February 2015, VOLUME135 /ISSUE Supplement 1

A “NEC Free NICU” Through Breastfeeding Quality Improvement Project (QIP)

  1. Roy Philipa,
  2. Abu Ismaila,
  3. Colette Quinna,
  4. Margo Dunwortha,
  5. Ailish Hanniganb, and
  6. Margaret O'Learya
  1. aUniversity Maternity Hospital Limerick, Ireland; and
  2. bDepartment of Statistics, University of Limerick, Ireland


Breastfeeding offers the best nutritional support for newborn infants. The value of breast milk in reducing the incidence of necrotizing enterocolitis (NEC) among premature infants admitted to the NICU has been reported. Ireland has one of the lowest breastfeeding rates in the developed world, however, and pursuing quality improvement projects (QIPs) aimed at improving use of breast milk among premature infants could be challenging. Our goals were to: (1) improve breast milk exposure of extremely low birth weight infants in the NICU from 80% to 100% over a 2-year period and among very low birth weight infants from 60% to 80% during the same period; (2) reduce the incidence of NEC in our NICU to a level below that reported by other network centers in Ireland benchmarked in the Vermont Oxford Network; and (3) improve the breastfeeding culture of our unit by ensuring the sustainability of a QIP.


A QIP was commenced in January 2011 with a clear goal statement and time lines, as well as agreed and quantified written goals. Primary and secondary drivers were established and Plan-Do-Study-Act cycles initiated for demonstrating “small improvements” and acquiring “buy-in” from the medical and nursing staff as well as the parents of premature infants. The World Health Organization’s definition for the mother's own milk and donor breast milk and modified Bell stage IIA or above for NEC were the denominators. The project was conducted in the tertiary NICU attached to University Maternity Hospital, Limerick, Ireland, which has an in-birth rate of 5000 per year. Approval of the hospital audit committee was obtained. During the project, senior medical and nursing teams of the unit as well as major clinical guidelines remained unchanged. Results of the study were analyzed by using SPSS version 18.


In a country with a low national breastfeeding rate, we found that 100% breast milk exposure to extremely low birth weight infants and 80% uptake by very low birth weight infants could be established through a QIP. For the first time in the history of our unit, in 2013, we had no NEC; the information is now uploaded to the Vermont Oxford Network. Our post-QIP staff surveys show evidence of sustainability of the project.


Through the adaptation of quality initiatives, breastfeeding rates among premature infants could be optimized, even in countries with traditionally low breastfeeding rates. Such low-cost interventions could significantly improve morbidity among premature infants, perhaps more than generally appreciated, as evidenced by our NEC-free tertiary unit.