Leveraging a Program of Research to Inform: Education, Clinical Practice, and Health Care Policy Linda P. Brown, PhD,

1. Leveraging a Program of Research to Inform: Education, Clinical Practice, and Health Care Policy Linda P. Brown, PhD, RN, FAANUniversity of Hong KongNovember 14, 2003

2. Breastfeeding Services for LBW Infants – Outcomes and Costs Linda P. Brown, PhD, RN, FAAN (PI) Paula Meier, DNSc, RN, FAAN (Co-PI) Alan Spitzer, MD (Co-I) Steve Finkler, PhD, MBA (Co-I) Barbara Jacobsen, MS (Statistician) Diane Spatz, PhD, RNC (Co-I) Ksenia Zukowsky, MSN, CRNP (Project Director)  Funded by the NINR, NIH (R01 NR03881)

3. Purpose:To Test a Model of APN Managed Breastfeeding Support for Low Birthweight Infants: Using Pre- and Post-Hospital Discharge Individualized interventions

4. Research Aims: A structured program of breastfeeding services provided by APNs compared to routine care for breastfeeding will result in: Improved maternal outcomes (breastfeeding outcomes; psychological outcomes; satisfaction with care)

5. Research Aims: A structured program of breastfeeding services provided by APNs compared to routine care for breastfeeding will result in: Improved infant outcomes (Decreased post-discharge morbidity; Improved development over 1 year post infant discharge)

6. Research Aims: A structured program of breastfeeding services provided by APNs compared to routine care for breastfeeding will result in: Decreased costs of care (Decreased total costs of care; Decreased average re-hospitalization costs per infant)

7. APN Intervention Goals To define a nutritional breastfeeding/human milk approach of care for low birthweight infants To educate parents and providers as to the role of breastmilk in providing optimal nutrition for the low birthweight infant’s growth and development To implement strategies to ensure maternal and infant success

8. Maternal Assessment Health history specific to breastfeeding Physical examination related to human lactation & breastfeeding Health assessment Knowledge assessment

9. Maternal Education Assess breastfeeding knowledge Instruct mother on concepts of supply and demand, milk expression, collection, storage, and transport to minimize bacterial contamination Instruct mother on adequate diet, fluid intake and rest

10. Family Support and Education Assess family beliefs and knowledge surrounding breastfeeding Instruct family on importance of breastfeeding for the low birthweight infant Examine cultural influences Incorporate culture into care

11. Staff Support for Breastfeeding Obstetrical nurses and physicians Neonatal nurses and physicians Allied health care professionals Lactation counselor Social Worker Speech Consultant Developmentalist

12. Maternal Breast Milk Limitations Adequacy of supply Calories Minerals and vitamins Requires intensive support and management from the hospital staff

13. Feeding Human Milk to the LBW Infant Early initiation of enteral feedings (goal - wean off hyperalimentation to full enteral feedings of breast milk) Oro-gastric/naso-gastric feeds of breastmilk prior to onset of suck reflex Alternative feeding methods (paladai)

14. Infant Assessment and Transition to Breast Infant assessment (gestational age and infant cues) Preparation for transition to breast skin to skin care non-nutritive sucking at the empty breast during naso-gastric feeds positioning

15. Transition to Breast Early breastfeeding once infant demonstrates cues and is at 32-34 weeks Begin with one breastfeeding session and increase as tolerated Monitor infants cardio-respiratory status during initial breastfeeding sessions Maternal/infant breastfeeding assessment and support are essential

16. Transition to Breast Milk intake and growth Gastric aspirate measurement Baby weigh scale for test weights Daily weight Daily weight growth curves Head circumference and length

17. Preparation for Discharge Infant feeding plan established Frequency and duration of breastfeeding Milk expression Alternative feeds Adequacy of intake at home Weight assessment Plans for follow-up

18. Post-Discharge Availability of breastfeeding follow-up First week at home is critical Care provider follow-up Where and when Knowledge of breastfeeding and LBW infants Portable Baby Weigh Scales Growth measures

19. Leveraging Research to: Create New Knowledge Advance Clinical Practice Inform Education Inform & Direct Health Care Policy Identify Future Research

20. Research Papers (New Knowledge) Bair, A., Brown, L., Pugh, L., Borucki, L., & Spatz, D. (1996). Taking a bite out of CRISP: Strategies for searching the CRISP database. Computers in Nursing, 14(4):218-223. Brown, L., Meier, P., Spitzer, A., Finkler, A., Jacobsen, B., Spatz, D., & Zukowsky, K. (1997). Resubmitting a grant application: Breastfeeding services for LBW infants-Outcomes and Cost. Nursing Research, 46(2); 119-122. Langston, M., Pugh, L., Franklin, T., Brown, L., & Milligan, R. (1998). Exemplary program development-A community health nurse and a breastfeeding peer counselor providing care to low-income women. The Journal of Perinatal Education, 7(3), pp. 33-39. Brown, L., Spatz, D., Hollingsworth, A. and Armstrong, C. (1998). Promoting successful breastfeeding of mothers of LBW infants. Journal of Perinatal Education, 1(1): 20-24. Meier, P., Brown, L., Hurst, N., Spatz, D., Engstrom, J. Krouse, A., & Borucki, L. (2000). Nipple shields for preterm Infants: Effect on milk transfer and duration of breast-feeding. Journal of Human Lactation. 16(2), pp. 106- 114.

