<%BANNER%>

Breastfeeding Practices in the Neonatal Intensive Care Unit before and after an Intervention

xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20110217_AAAAAW INGEST_TIME 2011-02-17T13:22:36Z PACKAGE UFE0015659_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 8423998 DFID F20110217_AAAXUF ORIGIN DEPOSITOR PATH pineda_r_Page_98.tif GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
8caab00da1e92b6ddd7718c783e36012
SHA-1
a0bf37bf7111347582740ceb81e6afb32f81c791
F20110217_AAAXTQ pineda_r_Page_62.tif
c6ed451e7dba9784c0a75fe6af51c4d4
fe207d207286f5bd222c702b3681a658f91e18a9
F20110217_AAAXUG pineda_r_Page_99.tif
d897a9a2a528440ce4d8de0a4cae439a
68645e6fe276302cb53c8d57c717c9b35c3f16a2
F20110217_AAAXTR pineda_r_Page_65.tif
4e5784edb71ffc98e7915d0caedabbae
a1137a175bd4a16c2553c38f062b5d11c45be439
99980 F20110217_AAAYAA pineda_r_Page_71.jpg
fd2d239b795d3ab4833655e52ee2bde2
165150441010d783859936f49fca62c87ecf9fce
123 F20110217_AAAXUH pineda_r_Page_02.txt
694b40e6fb0978b043124baaea765648
be8e48fea2aae099ec8c86cfedf76d48c1b20794
F20110217_AAAXTS pineda_r_Page_66.tif
fe791cab290cb0fcd91975edaf3626df
86b081de853b90ef193df62df2aa9d99c1e7bf52
98225 F20110217_AAAYAB pineda_r_Page_72.jpg
8c3b4e047a4a2b6f99ffbf7676857bff
0ba6fc98917e516f8b80319e4244dce28c333645
3179 F20110217_AAAXUI pineda_r_Page_06.txt
fd2aa0b8cf7a06681eb12e762c7857ee
4c81fc3ee79d34260181d06d73b6cf71d257fb86
F20110217_AAAXTT pineda_r_Page_67.tif
cf2eb820963f8973d530ed3400975bf3
806cc363dcd7e75c6972953422f5cae538a187e4
100991 F20110217_AAAYAC pineda_r_Page_75.jpg
41eef9058247144fcd7a43430a01e585
291879aa53bc34d66367e7e5b429ab8e95a08a5e
2990 F20110217_AAAXUJ pineda_r_Page_07.txt
99ee70043a6d320be6fc732ba29f09dd
32afd8181ea27d87b6a6a24c30f0da1f1a67d7a0
F20110217_AAAXTU pineda_r_Page_69.tif
45a7494494a575df69d6eba6563ac2fe
f43af6e42640d9ef53deac545925c88f4263fdde
33615 F20110217_AAAYAD pineda_r_Page_75.QC.jpg
ace74f2dd28fbefc86199baae9a3a906
f387fa8817b18572c7108a6758e10024494a9cd8
F20110217_AAAXTV pineda_r_Page_71.tif
7cb5685a7bc688740549804c416b7315
8fa38ba961b5c45580adec0eaef4daab3660a7e4
103104 F20110217_AAAYAE pineda_r_Page_76.jpg
e88a19d103f969f70a8823110266ef3b
a10c8f3309b7722a41aa3cd4f7582c5995669947
998 F20110217_AAAXUK pineda_r_Page_08.txt
c252d5ab302db3011148e4e3878cd765
b6baec41b8b14c49cd45ca75d47788a4f6cac732
F20110217_AAAXTW pineda_r_Page_72.tif
0109727dba94aa4742c0db949bd55b46
8f2f9d8ab68076ed8ea1bcdf0de81f18bac6cc5f
33371 F20110217_AAAYAF pineda_r_Page_76.QC.jpg
9231d8741d0f0cb1175079ee36b0680d
