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Background and Objectives: The challenge of identifying preterm infants with bronchopulmonary dysplasia (BPD) that need tracheostomy placement may delay goals of care (GOC) discussions. By identifying infants with a low probability of ventilation liberation, timely GOC discussions may reduce the time to tracheostomy. Our SMART aim was to reduce the postmenstrual age (PMA) of GOC discussions by 20% in infants with BPD and prolonged invasive ventilatory requirement by October 2020., Methods: Our group conducted a quality improvement initiative at the University of Alabama at Birmingham. Infants were included if born at <32 weeks' gestation and exposed to invasive ventilation for ≥2 weeks beyond 36 weeks' PMA. Interventions included (1) consensus of BPD infants at risk for tracheostomy dependence, (2) monthly multidisciplinary tracheostomy meetings, and (3) development and utilization of tracheostomy educational content for families. Statistical process control charts were used for all analyses., Results: A total of 79 infants were included in analyses, of which 44 infants either received a tracheostomy or died. From X-mR control chart analysis, there was special cause variation in the time to GOC discussions, which decreased from 62 to 51 weeks' PMA related to monthly multidisciplinary conferences. The average PMA at tracheostomy decreased from 80 weeks to 63 weeks with no change in the frequency of tracheostomy placement or discordant GOC discussions in which infants survived to hospital discharge without a tracheostomy., Conclusions: In infants with ventilator-dependent BPD, standardization of GOC discussions reduced the PMA of GOC discussions and tracheostomy., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: Our objective with this quality improvement initiative was to reduce rates of severe intracranial hemorrhage (ICH) or death in the first week after birth among extremely preterm infants., Methods: The quality improvement initiative was conducted from April 2014 to September 2020 at the University of Alabama at Birmingham's NICU. All actively treated inborn extremely preterm infants without congenital anomalies from 22 + 0/7 to 27 + 6/7 weeks' gestation with a birth weight ≥400 g were included. The primary outcome was severe ICH or death in the first 7 days after birth. Balancing measures included rates of acute kidney injury and spontaneous intestinal perforation. Outcome and process measure data were analyzed by using p-charts., Results: We studied 820 infants with a mean gestational age of 25 + 3/7 weeks and median birth weight of 744 g. The rate of severe ICH or death in the first week after birth decreased from the baseline rate of 27.4% to 15.0%. The rate of severe ICH decreased from a baseline rate of 16.4% to 10.0%. Special cause variation in the rate of severe ICH or death in the first week after birth was observed corresponding with improvement in carbon dioxide and pH targeting, compliance with delayed cord clamping, and expanded use of indomethacin prophylaxis., Conclusions: Implementation of a bundle of evidence-based potentially better practices by using specific electronic order sets was associated with a lower rate of severe ICH or death in the first week among extremely preterm infants., Competing Interests: FINANCIAL DISCLOSURE: Golden Week Program is trademarked with the US Patent and Trademark Office (serial number 87856747). The authors have indicated they have no financial relationships relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Mississippi CHAMPS addressed racial inequities in breastfeeding by implementing community and hospital-based practice changes in accordance with the BFHI and by parallel community work., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background: Race is a predictor of breastfeeding rates in the United States, and rates are lowest among African American infants. Few studies have assessed changes in breastfeeding rates by race after implementing the Ten Steps to Successful Breastfeeding (hereafter referred to as the Ten Steps), and none have assessed the association between implementation and changes in racial disparities in breastfeeding rates. Our goal was to determine if a hospital- and community-based initiative in the Southern United States could increase compliance with the Ten Steps, lead to Baby-Friendly designation, and decrease racial disparities in breastfeeding., Methods: Hospitals in Mississippi, Louisiana, Tennessee, and Texas were enrolled into the Communities and Hospitals Advancing Maternity Practices initiative from 2014 to 2017 and received an intensive quality improvement and technical assistance intervention to improve compliance with the Ten Steps. Community partners and statewide organizations provided parallel support. Hospitals submitted monthly aggregate data stratified by race on breastfeeding, skin-to-skin care, and rooming in practices., Results: The disparity in breastfeeding initiation between African American and white infants decreased by 9.6 percentage points (95% confidence interval 1.6-19.5) over the course of 31 months. Breastfeeding initiation increased from 66% to 75% for all races combined, and exclusivity increased from 34% to 39%. Initiation and exclusive breastfeeding among African American infants increased from 46% to 63% ( P < .05) and from 19% to 31% ( P < .05), respectively. Skin-to-skin care after cesarean delivery was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming in was significantly associated with increased exclusive breastfeeding in African American infants only., Conclusions: Increased compliance with the Ten Steps was associated with a decrease in racial disparities in breastfeeding., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background and Objectives: The American Academy of Pediatrics (AAP) has affirmed breastfeeding as the preferred method of infant feeding; however, there has been little systematic examination of how pediatricians' recommendations, affiliated hospitals' policies, counseling practices, and attitudes toward breastfeeding have shifted over the past 2 decades. These trends were examined from 1995 to 2014., Methods: Data are from the Periodic Survey (PS) of Fellows, a nationally representative survey of AAP members. PS #30 (1995; response rate = 72%; N = 832), PS #57 (2004; response