Quality and Child HealthQuality and Child Health

‘Milky way’- a Limerick model‘Milky way’- a Limerick model

Dr. Roy K PhilipConsultant Paediatrician & Neonatologist

University Hospital LimerickLimerick, Ireland

roy.philip@hse.ie @roykphilip

Jupiter, king of the Gods, tried covertly to have his son Hercules take a few sips of divine breast milk from his stepmother, Juno (queen of the gods), but startled, she awoke and milk shot from her breasts into the heavens thus forming the Milky Way galaxy. 

The Origin of the Milky Way, about 1575, oil on canvas.  National Gallery, London

Breastfed children have at least six times greater chance of survival in the early months than non-breastfed children.  Breastfeeding drastically reduces deaths from acute respiratory infection and diarrhoea, two major child killers, as well as from other infectious diseases (WHO-Lancet 2000).

Survival of ELBW and VLBW neonates over 5 decades

• Causes and Timing of Death in Extremely Premature Infants from 2000 through 2011

• Ravi M. Patel, M.D.

• N Engl J Med 2015; 372:331-340 January 22, 2015

• Analyzed prospectively collected data on 6075 deaths among 22,248 live births, with gestational ages of 22 0/7 to 28 6/7 weeks, among infants born in study hospitals within the National Institute of Child Health and Human Development Neonatal Research Network.

• We found that from 2000 through 2011, overall mortality declined among extremely premature infants. Deaths related to pulmonary causes, immaturity, infection, and central nervous system injury decreased, while necrotizing enterocolitis–related deaths increased.

NECROTIZING ENTEROCOLITIS (NEC) is the most common acquired gastrointestinal emergency in the preterm low birth weight newborn.

Breastfeed Med. 2011 Jun 30.

Costs of Necrotizing Enterocolitis and Cost-Effectiveness of Exclusively Human Milk-Based

Products in Feeding Extremely Premature Infants.

Ganapathy V, Hay JW, Kim JH.

•Nationally, the total economic benefit from avoided direct and mortality costs would be a $1.8-2.1 billion per year savings.

65% decrease in the incidence of NEC and an 8 fold reduction in the odds of needing surgery in the group getting the fully human milk based diet compared with the group getting the standard diet which includes bovine-based components.

IRELANDIn 2013, 55.8% 55.8% of mothers were breastfeeding on discharge from hospital, 46.6% exclusively.

Figures for 2012 showed that five out of every 10 babies born in Ireland were being breastfed on leaving hospital.

This compares with eight out of every 10 in the UK.

Across Europe on average nine out of every 10 babies born are breastfed, with almost all babies born in Norway, Denmark and Sweden being breastfed.

Less than 10% at 6 months of age.

University Hospitals Limerick (UHL)

University Maternity Hospital Limerick

Model 4Population served 375,000

Stand-alone maternity hospitalIn-house births 4,600 per yearRegional NICU

QIP• Aim statement• Aim checklist• Driver diagram• Test of change• Primary drivers• Secondary drivers

100 % exposure to breast milk for ELBW

(from below 20%)

Zero NEC

(from 12 - 20%)

http://www.google.ie/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=RTy-rG3n3nhJDM&tbnid=hhuScj-qFgE8wM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.neonatologija.rs%2Fbankamleka.htm&ei=vot6U8GdJOyS7Qbf8IDoAQ&bvm=bv.66917471,d.ZGU&psig=AFQjCNH5q2LZG4dGDLZhyn1oeDgxnGA59Q&ust=1400625866097072

How to achieve 100% breast milk How to achieve 100% breast milk uptake by ELBW uptake by ELBW

• 1. Nutrition of premature neonates & routes of nutrition (policy)• 2. Choice of nutritional products (policy)• 3. Advantages of breast milk for premature infants• 4. Barriers to breastfeeding & psychology of mother (Father,

grand mother)• 5. Maternal involvement in the ‘care team’ / ‘Peer support’• 6. ‘Senior’ discussion with mother & father on day one* • 7. Challenges & changes; Reinforce• 8. Cultural aspects & history• 9. Coach, cultivate and convert – key message• 10. Staff belief, empowerment – create BF advocates & champions

Bring to sustainability and pride (still keep an eye)

Potential other contributors to a Potential other contributors to a ‘NEC free NICU’‘NEC free NICU’

• Hand hygiene • Antibiotic stewardship • Central lines• SaO2 monitoring• Maternal management• Antenatal steroids• PDA management• Blood transfusion• Ventilation• Improved formula / volume• (Probiotics)• KMC / KFC

Breastmilk exposure and NEC: ELBW experience UMHL

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Years 2000 - 2013

Num

ber o

f ELB

W

Numbero ELBW

EBM exposure number

Number of NEC

‘‘NEC free NICU’NEC free NICU’• Breast milk for premature babies.• From below 20% to 100%• ZeroZero Necrotising enterocolitis (NECNEC) at UMHL.• Maintenance of success for 3 years• Saving of over €250,000• Through QIP, buy-in, parent in the treating team.• International black spot to hot spot in

breastfeeding.• International acclaim – awards & publications.

Excellence in Pediatrics (EiP) – world congress. Excellence in Pediatrics (EiP) – world congress.

Best educational project award – 70 countries and over 2000 participants. Best educational project award – 70 countries and over 2000 participants.

• A 'NEC free NICU' through A 'NEC free NICU' through breastfeeding quality improvement breastfeeding quality improvement project (QIP)project (QIP)

• RK Philip, A Ismail, C Quinn, M Dunworth, A Hannigan, M O'Leary

• Pediatrics 2015; 135:Supplement 1 135S1; doi:10.1542/peds.2014-330W

• Extract Full Text Full Text (PDF)

Breast milkBreast milk

• A prebiotic• A probiotic• A synbiotic• An antibiotic

• A lovebiotic

@roykphilip

Breast milk: the best lovebioticlovebiotic• Crealey MR, Ludusan E, Philip RK.• J Perinatol. 2015 Aug;35(8):665. PMID: 26219700

Generally speaking, the number of people an organization needs to train in process improvementtrain in process improvement is the square root of the total number of personnel.

Rule of ThumbRule of Thumb

Thomas H Lee, MD, chief medical officer at Press Ganey Associates. Engaging doctors in the health care revolution ... HRB 2010

Turning Doctors into LeadersThomas H. Lee, MD

1.India: 3, 519 1001.India: 3, 519 100

The 10 countries with the greatest number of preterm births

In summary…..In summary…..• Initiating change• Effective clinical leadership• Clinical innovation• Value in healthcare• Adapt, Articulate, Buy-in• Collective mission• Goal – feel proud• Break it down - process

Dr Roy Philip Clinical Leaders Summit 26th May 2016

Mahatma Gandhi once said,

“Be the change that you wish to see in the world.” and

"Your beliefs become your thoughts,

Your thoughts become your words,

Your words become your actions,

Your actions become your habits, Your habits become your values,

Your values become your destiny.”

roy.philip@hse.ie @roykphilip

Breast milk: the best lovebioticBreast milk: the best lovebiotic