India is home to the world's largest number of preterm births and deaths. Ensuring all sick and vulnerable babies have access to breastmilk in the days and weeks after they are born is critical to keeping these babies alive. But as leading research group AIIMS discovered in its own hospital, a minority of NICU babies were being fed breastmilk. Meena Joshi describes how they turned that situation around.

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