rate = 55%; N = 675), and PS #89 (2014; response rate = 51%; N = 620) collected demographics, patient and practice characteristics, and detailed responses on pediatricians' recommendations, affiliated hospitals' policies, counseling practices, and attitudes toward breastfeeding. By using bivariate statistics and logistic regression models, the analysis investigated changes over time with predicted values (PVs)., Results: From 1995 to 2014, more pediatricians reported their affiliated hospitals applied for "baby-friendly" designation (PV = 12% in 1995, PV = 56% in 2014; P < .05), and more reported that they recommend exclusive breastfeeding (65% to 76% [ P < .05]). However, fewer respondents indicated that mothers can be successful breastfeeding (PV = 70% in 1995, PV = 57% in 2014; P < .05) and that the benefits outweigh the difficulties (PV = 70% in 1995, PV = 50% in 2014; P < .05). Younger pediatricians were less confident than older pediatricians in managing breastfeeding problems ( P < .01)., Conclusions: Pediatricians' recommendations and practices became more closely aligned with AAP policy from 1995 to 2014; however, their attitudes about the likelihood of breastfeeding success have worsened. These 2 divergent trends indicate that even as breastfeeding rates continue to rise, continued efforts to enhance pediatricians' training and attitudes about breastfeeding are necessary., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background and Objective: In response to a low number of Baby-Friendly-designated hospitals in the United States, the Centers for Disease Control and Prevention funded the National Institute for Children's Health Quality to conduct a national quality improvement initiative between 2011 and 2015. The initiative was entitled Best Fed Beginnings and enrolled 90 hospitals in a nationwide initiative to increase breastfeeding and achieve Baby-Friendly designation., Methods: The intervention period lasted from July 2012 to August 2014. During that period, data on process indicators aligned with the Ten Steps to Successful Breastfeeding and outcome measures (overall and exclusively related to breastfeeding) were collected. In addition, data on the Baby-Friendly designation were collected after the end of the intervention through April 2016. Hospitals assembled multidisciplinary teams that included parent partners and community representatives. Three in-person learning sessions were interspersed with remote learning and tests of change, and a Web-based platform housed resources and data for widespread sharing., Results: By April 2016, a total of 72 (80%) of the 90 hospitals received the Baby-Friendly designation, nearly doubling the number of designated hospitals in the United States. Participation in the Best Fed Beginnings initiative had significantly high correlation with designation compared with hospital applicants not in the program (Pearson's r [235]: 0.80; P < .01). Overall breastfeeding increased from 79% to 83% ( t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% ( t = 9.72; P < .001)., Conclusions: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Skin-to-skin care (SSC) and rooming-in have become common practice in the newborn period for healthy newborns with the implementation of maternity care practices that support breastfeeding as delineated in the World Health Organization's "Ten Steps to Successful Breastfeeding." SSC and rooming-in are supported by evidence that indicates that the implementation of these practices increases overall and exclusive breastfeeding, safer and healthier transitions, and improved maternal-infant bonding. In some cases, however, the practice of SSC and rooming-in may pose safety concerns, particularly with regard to sleep. There have been several recent case reports and case series of severe and sudden unexpected postnatal collapse in the neonatal period among otherwise healthy newborns and near fatal or fatal events related to sleep, suffocation, and falls from adult hospital beds. Although these are largely case reports, there are potential dangers of unobserved SSC immediately after birth and throughout the postpartum hospital period as well as with unobserved rooming-in for at-risk situations. Moreover, behaviors that are modeled in the hospital after birth, such as sleep position, are likely to influence sleeping practices after discharge. Hospitals and birthing centers have found it difficult to develop policies that will allow SSC and rooming-in to continue in a safe manner. This clinical report is intended for birthing centers and delivery hospitals caring for healthy newborns to assist in the establishment of appropriate SSC and safe sleep policies., (Copyright © 2016 by the American Academy of Pediatrics.)

Objectives: Multiple studies have revealed inadequacies in breastfeeding education during residency, and results of recent studies have confirmed that attitudes of practicing pediatricians toward breastfeeding are deteriorating. In this we study evaluated whether a residency curriculum improved physician knowledge, practice patterns, and confidence in providing breastfeeding care and whether implementation of this curriculum was associated with increased breastfeeding rates in patients., Subjects and Methods: A prospective cohort of 417 residents was enrolled in a controlled trial of a novel curriculum developed by the American Academy of Pediatrics in conjunction with experts from the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and Association of Pediatric Program Directors. Six intervention residency programs implemented the curriculum, whereas 7 control programs did not. Residents completed pretests and posttests before and after implementation. Breastfeeding rates were derived from randomly selected medical charts in hospitals and clinics at which residents trained., Results: Trained residents were more likely to show improvements in knowledge (odds ratio [OR]: 2.8 [95% confidence interval (CI): 1.5-5.0]), practice patterns related to breastfeeding (OR: 2.2 [95% CI: 1.3-3.7]), and confidence (OR: 2.4 [95% CI: 1.4-4.1]) than residents at control sites. Infants at the institutions in which the curriculum was implemented were more likely to breastfeed exclusively 6 months after intervention (OR: 4.1 [95% CI: 1.8-9.7])., Conclusions: A targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.