2183a47f4c7921c64ca6efd92f7151d232870d04
335 F20110217_AAAXUL pineda_r_Page_09.txt
3f1ede6cdc6fdf286da87cc29f867c09
914d0cd10fddf91c9fc26c079cd0677631f8058f
F20110217_AAAXTX pineda_r_Page_74.tif
7494c463df5d0aaa897eab00c683d115
3acbe786f5ac3dd0ba79177b79732c66e80eec1b
105174 F20110217_AAAYAG pineda_r_Page_77.jpg
9dcfd1df0cf17b29aa790b5e108a65b5
8236b274ce9a6aea769044624b837e9f6140cd5c
1695 F20110217_AAAXVA pineda_r_Page_57.txt
bdfc3bb06a6ed8b8199bccd7735da64e
183f26c55100d2e6664f21ec89cf08128a96ed46
1893 F20110217_AAAXUM pineda_r_Page_16.txt
4ac2800aeabc3fb068b1c79d02b44722
e740066fe39729f238e71c79a12ddf400a99f376
F20110217_AAAXTY pineda_r_Page_77.tif
3e1d7b8792b03d5116b93ff746e6c4ed
8c3a0ced28cb166dc594ca3504f4206e3972660e
33661 F20110217_AAAYAH pineda_r_Page_77.QC.jpg
04ddda7c5d5ea44cec844b398583ebac
b00c278969f9e6d9ea50a40a8a22287d78bfadcb
2068 F20110217_AAAXVB pineda_r_Page_59.txt
3df17266383d50172ffcf735873c7bf1
995650499c2cdc4d2dd0d4f94c2c11c0af88b45c
1967 F20110217_AAAXUN pineda_r_Page_20.txt
f45fe4d0dc04af05409f6f587e2d0d3e
b780ad723adbb9d4acb8b63dff37a9e1d5525caf
F20110217_AAAXTZ pineda_r_Page_82.tif
89cead83e5789b65ba4f69e065392883
c5d1877d35d2ae3ea97c1c2632055c7a481c7622
32906 F20110217_AAAYAI pineda_r_Page_78.QC.jpg
f5164b6655a3f548ac42c1c9b458346a
2c880fb935670b97958d5fc8b37372af70ae2bef
2033 F20110217_AAAXVC pineda_r_Page_60.txt
3ec1fc615efae5b2358f7caa749d6314
927414663b5320a424ad5cf88455b998087092a4
1995 F20110217_AAAXUO pineda_r_Page_23.txt
0439084c7707f1c86c45f359241ed90d
9b8ae82738831ec33899d403a49d6b98712f9a5a
33384 F20110217_AAAYAJ pineda_r_Page_79.QC.jpg
0bb7f982807ab6a0f10f84fa2e31d525
f226475b85b316888d2e305856c1de6e51b4e93e
2224 F20110217_AAAXVD pineda_r_Page_62.txt
8d731495b5ff3c9997086f84909e7d33
cba305c84f7742e6afa10c5e88e20f069e0cd2d8
2041 F20110217_AAAXUP pineda_r_Page_25.txt
7e04560cfd8c185656835053832a6ab9
85b936af5a4d5d10bbe96c1f133ba44c1be7eec4
31782 F20110217_AAAYAK pineda_r_Page_80.QC.jpg
35ad298bdd2c27473929ea7135bcae28
714ce582d22b23530b92c0a4ab4c4940169554f7
1938 F20110217_AAAXVE pineda_r_Page_63.txt
abd51624129538be8ae5adb90a6f189b
9c550d46dd526a9e8925a4c421b399186883d804
1781 F20110217_AAAXUQ pineda_r_Page_30.txt
d57ce6f55557b5195d4d7076c7cce691
5f2c3a1c5514e448ee3ddac2ec42e52792104d67
32501 F20110217_AAAYAL pineda_r_Page_81.QC.jpg
66211c5099feb0d095427d222aebb221
9eabffce99c2ae401c1f146016255026a0947975
1848 F20110217_AAAXVF pineda_r_Page_67.txt
f0f521caf796c40547e2a16878284cc2
9e340de817249c6e0549b40f803c3a3f24a61de5