21. Research Papers (New Knowledge) Milligan, R., Pugh, L., Bronner, Y., Spatz, D., & Brown, L. (2000). Breastfeeding Duration among low income women. Journal of Midwifery & Women’s Health, 45(3), pp.246-252. Brooten, D., Naylor, M., York, R., Brown, L., Munro, B., Hollingsworth, A., Cohen, S., Finkler, S., Deatrick, J., Youngblut, J. (2002). Lessons learned from testing the quality cost model of advanced practice nursing (APN) transitional care. Journal of Nursing Scholarship, 34,4, pp. 369-376. Pugh, L., Milligan, R., & Brown, L. (2001). The breastfeeding support team for low-income, predominately minority women: A pilot intervention study. Home Care for Women International, 22, pp 501-515. Brown, L., Bair, & Meier, P. (2003). Does federal funding for breastfeeding research target our national health objectives? Journal of Pediatrics, Apr;111 (Pt 1):e360-4.

22. Dissertations (New Knowledge) Chair – Mary Ann Couch – An Examination of Breastfeeding Protocols for Cultural Congruency (University of Pennsylvania, data collection on-going) Chair – Angel Bair – Screening for Cervical Cancer among Chinese-American College Students (University of Pennsylvania, 2003) Chair, Ann Phalen – “Measuring Human Milk Intake in Preterm Infants: Correlation of the Preterm Infant Breastfeeding Behavior Scale (PIBBS) and Test Weighing (University of Pennsylvania, 2003) Member, Ksenia Zukowsky – LBW Infants: Feeding patterns in the first six months of life (New York University, 2002) Chair, Lynne Borucki - Mothers Experiences Using a Supplemental Feeding device (University of Pennsylvania, 2001) Member - Anne Krouse - Family Management of Breastfeeding Low Birthweight Infants, (University of Pennsylvania, 1998)

23. Clinical Papers (Inform Clinical Practice) Brown, L., Meier, P., Spatz, D., Zukowsky, K. & Spitzer, A. (1996). Use of human milk for low birthweight infants. The Online Journal of Knowledge Synthesis for Nursing, Available: Volume 3, Document 3, Online Number 27. Meier, P., & Brown, L. (1996). State of the science: Breastfeeding for mothers of low birthweight infants. Nursing Clinics of North America, 31(2):351-365. Meier, P. & Brown, L. (1997). Strategies to assist breastfeeding in preterm infants. Recent Advances in Paediatrics. pp.137-150. Meier, P. & Brown, L. (1997). Letter to the editor. Journal of Nurse- Midwifery, 42(1):65-66. Brown, L., Bair, A., Meier, P., Pugh, L., Spatz, D., Borucki, L., & Morin, K. (1998). Accessing on-line information at the National Institutes of Health: Highlights and practical tips. Computers in Nursing, 16(4), pp. 198-201. Meier, P., and Brown, L. (1998). Breastfeeding a preterm infant after NICU discharge: Reflections on Ryan’s story. Breastfeeding Abstracts, pp2-4.

24. Education Courses (Inform Curriculum) Developed undergraduate course Nursing 361 – Case Study – Breastfeeding and Human Lactation (highly rated) Work with undergraduate students via independent study to develop course (highly rated) Plan for UG/GRAD/PhD research projects (on-going) Develop graduate course on breastfeeding and human lactation with associated clinical experiences (on-going) Seek opportunities for interdisciplinary offerings Develop a UG/GRAD minor or cluster in the content area and seek training grant monies for this innovation from the Division of Nursing, DHHS Plan for doctoral seminar in content area Involve and mentor nursing and non-nursing students at all levels in grant activities

25. Book Chapter (Educational Materials) Meier, P., and Brown, L. (1998). Breastfeeding the preterm infant. In J. Riordan & K.G. Auerbach (Eds.), Breastfeeding and Human Lactation. Boston: Jones & Bartlett.

26. Future Research Projects for Undergraduates (Funded) Breastfeeding Services for LBW Infants - 0utcomes and Cost – Minority Supplement (Brown, L., Couch, M. Funded: NINR, NIH, (Grant R01 NR03881 – S1), Total Costs $167,694 (1996-2001). An Examination of Breastfeeding Protocols for Cultural Congruency, Couch, M. Nassau Fund - $800 An Examination of Federal Funding for Infant Nutrition: 1983 - 1995, Bair, A. Nassau Fund - $800

27. Inform & Direct Health Care Policy: An Exemplar on Integrating Research, Education, and Practice Goal DETERMINE CONGRUENCY OF FEDERAL FUNDING ON INFANT NUTRITION WITH HEALTHY PEOPLE 2000/2010 GOALS (OBJECTIVE 14.9) Objective 14.9 Increase to at least 75% the proportion of mothers who breastfeed their infants in the early postpartum period Increase to at least 50% the proportion of women who continue breastfeeding until their infants are 5 to 6 months old

