Alison Volpe Holmes

Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost.

BACKGROUND AND OBJECTIVE: The incidence and associated costs of neonatal abstinence syndrome (NAS) have recently risen sharply; newborns with NAS occupy 4% of NICU beds. We implemented a coordinated program for NAS including standardized protocols for scoring, medications and weaning, and a calm rooming-in environment, to improve family-centered care and to decrease both length of stay (LOS) and hospital costs. METHODS: In early 2013, a multidisciplinary quality improvement team began consecutive plan-do-study-act (PDSA) cycles. We trained nurses in modified Finnegan scoring, ensured scoring only after on-demand feeds during skin-to-skin care, and standardized physician score interpretation. We provided prenatal family education, increased family involvement in symptom monitoring and nonpharmacologic treatment, and treated otherwise healthy infants on the inpatient pediatric unit instead of in the NICU. We measured outcomes using statistical process control methods. RESULTS: At baseline, 46% of inborn infants at-risk for NAS were treated with morphine; by 2015, this decreased to 27%. Adjunctive use of phenobarbital decreased from 13% to 2% in the same period. Average LOS for morphine-treated newborns decreased from 16.9 to 12.3 days, average hospital costs per treated infant decreased from

Combination Feeding of Breast Milk and Formula: Evidence for Shorter Breast-Feeding Duration from the National Health and Nutrition Examination Survey

19 737 to

A Barrier to Exclusive Breastfeeding for WIC Enrollees: Limited Use of Exclusive Breastfeeding Food Package for Mothers

8755, and costs per at-risk infant dropped from

Part-time residency in pediatrics : Description of current practice

11 000 to

ABM Clinical Protocol #14: Breastfeeding-Friendly Physician's Office: Optimizing Care for Infants and Children, Revised 2013

5300. Cumulative morphine dose decreased from 13.7 to 6.6 mg per treated newborn. There were no adverse events, and 30-day readmission rates remained stable. CONCLUSIONS: A coordinated, standardized NAS program safely reduced pharmacologic therapy, LOS, and hospital costs. Rooming-in with family and decreased use of NICU beds were central to achieved outcomes.

Establishing Successful Breastfeeding in the Newborn Period

OBJECTIVE To examine combination breast milk and formula-feeding (CBFF), defined as daily breast-feeding and formula-feeding begun in the first week of life and to examine associations between CBFF and overall breast-feeding duration. STUDY DESIGN We used the National Health and Nutrition Examination Survey, 1999-2006, to determine the prevalence of CBFF in both univariable and multivariable analyses. We examined breast-feeding duration using Kaplan-Meier and Cox proportional hazards analyses. RESULTS Among 6788 children ages 0-71 months, 8% were CBFF and 55% were exclusively breast-fed during the first week of life. Factors independently associated with CBFF were Hispanic ethnicity (adjusted OR, 3.81) and black race (adjusted OR, 2.59). CBFF was associated with decreased overall breast-feeding duration in the full cohort (P < .001) but not in the Hispanic or black subgroups. CBFF and formula-feeding, when compared with 4 months of exclusive breast-feeding, were associated with an increased risk for overweight/obesity between ages 2 and 6 years. CONCLUSIONS In a nationally representative sample, CBFF is associated with shorter overall breast-feeding duration in white but not Hispanic or black mother-baby dyads. A significant number of US infants, though breast-fed, do not receive the health benefits of exclusive breast-feeding.

Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis

BACKGROUND In the first 2 weeks of life, most breastfeeding mother-infant dyads in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) receive infant formula from WIC, instead of a larger food package designed for exclusively breastfeeding mothers. This study was designed to explore reasons for high rates of formula supplementation of breastfeeding newborns enrolled in WIC and the limited use of the WIC expanded food package. METHODS We conducted in-depth interviews with 29 mothers who either partially or exclusively breastfed for at least 2 months. Interviews were transcribed verbatim, analyzed, coded, and organized into 10 themes. RESULTS Participants view the WIC program in a contradictory manner. They see it as highly supportive of breastfeeding, but also as a promoter of infant formula. The expanded food package for mothers is not valued, but free supplemental formula is highly valued. Misinformation about breastfeeding pervades the healthcare system, and exclusive breastfeeding is not promoted as an important health goal. Lack of access to breast pumps, the unacceptability of pumping in the workplace, and difficulties with nursing in public all contribute to formula supplementation. CONCLUSIONS The healthcare system, the WIC program, and demands of daily life all contribute to low rates of exclusive breastfeeding in the WIC program. The available expanded food package for mothers who are exclusively breastfeeding is both disliked and underutilized, while free supplemental formula is rarely discouraged.

Writing medical student and resident performance evaluations: beyond "performed as expected".

Objective. To determine current national utilization levels of part-time pediatric residency and to identify reasons for pursuing training on a part-time basis. Design. Data were obtained through (1) a survey regarding part-time residency mailed to all accredited pediatric residency programs, (2) the American Medical Association Fellowship and Residency Interactive Electronic Database, and (3) the American Academy of Pediatrics postgraduate level 3 survey, 2003. Results. Of the 190 accredited pediatric residency programs surveyed, 156 (82%) responded; 18 (12%) of these programs had ≥1 part-time resident during academic years 2000–2003. Nationally, 43 of 6609 residents represented in the survey (0.7%) undertook some of their training on a part-time basis. All programs prorated salaries in proportion to time percentage, 10 (71%) continued full benefits for part-time residents, and 15 (88%) used a reduced call schedule. Although multiple reasons were given for part-time status, including travel (16%), research (14%), advanced degrees (9%), personal illness (9%), and family illness (5%), 67% cited child care as 1 reason. Length of residency was extended by an average of 15 months (range: 4–36 months). Analysis of the American Medical Association Fellowship and Residency Interactive Electronic Database showed that 45 (24%) of 190 programs advertise part-time slots. Conclusions. Although numerous pediatric programs advertise part-time positions, few residents actually held such positions during a 3-year period. There is variability among programs in how benefits and call schedules are managed. Part-time positions are chosen for multiple reasons, but the most common reason is to care for children. Pediatric residency programs can use this information to meet resident needs.

Neonatal abstinence syndrome management: A review of recent evidence

and the Academy of Breastfeeding MedicineA central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing commonmedical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breast-feeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care.Variations in treatment may be appropriate according to the needs of an individual patient.

What Works to Reduce Unnecessary Care for Bronchiolitis? A Qualitative Analysis of a National Collaborative

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.