1993 F20110217_AAAXUR pineda_r_Page_35.txt
3d3b3de64dff02c2b41805b1083d301a
5168d51a180dfbb4f2867f688669b57388d97df9
30122 F20110217_AAAYBA pineda_r_Page_98.QC.jpg
d9a08d50a7050c7c8a31286f940652a3
24dc9cc42115250394a58685a6b7862d186025d1
99490 F20110217_AAAYAM pineda_r_Page_82.jpg
4d716c403bdbb4250e04feb9e38529d2
e85aa419feeca7099aa05bc2d8a09ebede13a013
1998 F20110217_AAAXVG pineda_r_Page_68.txt
077597bc69bf2da992dbf63bd9cf4d87
90fb24f4cba997e9b2470b6321694fca4e8be7ac
2249 F20110217_AAAXUS pineda_r_Page_39.txt
ae77840122e40c15b150f977ae8342fc
008bf2e00bb5e07a8c690c9f76010cc5714e490c
24072 F20110217_AAAYBB pineda_r_Page_99.jpg
3868f421ad1d8ea2d4c44b2ca777e923
2395b2e4289a88bf1ffb1ca322e37db57f3fdd4b
32959 F20110217_AAAYAN pineda_r_Page_82.QC.jpg
7006562a414713abb36edff3533ef733
92671860233ca097e8301b02bb41eafa281ae09b
1956 F20110217_AAAXVH pineda_r_Page_73.txt
08ed51f06c060c7db267efe8328a8374
a163693016b72331ded97ce0f6c530cc7b5bae98
F20110217_AAAXUT pineda_r_Page_44.txt
1350c7cb69c7983e781d7377f1848e5e
9cbdfa4a41d88c3c2390c245ecee70dee398bf4d
31838 F20110217_AAAYBC pineda_r_Page_02.jp2
7aa8132f2d6db50f70796b2acf557c52
11e8164dec22d6fa6a2e4b955dbe3a6f976560b4
9305 F20110217_AAAYAO pineda_r_Page_83.QC.jpg
4b7a5d7f72ba2fd2a09bcfd36f9357e5
2baa335616cdc144eaa2ce07d035512ffdfabb3d
2015 F20110217_AAAXVI pineda_r_Page_74.txt
ab332b50b7817d4130d6be1e2aca07bc
ec2eba28c35e76adba29d876dc0762b173716bba
1813 F20110217_AAAXUU pineda_r_Page_46.txt
7348b8cd7077d8748f788939ee29f693
156d6b439c0ce55a8219ee6cf77c98d58723095d
512518 F20110217_AAAYBD pineda_r_Page_03.jp2
5868e8725b88da8516b10b7b787067b4
a3d4abc19df2874b7bb4cd8d7a91f4980856c514
46446 F20110217_AAAYAP pineda_r_Page_84.jpg
c93b31ef8523a73de1a72ad0e8498645
19392c84238279f43671425f7b7c72beec779ecc
2009 F20110217_AAAXVJ pineda_r_Page_75.txt
534d5a8108565b91205c39353dd2927b
b42056476469becc15dafc077d1457575b2aa163
2049 F20110217_AAAXUV pineda_r_Page_47.txt
8231c149a7cd29162f0b6f8b5a977d35
5592c4617e5d78f51ac00c7087ee11d945398968
1010029 F20110217_AAAYBE pineda_r_Page_04.jp2
1aa743185565f037e898d567cb38e60d
28c62476a27092bbae2f85abe2bd4d389114841e
13650 F20110217_AAAYAQ pineda_r_Page_84.QC.jpg
64da4ec8f7e451ca3739b2506772a149
ecae5dbd463d0cefff16999a34b2f0b8f19f04ab
1997 F20110217_AAAXVK pineda_r_Page_76.txt
e66a3b8f0997b6b442be2bc222ae17ab
7b92f11740b37b0900687dacad88a710e58bd2d7
2056 F20110217_AAAXUW pineda_r_Page_48.txt
965bf0b3099db8b2580a026ba6fbb2cb
3c43eeedc92e29b5a0b467527965b158ebb0696a
263624 F20110217_AAAYBF pineda_r_Page_05.jp2
