sick
neonates”
admitted in a level III NICU
Ms. Meena Joshi BSc RN
Nurse Educator, Division of Neonatology
Department of Pediatrics
All India Institute of Medical Sciences
Email id: meena_joshi1000@yahoo.com

2. Breast Milk: It’s importance
and role
 Breast milk is unquestionably the best milk for a baby.
 All neonates should get mother’s milk from day 1 till 6 months
(WHO recommendation)
 Late expression of milk leads to inadequate milk resulting in lactation
failure
 Formula feeding: risk factors for Necrotising Enterocolitis (NEC)
(Yaseen H., Al Umran K., Darwich M. et al. 2003)
AIIMS NICU
 Neonates are fed with own mothers’ milk
 At times formula feed/ other mother’s intermittently till the time their
mothers can produce their own milk in sufficient quantity
 This period of formula /other mother milk feeding: 6-7 days after
birth.

3. “Area to focus on in quality improvement initiative”
 Mothers whose babies are admitted in NICU start expressing
milk only after day 3
 The frequency of milk expression in these mothers is limited to
two to three times in a day including expression of breast milk
during the night
“Problem Statement”
AIM Statement
• To increase the amount of breast milk intake in admitted
neonates from 12.5% to 30% over six weeks

4. Problem Analysis and data
collection
Fish Bone diagram for problem analysis
■ Baseline assessment of
BM practices over a
period of one week
■ Time of first
expression of BM
■ Amount and frequency
of EBM from Day 1- 6
■ Amount & Type of
feed provided to the
baby
■ Planned a PDSA Cycle
(Plan do study Act)

5. ■ Frequency of expression of
milk including night
increased from 2-3 times to
5-6 times/day
■ Amount of EBM increased
by 50%
■ Proportion of neonates on
EBM intake increased by D7
from 1/8 (12.5%) to 5/6
(83%).
■ Breast milk production on
Day 1 increased after the
intervention phase
PDSA Cycle (Plan do study Act)
Results:

6. Sustenance in the unit
■ Primary nurse responsible for early
expression
■ Part of daily treatment order
■ Faculty involvement
■ SMS/ What’s app reminder in group
■ Sister-in charge of the unit is the
team leader
■ Facilitating Nurses with certificate
of appreciation
■ Continuing on-going Comprehensive
Postnatal Counselling (CPNC)
■ Sharing results at periodic intervals
on a run chart
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
N1 N2 N3 N4 N5 N6 N7 N8 N9 N10 N11 N12
FF
EBM
Current status of EBM vs. Formula intake
at day 7 (12 months after the QI
initiative)

7. Lessons learnt
■ We started on a small scale with very few
mothers
■ The approach was then implemented in the
unit
■ We are able to sustain the gains even after
12 months of this initiative by small steps
■ This quality improvement approach helped
improve care for babies and reduced the
cost related to formula
■ EBM feeding among sick neonates promoted
early discharge from the hospital