Does your institution value human milk? Are there institutional barriers in place that do not support the use of human milk and breastfeeding? What facilitators are present? The Centers for Disease Control (since 2007) conducts the biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey to all birth hospitals in the United States.1 The mPINC survey covers 7 domains of care that influence breastfeeding including: labor and delivery, postpartum care routines, provision of breastfeeding assistance, maternal-infant contact including rooming-in, breastfeeding support at discharge, structural and organizational components to support breastfeeding, and staff education.1 The most current mPINC data available (2011) shows an average national score of 70/100 possible points.1 With national average scores being this low, it is clear that many institutions may not value human milk and breastfeeding or make it a priority in terms of financial, time, and other resources. If all birth hospitals and all children's hospitals provided evidence based lactation support and care, I am confident that breastfeeding initiation, duration, and exclusivity rates in the United States would be much higher. Currently, a mere 16.4% of infants receive exclusive human milk for the first 6 months.2 Clearly, there is work to be done.

When considering how to change your institution's culture to make it more supportive of human milk and breastfeeding, consider using the "evidence-based management" strategy developed by Pfeffer and Sutton.3 In my role as a nurse researcher and manager of the Lactation Program at the Children's Hospital of Philadelphia (CHOP), I have used this model in implementing change for more than 10 years. There are 5 basic tenets of evidence-based management:

1. Face the hard facts and encourage people to tell the truth even if it is unpleasant,3

2. "Fact-based" decision making is essential,3

3. Treat your organization as an unfinished prototype,3

4. Look for risks and drawbacks,3 and

5. Avoid basing decisions on untested but strongly held beliefs.3

When you consider these statements and think of your own institution and apply the model to human milk and breastfeeding, it will be easy to see how you can improve and change your institution's culture to be more supportive of breastfeeding. Consider step 1. Breastfeeding is not always the most popular topic. Have you ever heard a neonatal intensive care unit (NICU) nurse say "I can't help that mom breastfeed" or have you met staff who are squeamish about human milk? In our current U.S. culture, breastfeeding is not the cultural norm. Therefore, many nurses and other health professionals have little exposure to or knowledge about breastfeeding. The "Surgeon General's Call to Breastfeeding Action" explicitly addresses the need for health professional education and training.4 Within the university portion of my job, I provide an entire semester (28 hours of lecture and 14 hours of clinical time) undergraduate course on breastfeeding and human lactation5 and as an aspect of the clinical portion of my job I developed the breastfeeding resource nurse (BRN) model.6 BRNs receive an intensive 2-day educational course focused specifically on human milk and breastfeeding in the context of a children's hospital.6 Nurses receive continuing education credit and are paid to take the course. The BRN serves as a resource to our families and to other staff in their patient care area.6 BRNs take a 4-hour refresher course every 2 years to stay up to date on current research and policies. To provide excellent care, health professionals must have excellent education and training.

Step 2 and 5 go hand in hand; we need to use the best available evidence and if we do not know where the gaps in care are, we need to collect data. The evidence that human milk and breastfeeding is the preferred form of infant nutrition for all infants is clear.7 As noted in the ethics article, we have a significant role as health professionals in ensuring that all NICU infants receive a human milk diet. However, when trying to change practice, health professionals do not always know where to start. You need to begin by collecting data and determining where the gaps in care are in your healthcare setting. Which directly relates to step 4 of understanding any risks and drawbacks related to making your planned change? I would encourage you to start by making a list of all the positive components in your institution that support the use of human milk and breastfeeding and all the negative components or barriers. Things to consider include: Do you have an adequate number of refrigerators and freezers for storing human milk? Do you have an adequate number of breast pumps for your mothers to use at the infants' bedsides? Do you have a human milk management system in place? Do all staff have specific required education related to the use of human milk and breastfeeding in the NICU? Are there appropriate educational materials? Do all health professionals send the message to families that human milk is an essential required component of caring for a critically ill infant? And are mothers and their families presented with specific information about how human milk can improve the health and developmental outcomes of their child allowing them to make an informed decision.

Step 3 is essential for evolving institutional culture: "Treating your institution as an unfinished prototype." At CHOP, we have an interdisciplinary hospital-wide breastfeeding committee that meets monthly to ensure that every day, every month, every year, we are continually working to make our institutional culture the best that it can be to support the use of human milk and breastfeeding. The participation of the hospital wide committee members has been integral to ensuring the cultural change permeates the entire institution. It is not enough for a hospital to have the availability of lactation consultants-all members of the healthcare team must be supportive of human milk and breastfeeding. Nurses in particular play a critical role in ensuring that families receive evidence based support and advice while an infant is being cared for in the NICU. 8

At CHOP, we use World Breastfeeding Week (WBW) as a way to continuously improve our institutional culture. Every year, the World Alliance for Breastfeeding Action (WABA) sets a theme for WBW which is celebrated August 1-7. The 2014 theme is "Breastfeeding: A Winning Goal for Life."9 We use WBW as a way to increase awareness about human milk and breastfeeding and its importance. Hospital employees, families of patients, visitors and local community members are invited to participate in the week's events. Each year a WBW grand rounds is held during the week and the scholarly presentation is opened to all hospital staff and lactation professionals from the community. We have a lobby display with educational materials about human milk and breastfeeding and local community resources. Donations are obtained from local businesses, so that when participants visit the display and fill out a short quiz, they can enter to win a variety of gifts. And perhaps, the event that provides the most hospital-wide and community impact is the WBW poster competition. All inpatient units are invited to develop 2 posters (1 for their unit and 1 for the main hospital atrium, where it can be seen by anyone who visits CHOP). These posters are displayed in the lobby for the week and most posters stay on the unit's for the whole month and sometimes the whole year. Through these posters, hospital employees, families, and visitors are consistently exposed to positive messaging regarding breastfeeding. I believe the impact of our WBW events is substantial.

For those of us privileged to care for the most vulnerable of patients, infants in the NICU, it is our responsibility to ensure that these infants have access to human milk. It is essential that we question our practice on a daily basis to make sure that we are providing the best evidence based lactation support and care by all members of the health care team. As Surgeon General Regina Benjamin states: "We all have a role in supporting breastfeeding."4 Let's make sure we work together so the institutions we work in support and value human milk and breastfeeding.

EDITORS' NOTE

The editors would like to thank Dr. Spatz for her contributions to this special issue of Advance in Neonatal Care related to Breastfeeding the High Risk Infant. Her leadership has made this an incredible issue that we hope will inspire and stimulate lots of discussion and hopefully practice change around this important topic.

References