4005ef312f1cf48dd835afd1ce8128b2
1beee0af19f231f9f8959c4ca6960b81ecbb0386
7580 F20110217_AAAYAR pineda_r_Page_85.QC.jpg
7181fb0565c8446d45da0c51f5223e81
213ed91d8c061443ef94f91f6732c436d43c21ef
1930 F20110217_AAAXUX pineda_r_Page_49.txt
d83547b49bc95fd79f609be36da61f7b
d38f85af73dd012c27e82c26d124e8b88b7259c4
941690 F20110217_AAAYBG pineda_r_Page_06.jp2
ffd42b53b3a7b0f9aa985d3d3fceeaa9
4335c5c9ff2c078e1457d2e365ca720f73f7eef7
39942 F20110217_AAAXWA pineda_r_Page_10.pro
db99870def578b35b6adc04d83e52479
57df1a9b9953cd912158bb61090cc23011a57686
14236 F20110217_AAAYAS pineda_r_Page_86.QC.jpg
43ba9c980da72c49b31baab238b0ea1e
0e7b34def39c451dfc0034bf71131f8712ae94bc
2005 F20110217_AAAXVL pineda_r_Page_78.txt
8eb645ab5ad623213704765c222c26e2
875a186d4fd3c9f53b051fad34001ecb9c8a2e12
1953 F20110217_AAAXUY pineda_r_Page_50.txt
7e129aa6c32b1a6606f85dd78eacc940
3e39dac8d4c08109ca67af9fc839fcccf031e36d
340603 F20110217_AAAYBH pineda_r_Page_08.jp2
fb438f6b6108ecb43471d7889b547398
aafdbe2881efdbed3a22fae0124caa275313b37d
46549 F20110217_AAAXWB pineda_r_Page_12.pro
d5bfd12c844b1cb16c986e744bc03dd8
8e52e2f8b20ed44986b6cb90ea13f87ae93b946d
81967 F20110217_AAAYAT pineda_r_Page_87.jpg
a84ed51d998369cd1b606ae84ec6cb0e
da1f1f1e482fc1649816f0dda3aaf039bba3bc2d
2030 F20110217_AAAXVM pineda_r_Page_79.txt
1b92c5ddf820c36e20674020577586db
9366e4e05aeb06726a679172b3730bc3082a57cf
2010 F20110217_AAAXUZ pineda_r_Page_51.txt
161875ef5a8890ab476b0137b79605a9
b9889cf70091446d21ceea74f6006780795cf790
1025450 F20110217_AAAYBI pineda_r_Page_12.jp2
8539ae50474b5cbc000d0f90024f31aa
012532fcb3a598c31d750bcd411f573a4a053b54
50190 F20110217_AAAXWC pineda_r_Page_15.pro
83fc0c582ed650bfac09eab0faeec269
4e4e97dc28ed8a3c34c4cc08b9ae1230d82aeba7
97773 F20110217_AAAYAU pineda_r_Page_89.jpg
bc505c479d521a980f8c95f876623430
c0f6a5075c90484fb7aa675d12038f7d4e6a8a4b
F20110217_AAAXVN pineda_r_Page_81.txt
03c8a78e8ca428982034040baaf073d8
361bf451a088eeb420a169a0927f9a7a3f0493d6
1051960 F20110217_AAAYBJ pineda_r_Page_13.jp2
837bb986b60bd357ad1f8d0ca6ae5959
f2871e139b538c618aa5b3f4ac028725f1fae8d8
48011 F20110217_AAAXWD pineda_r_Page_16.pro
2acfcf6bace7f8787f800d6197f74ad6
227d663cac51f2d1388e3b579d6fd90d84e6289e
2003 F20110217_AAAXVO pineda_r_Page_82.txt
0c0c9c346dac9a7fde7587af9ee40739
6a74c5d1f644a3b51036ab6a7b718a243752928d
1051936 F20110217_AAAYBK pineda_r_Page_15.jp2
8a9f14ae028c5339cbb8775f5516d869
dec3d12921ace5195d03bf4efc2ab73cfdcbc3f6
50531 F20110217_AAAXWE pineda_r_Page_18.pro
60e9b3a12a00f4446b7468f0d0bf4f95
