The AAP recommends that all babies be exclusively breastfed for the first 6 months of life. The importance of breastmilk diets is even greater for preterm, very low birth weight babies hospitalized in NICUs, but it can be a struggle to provide these infants with the nutrition they so desperately need. That's where the TCHMB's NICU collaborative comes in.
By Kaulie Lewis
Population Health Scholar
University of Texas System
Master's Student in Journalism
UT Austin Moody College of Communication
When Dr. Nancy Hurst started working at Texas Children’s Hospital in Houston, she was the first lactation consultant the hospital had ever hired. There wasn’t even a certification for the specialty yet. “It was crazy,” she says now, thinking back 30 years.
Her timing couldn’t have been better: The team Hurst joined at Texas Children’s was pursuing a growing interest in the benefits of breastfeeding and human milk diets for infants, a field of study she naturally gravitated towards.
“There were physicians at Texas Children’s and Baylor College of Medicine at the time who were very interested in studying human milk and feeding strategies for preterm infants in the NICU,” Hurst remembers. “And a lot of the research was really starting to ramp up in the late 80s, so it was a perfect time to be involved in the work and to see how the science progressed over the years.”
In the 1980s, when Hurst began her career, the American Academy of Pediatrics didn't yet recommend all babies be exclusively breastfed, and the short and long-term importance of human milk on infant immune, brain and gastrointestinal development was unclear.
Even less was known about the significant impact preterm formula was having on the health of very low birth weight (VLBW) babies being cared for in neonatal intensive care units (NICU). The inability of VLBW infants to process bovine proteins found in formula can cause a number of severe, even life-threatening, medical conditions. These include diseases such as necrotizing enterocolitis (NEC), a condition in which portions of the intestines become inflamed or die.
As researchers began to turn their attention to neonatal nutrition, a series of studies were published establishing the benefits of human milk. With more and more evidence to support breast milk usage, the medical consensus and common practice slowly began to change.
Hurst, now the Director of Women’s Support Services at Texas Children’s, eventually went on to get a doctorate degree in nursing, writing her dissertation on the experiences of new mothers providing breast milk for their infants in the NICU. More recently, her interest in neonatal nutrition and the importance of breastfeeding led her to join the executive committee of the Texas Collaborative for Healthy Mothers and Babies’ (TCHMB) where she serves on the neonatal sub-committee as co-chair alongside Dr. Charleta Guillory, the Director of the Neonatal-Perinatal Public Health Program at Texas Children’s.
The TCHMB, a multidisciplinary network of health professionals from across the state, was formed in 2015 with the goal of improving health care quality for Texas’ mothers and babies through a series of joint quality improvement initiatives. The TCHMB's neonatal initiative to increase breastfeeding and human milk use in the NICU was launched shortly after and now includes 17 hospitals and NICUs working together to implement and improve breast milk diets for preterm and VLBW children.
“It’s a high-impact project that’s improving the lives of premature babies throughout Texas,” says Guillory, who’s work with the Texas Pediatric Society Committee of Fetus and Newborn Health helped mobilize support for the collaborative’s project.
The motivation for creating a learning collaborative to address VLBW infant nutrition was a simple one, according to Dr. Alice Gong, one of the physicians most involved in the initiative’s beginnings.
“One of our goals is to decrease infant mortality, and as a neonatologist you sort of have a good understanding of what causes that,” says Gong, a specialist in neonatology and perinatology at UT Health San Antonio.
“Many causes of infant mortality are out of doctors’ control,” she explains. “Kids with congenital anomalies, that’s not something we can do something about. Prematurity is a major cause of infant mortality, and neonatalogists can’t really make much of an impact on that. But two of the things that are the most devastating to babies in the NICU are necrotizing enterocolitis and infections. The use of mother’s breast milk reduces both of those, and that is something we should be able to impact.”
Even with the evidence of the positive impact of mother’s milk for preterm babies — VLBW infants fed an exclusively human milk based diet were 75% less likely to develop surgical NEC — it was often difficult to supply the milk needed for these infants. Mothers who deliver preterm babies often struggle to produce enough milk to fully provide for their children’s dietary needs, and supplemental donor milk sourced from milk banks is expensive and sometimes scarce.
“But I kept looking at this and saying, it’s not just about using human milk and getting human milk paid for,” says Gong. “It’s about getting the moms to pump, teaching them that that’s the right thing to do for their babies, making sure that they have the right equipment so that they can pump, and removing the barriers in their way.”
The barriers that prevent mothers from providing milk for their hospitalized infants, says Gong, are numerous and all too common. It’s these barriers that the learning collaborative is most concentrated on easing or removing.
In its original conceptualization, the project modeled itself on a California-based collaborative that was addressing similar issues. It quickly became apparent, however, that the states’ needs were very different.