28. Specific Aims To determine the number and dollar amount of federally funded research projects in the area of infant nutrition, breastfeeding, and lactation from 1994 to 1996; and To determine the impact of these funded projects on the achievement of our national goals for breastfeeding

29. Methods – Qualitative Study Data obtained from research abstracts in the federal data-base called CRISP: C OMPUTER R ETREIVAL I NFORMATION S CIENTIFIC P ROJECTS

30. Key words used to identify all possible funded projects in desired categories Developmental nutrition Infant nutrition disorder Infant food Breastfeeding Human milk Colostrum Milk Lactation Lactation disorder

31. Data Analysis Each abstract subjected to content analysis at the manifest level Content analysis was performed by a panel of 3 experts in the field of maternal-child health A coding form was developed to standardized to obtain relevant data Each abstract was reviewed to determine eligibility for inclusion

32. Data Analysis A total of 462 abstracts were generated by the search Of these, 362 (78.4%) abstracts were identified as appropriate for the sample 10% of the remaining dataset was randomly selected to be coded independently by the 3 panel members to establish inter-rater agreement 95% of these abstracts were coded identically

33. Major Findings: A total of $40.4 million in federal research funds were awarded over the 3 year time period studied Of this total amount, only 13.7% ($5.6 million) was awarded to projects determined to have either a direct impact (6 of 362 projects ; 1.7%) indirect impact (25 of 362; 6.9%) on achieving national goals for increasing incidence and duration of breastfeeding

34. Policy Implication Findings suggest a significant disproportion in both number and dollar amount of NIH projects targeted toward basic versus applied lactation and human milk science This imbalance has resulted in an extensive knowledge base about the composition of human milk and lactation physiology but little about effective intervention to promote and sustain the practice of breastfeeding

35. Policy Implications Few projects involved populations known to be at risk for poor breastfeeding outcomes 27 studies within the breastfeeding category involved the adaptation of human milk science to improve or develop other foods, giving the erroneous impression that the corresponding $4.1 million was awarded to fund breastfeeding studies Should NIH direct millions of dollars toward the improvement of infant formulas?

36. Limitations Process of retrieval of abstracts complicated Only the CRISP data-base was used; leaving the possibility the research by other federal agencies other than the US Public Health Service and its major branch, NIH may have been omitted

37. Funding and Publications for the CRISP Project An Examination of Federal Funding for Infant Nutrition: 1983 - 1995, Bair, A. Nassau Fund - $800 (Faculty Sponsor – Brown, LP) Bair, A., Brown, L., Pugh, L., Borucki, L., & Spatz, D. (1996). Taking a bite out of CRISP: Strategies for searching the CRISP database. Computers in Nursing, 14(4):218-223. Brown, L., Bair, A., Meier, P., Pugh, L., Spatz, D., Borucki, L., & Morin, K. (1998). Accessing on-line information at the National Institutes of Health: Highlights and practical tips. Computers in Nursing, 16(4), pp. 198-201. Brown, L., Bair, & Meier, P. (2003). Does federal funding for breastfeeding research target our national health objectives? Journal of Pediatrics, Apr;111 (Pt 1):e360-4.

38. Future Research Projects (Funded) “Breastfeeding Services for Low Income Women: Maternal and Infant Outcomes.” (Brown, L., Pugh, L., & Milligan, R.) (Principal Investigator). Funded: University Research Foundation, University of Pennsylvania, Total Costs - $15,000 (1997-1998). “Nurse Intervention for Low Income Breastfeeding Women. Pugh, L., Bronner, Y., Brown, L., Localio, A., Milligan, R., Poles, G., & Spatz, D. Funded: National Institute of Nursing Research, NIH, (R55 NR), Total Costs - $100,000 (1998-2000; with Johns Hopkins University). “Breastfeeding Services for Low Income Women” (Brown, L., Bret-Schneider, J., & Dastous, R.) (Program Director). Funded - March of Dimes Birth Defects Foundation, Total Costs $2,500 (1997). Breastfeeding Services for LBW Infants - 0utcomes and Cost – Minority Supplement (Brown, L., Vogler, J. Funded: NINR, NIH, (Grant R01 NR03881 – S2), Total Costs $20,000 (1999-2001; with University of Hawaii) “Research on Vulnerable Women, Children and Families” (Gennaro, S., Deatrick, J., & Brown, L.). Funded: National Institute of Nursing Research, NIH, (T32), Total Costs - $1,832,691 (1998-2003).

39. Grant Staff Accomplishments D. Spatz, PhD, RNC Assistant Professor and Lactation Specialist at Children’s Hospital of Philadelphia A. Krouse, MSN, RNC PhD A. Phalen, MSN, RNC PhD M. Couch BSN, MSN,MBA, PhD Candidate A. Bair BSN,MSN, PhD R. Dastous BSN, MSN CNM K. Zukowsky, NNP PhD J. Vogler, PhD, RNC Associate Professor