4e674349cebbb1a76b2342c97adafca9387049b1
28892 F20110217_AAAYAV pineda_r_Page_89.QC.jpg
3419538ed27cb18032b2a4228b3ae082
6964efae5c4c1102707e8ba4a74834163f424020
1050 F20110217_AAAXVP pineda_r_Page_84.txt
223b1fa02bd238f9c50a599ebc053566
43ddf3595233b45d187e1d2b8ead8107ec88b547
1051979 F20110217_AAAYBL pineda_r_Page_16.jp2
c53978be45e353db0a7fc93f0e784175
80dfe3f60fb61514bf50468aec6c03495b6097a6
51743 F20110217_AAAXWF pineda_r_Page_19.pro
dd0daac67839a2f9aaeaf9c8cb0c7e92
63a9c96700fa30d7e328a34c51d47b2da0b662e8
133726 F20110217_AAAYAW pineda_r_Page_91.jpg
e7f1c1268f6343f1ce2b0242d2ba107f
1e9840314d1a864474d07b859d1366e519a830f8
810 F20110217_AAAXVQ pineda_r_Page_86.txt
bf8aba79c6218da9685e02f033a48ea9
9128ba52335ba7c4b030ac0e82fe96f17e0b4565
1051969 F20110217_AAAYBM pineda_r_Page_17.jp2
1845220b406c3678d38e1e7c5d42d2fd
0673757c553eceae6cd86cc8b48ed0aa6c4a2ad5
50189 F20110217_AAAXWG pineda_r_Page_21.pro
970115cafea96abf5632111e33144adf
a6a077a3cae44a5ec7a68297246c36aeb9436897
35100 F20110217_AAAYAX pineda_r_Page_93.QC.jpg
97a50355f96d27a967cff6cdefa79add
ed1679c13833b8807d67b1f61b8a3d36b58ee492
153 F20110217_AAAXVR pineda_r_Page_88.txt
a92cfc747116fae35735fe02fada2fa4
1f4ae29fb9afb5cfc8951fb3bd6754e7dcc13e1f
1051913 F20110217_AAAYCA pineda_r_Page_47.jp2
a3e88f6dab2f8ec681b905190601ee3a
1e570b0651287448343b116b68e17bffa373d95a
1051973 F20110217_AAAYBN pineda_r_Page_18.jp2
32215eed1074ff54ea1ae37a45523899
76cd03a372eb7f985245d096a9864b909519e259
49032 F20110217_AAAXWH pineda_r_Page_22.pro
0af41284ca7ce52a2e8190cf9303a355
fac21013dbf1c90c32807cf709b4f4f4ba0a7271
35048 F20110217_AAAYAY pineda_r_Page_94.QC.jpg
36d97ef90e2b5161d16fee2438cb8429
bcf52d4e941404e66a65dd94b50982d001e5f9cb
2505 F20110217_AAAXVS pineda_r_Page_90.txt
4cc40145595d38e1c6b03dd5e0ef35c3
70bd255e1365f3c2599fe292a0b0e62d658ab658
1051950 F20110217_AAAYCB pineda_r_Page_50.jp2
27c7e005255309d4a0b99b8673164d8c
29d7a0c6fda85f2381e03a7b58b608de2a6677b7
1051983 F20110217_AAAYBO pineda_r_Page_19.jp2
996f621cbe02909ba31d591e27d82e90
9571d10bcf3ce205ba8f2644359dc61ce62f0525
49962 F20110217_AAAXWI pineda_r_Page_24.pro
a56d5226cd862c49b313b10092ddb393
12482cb70dc0034c8e810ad81b85e364c9187485
91963 F20110217_AAAYAZ pineda_r_Page_98.jpg
6636b066d5eb9d3d5b86f11d41e25dc6
15bb5793fbb697fda5e50b53d184961e6465e881
2605 F20110217_AAAXVT pineda_r_Page_91.txt
b23fadfc34ce77d631386fc5883bb2e7
67bb3e97fd3bb0c936193f0cc97a1ba1ecb07595
1051959 F20110217_AAAYCC pineda_r_Page_52.jp2
6680f68ea0ead9b74cf1b4a3e90ef8f4
