In a recently released quality report article in Pediatrics, Dr. Ann Kellams and colleagues describe their work bringing the safe sleep message to 8 demographically diverse birthing hospitals that participated in a nursing-driven Quality Improvement (QI) project (10.1542/peds.2017-1816). The project goals were to improve both (1) parental receipt of safe sleep information from nursing staff and (2) the actual rate of actually supine sleep in a safe environment among infants in the hospitals. Broadly speaking, the project was highly successful.
This was a phenomenal Quality Improvement (QI) study: it was accomplished in the context of usual care with minimal added documentation and time requirements, yet broadly engaged nursing staff in the process, and met almost all goals. Take-home learning points from this well described intervention that might be useful in “kick starting” a similar project in one’s own hospital or practice are many. The authors used multiple sources of information to design their intervention, all of which are within the practitioner’s reach. These included: (1) existing tools (why reinvent the wheel?), (2) prior research about barriers to safe sleep implementation (learn from distant experts), (3) interviews with nursing leadership about successful strategies (learn from local experts), (4) nursing staff focus groups about facilitators and barriers to safe sleep messaging (empowerment of future participants), and finally (5) consultation with an advertising agency to brand and market the intervention (let those who know how do what you cannot!). Safe sleep messages were stated without ambiguity and were limited to 4 specific messages: baby sleeps on his/her back, nothing else is in the crib, share the room not the bed with the baby, and start a pacifier when breastfeeding is established. Feasibility of PDSA (plan-do-study-act) cycles was enhanced by conducting brief 2-3 week cycles, and burden was reduced with a systematic strategy including audits of just 10 mothers and 10 infants each cycle. These features would all be replicable in a single site (office or clinic) study conducted on a smaller scale.
One additional point stood out to me as particularly interesting. That is the ongoing challenge of accurately conveying and supporting the breastfeeding/pacifier message, which is basically that pacifiers should be introduced after breastfeeding is well established. Even this highly successful QI initiative could not quite push that rock up the hill. It is difficult for many parents and professionals to embrace the key point that pacifier use may silence critically important hunger cues of sucking and rooting, especially in the first 2-3 weeks of life. Use of the term “pacifier restriction” for this breastfeeding-friendly, infant-friendly and mother-friendly practice implies that babies are being deprived of an inalienable right to enjoy form-fitted plastic nipples! The most recent Cochrane review on this topic (Jaafar et al Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database Syst Rev. 2016 Aug 30;(8):CD007202) indeed concludes that pacifier use in healthy term infants does not impact later breastfeeding. However, careful reading of this review reveals that of the 2 reviewed studies with 1302 total mother-infant pairs, the larger study (Jenik AG et al Does the recommendation to use a pacifier influence the prevalence of breastfeeding? J Pediatr 2009;155(3):350-4.e1.) included 1021 mothers, enrolling only those who were “highly motivated to breastfeed,” and “only those who were already successfully breastfeeding at 2 weeks and who indicated their intention to do so for at least 3 months… mothers with breast problems that could interfere with breastfeeding (sore nipples [lists other problems]…) were not included.” Thus the lion’s share of the Cochrane mother-infant pairs started pacifiers exactly when the AAP recommends!
Anyway, enjoy this terrific QI study and take home your own points of interest – there are many.
