Implementing a Breastfeeding Establishment Guideline in the NICU

Breastfeeding rates in the newborn intensive care unit (NICU) are suboptimal. Prematurity is a significant barrier to breastfeeding in the NICU. Evidence shows that direct breastfeeding does not increase the length of hospital stay for a preterm infant in the NICU. Local Problem: A level III NICU in Utah has no guidelines for introducing bottles while establishing breastfeeding in preterm infants. The lack of guidelines has led to inconsistencies in clinical practice regarding breastfeeding establishment and bottle introduction. Methods: The setting included a 48-bed level III NICU. Participants include advanced practice providers, registered nurses, neonatologists, fellows, lactation specialists, and NICU developmental therapists. Interventions: This quality improvement project assessed current breastfeeding practices, attitudes, knowledge, perceived barriers, and facilitators from caregivers. The QI team created and implemented a breastfeeding establishment guideline for preterm infants under 35 weeks. Caregivers were provided education through various platforms. Two PDSA cycles were completed post-implementation for rapid cycle changes over eight weeks. Post-implementation assessments included feasibility, usability, and satisfaction. Results: Guideline development occurred using quality evidence and expert clinician opinion. Approximately 270 caregivers received questionnaires, with a 26% (n=70) pre-questionnaire response rate and a 16% (n=43) post-questionnaire response rate. 40% (n=28) of participants felt a need for a breastfeeding guideline pre-implementation. Feasibility: 67% (n=29) reported that the guideline benefits infants and their mothers. Usability: The frequency of breastfeeding before bottle feeding increased by 6%. Satisfaction: 44% (n=19) reported satisfaction with the guideline. Conclusion: Although low satisfaction occurred, more time and ongoing education were needed during the implementation phase to improve satisfaction. This project is sustainable with future steps of continuing education and monitoring of guideline usage.