0ed06fe03883e8ee61421028cda04091d85ff8c1
1051970 F20110217_AAAYBP pineda_r_Page_22.jp2
98306e5c1bdee5ff6949f40e0fc68df8
5f9a52023b48631142c6771e3dfaf5c9c91d6bb8
51565 F20110217_AAAXWJ pineda_r_Page_25.pro
12e9779d7bc1fd3d1e560b177db1832d
e37459c4d3f507edc0a81f18f4018bbe50ad5cc3
2551 F20110217_AAAXVU pineda_r_Page_93.txt
d81f9e9c6fbef932144b2f71a6ccbebe
b86892880c1f0de71b2aae07b880f1679d0deb09
403317 F20110217_AAAYCD pineda_r_Page_56.jp2
9fac083560a0363ac9d3d938bfe3d829
3f401d7e464641ceedd7c6023d4f3eaf5cf4b4e2
1051985 F20110217_AAAYBQ pineda_r_Page_26.jp2
f1e3aabf699629ddf614e6c717199a5a
35ff845e9fc1eb87286a736fb3216c4d161d5410
51370 F20110217_AAAXWK pineda_r_Page_26.pro
8b622dfe7280e2b36ffe329886f10582
4b271d726ba8dfd40dabcd6bf286c36566ca80d0
2300 F20110217_AAAXVV pineda_r_Page_95.txt
8cb2319f4f0595b8420eeb8f56f2beab
bd406e5762aaf5fc96ae0078a4c5c90c466f2b9f
1051984 F20110217_AAAYCE pineda_r_Page_61.jp2
64800528097fde31b88e6036fcce4577
a69d7c2f566fa96be618ee303b6472310bfd5e4f
994505 F20110217_AAAYBR pineda_r_Page_27.jp2
c8f386a98d08f0609d78cefe8138b327
72d528ab00e76ceed151281a482e2f03d5be8b3c
52572 F20110217_AAAXWL pineda_r_Page_28.pro
3bccd73ef3f5d44c87a5b9ff0b5b5338
df4fe5ad69a467e5bd40581b6ebcff3416845c29
1984 F20110217_AAAXVW pineda_r_Page_97.txt
f1928aad10c411bdc8bf4ab0d90fde12
c51a01ad285472d5c8f589c60f151e01ae89043e
1051968 F20110217_AAAYCF pineda_r_Page_62.jp2
583d800d291820765ac908818c679e66
8e3d7d0e58a8ad11d90c08e3ad35ad7440630682
F20110217_AAAYBS pineda_r_Page_28.jp2
272c4be3c03a3df6fe5ad02bd66bff60
881fc330a12228ec9491f032d64b0ba2c57e8803
24227 F20110217_AAAXVX pineda_r_Page_03.pro
790b14a84ae1e13158dfbef8ca9e6038
bde6b142742010b5db56a1a536347c2dde36f15a
812526 F20110217_AAAYCG pineda_r_Page_65.jp2
8fe37e33b6680e7bcafe802a4c0ac334
aeefd538ca7e335691a38963fa3958eb088b7735
36343 F20110217_AAAXXA pineda_r_Page_54.pro
5077b1c15dcc090e3c504defdebbb1bb
635c68c8c99d87b63455ecdc3be83ba6f6641737
1051952 F20110217_AAAYBT pineda_r_Page_29.jp2
4dbc6767a247d612ae4c9ad3bd827e57
311ece4e60d8c4ef34dc44189cd6012b8177cff4
50371 F20110217_AAAXWM pineda_r_Page_32.pro
97b7ac8c1e28d190547287d28ba1bce8
bc178f20eb3ed5f78a83f5e01fadb0b192697091
11749 F20110217_AAAXVY pineda_r_Page_05.pro
45b374dbfd8e44fdd38bbef08530cf57
67cdb5bcf5e16146ff4c8e8bc82398bc43309002
696982 F20110217_AAAYCH pineda_r_Page_66.jp2
131a5235ac877df2e1dabcb21affb5f7
5478e34b6f45ffc28c6017da67e0cbc8c359f731
45826 F20110217_AAAXXB pineda_r_Page_55.pro
19c28863c9fd70536ae878aa28c136c3
c62e6a39fafa74b54243176c2a574b5c9b4c7f35