“We realized that the NICUs we have here in Texas, those that were part of this first wave, were already doing a lot right,” says Dr. Dorothy Mandell, who is coordinating the NICU project for the TCHMB. “They were already doing a good job of initiating breast milk expression for these mothers and babies. So for the past year we’ve been working through how, based on where people are now, to improve those rates and to increase the number of women who transition to breastfeeding.”
In order to ensure participating hospitals and NICUs were on a similar level, Mandell, with the input of the collaborative’s members, implemented a bundle of ten components for participating units to develop and improve.
“They’re a modification of the ten-step program that’s associated with being designated Baby-Friendly,” she explains. “They have been modified to be more appropriate to a NICU. They give us a baseline, and the collaborative wanted to start off making sure we’re addressing these main components before we started talking about moving forward.”
"One of our goals is to decrease infant mortality, and as a neonatologist you sort of have a good understanding of what causes that. ... The use of mother's breast milk reduces [mortality], and that is something we should be able to impact."
Most of the 17 participating hospitals are meeting these steps and doing well at getting mothers to initiate milk production. The focus is now on keeping women pumping and providing breast milk until the baby is discharged.
“That’s a hard thing,” Mandell says. “So what we’re working on now is slightly different than getting those ten steps in place. The collaborative hospitals have been great at getting mom’s started on pumping, now the question is how do we keep them going until discharge and how do we transition them to breastfeeding, if mom want to breastfeed?”
Less than a year after the collaborative began, member NICUs have worked out a number of solutions to counter common barriers that prevent mothers from providing sufficient milk for their infants. One of the most common issues facing new mothers is the difficulty of getting a hospital-grade breast pump for home use, says Gong. “We have moms that want to provide milk but then they go home and they don’t have a pump and they dry up.”
The problem lies in the time required for most hospitals to process the insurance authorizations. There’s often a delay in processing and her receiving the pump, effectively ending a new mother’s chance at building the necessary volume.
In response to this problem, one of the collaborative’s member hospitals worked out a policy solution that would enable mothers to go home with the required pumps.
“What they have been able to do is set up a good relationship with the medical device provider directly, so that the initiation and the pre-authorizations that need to happen, happen so much faster,” Mandell explains. “They request the pump the day the baby is born and then when the mother gets home, there’s a pump waiting for her.”
The hospital then presented their success to the wider learning collaborative, leading several other members to begin implementing similar policies.
The direct partnerships with medical device providers that make these speedy authorizations possible aren’t the only innovations coming out of the learning collaborative. Teams are also working on finding new ways to facilitate communication between lactation consultants and new mothers, as well as on improving training techniques for all NICU nursing staff.
“It’s so important to have the nursing staff engaged and to be knowledgeable about what is required to initiate and maintain lactation, as well as initiating direct breastfeeding,” says Hurst, “because you’re never going to have enough lactation consultants.”
But human training and improved interactions are only one way the collaborative works to increase the use of human milk in the NICU. There have also been significant changes to state-level Medicaid policy surrounding reimbursements for human donor milk.
Medicaid doesn’t cover the full price of donor milk. “But now they will reimburse for the storage and processing of the donor milk,” Mandell says. “And that’s one of those things that takes a little bit of the burden off hospitals.”
That doesn’t mean those reimbursements are easy to claim. “One of the things we’ve been doing in the collaborative is making sure all of our hospitals are on the same page on how to do that reimbursement,” Mandell explains.
Luckily, collaborative members are eager to cooperate. When one of the collaborative’s member hospitals experienced difficulties with reimbursement, another hospital connected their claims processing departments in order to help sort out the process.
“Those kinds of things aren’t going to show up in the data, but that’s really cool,” says Mandell.
The first year of the collaborative has been a learning process for all involved, and there are more changes ahead. Texas Medicaid has changed its policies and will soon no longer reimburse hospitals for NICU stays unless their level of care has been state certified. The certification standards for determining those care levels require 24 hour lactation support in NICUs treating the most fragile babies, and interest in the TCHMB’s neonatal initiative is increasing as result.
“We’re seeing a lot more NICUs going, ‘oh, hey, I hear you guys are doing something about this, how can we participate?’” says Mandell. “That’s led us to talk about round two, let’s see if we can bring in more hospitals. For those who are maybe less experienced, we’ll have this nice mentoring situation set up. We can say ‘this is how we started’ so that these hospitals aren’t reinventing the wheel over and over again.”
Looking back over the success of the collaborative so far, staff give credit to the doctors who laid the project’s groundwork.
“Everything changes and everything starts because there’s one or two people who will it into place, and that can’t be understated. And there are several people in this state who really willed this into place,” says Mandell, emphasizing the roles played by Dr. Alexander Kenton and Alice Gong.
What does Gong, capable of willing major projects into existence, have coming up?
“I always have projects,” she says. Now that progress is being made in NICU nutrition, Gong is moving a step higher, following up with families after their babies are released from the NICU. “We do a lot with baby, but we don’t do much with the parents besides talk to them,” she explains, but that can present profound challenges for families.
“There are a lot of projects involved here,” she says. “So, we’re learning.”