1004100 F20110217_AAAYBU pineda_r_Page_30.jp2
a38a94f7974663082dd64c8cee7c5e25
ae2c0d2cfafc33a8dd84eca91014c48e92977389
49387 F20110217_AAAXWN pineda_r_Page_34.pro
19134cbd75167dd20f8e89248c45af3c
caab5203c6fb48026191a9e8946ba6331b5ac50e
73384 F20110217_AAAXVZ pineda_r_Page_07.pro
bf1804e4775876d31341e6d9b0799c02
156dafcf69bd581bed92d28d53f54e92993f48ae
728454 F20110217_AAAYCI pineda_r_Page_67.jp2
73e897af9f2649e9227c2977f173e4ea
b78358566b376b8993edeffe2624c72de87582e5
50627 F20110217_AAAXXC pineda_r_Page_58.pro
5b7bd04997163dded0c98b64426dea6b
6ac774cfa51cc8e13263d9d37e3c3e98a103a5e6
1051965 F20110217_AAAYBV pineda_r_Page_31.jp2
278eb19f41f50b9042e783749351f0bd
a95370ba1606c7ee61c8f9180e2a6822174b9cd0
48071 F20110217_AAAXWO pineda_r_Page_37.pro
f8969bf670a876e7f45c3fd9f90cb85b
50112c0915753d15285af85e6c570a911a5e107f
825186 F20110217_AAAYCJ pineda_r_Page_68.jp2
31890ab17077493ac184dfa319f9d1f1
26766b76fbe8fbe6cf879616993cc34942ab70a6
51724 F20110217_AAAXXD pineda_r_Page_59.pro
fb57b2ae99c0923c797a1544194b78cc
644138203d752e9b51210d8cf790c8a386bafe2d
51540 F20110217_AAAXWP pineda_r_Page_38.pro
bb3603a5cb26d5cc3cdfc35d438160d1
230a98e719e4f36bb95b19746d6e7c19d9d6872d
982092 F20110217_AAAYCK pineda_r_Page_70.jp2
5d5175d6a67af514746cf5575679e78c
09946cba358fdbd9970fedc172a7762b17462b78
48158 F20110217_AAAXXE pineda_r_Page_61.pro
2c9407b0fdfc1bcba56db2bea0fc58d6
66ceaaaa6d259bd8a4a741e1da07afdcdb8ca65e
1051938 F20110217_AAAYBW pineda_r_Page_32.jp2
14877707a144c20628bf9d9d06f810c3
a8dd743a6d3dd5d2ef9b1e9863240e6b4867866d
50888 F20110217_AAAXWQ pineda_r_Page_40.pro
b01e1061e9568e5a76624efe0d1dd6a4
09301e530352ecce0860b996cbfbb03e31fdbcf7
1051967 F20110217_AAAYCL pineda_r_Page_72.jp2
36c6f7d273731169f81e51bd734f38fe
7106a843dee8e75ca342c5f0918fad7ced9eac5a
51666 F20110217_AAAXXF pineda_r_Page_62.pro
ed06e813f4a5f515ab2f9c4210317eae
989a0669e34009ee4593aa6641d29cc7dbe486da
1051933 F20110217_AAAYBX pineda_r_Page_33.jp2
f9a2d3d245e0f18c0d472f775936f3a5
41196619fd6eb0adb9eb5c3fb43ac67428ad5bf1
47357 F20110217_AAAXWR pineda_r_Page_41.pro
1be0a8c8cda6d64faa813fd136f6226e
09bfd1023a01ad0dfd3d7cb57fe23966ca975d99
7556 F20110217_AAAYDA pineda_r_Page_04thm.jpg
78792792842b09f403a6d7484a5d307c
a345b7eac0feaca94792cbdbd39a06301df296fa
F20110217_AAAYCM pineda_r_Page_73.jp2
227c5b61c25ba4a71ea975623411d778
6d69c4d2654c6cd08a18b34990501a15b141d85f
17520 F20110217_AAAXXG pineda_r_Page_65.pro
1acef273dbf5f7474d293d8ad0ce0e3a
c720190003fde93cab3b70ff49a902beaae44c21
54419 F20110217_AAAXWS pineda_r_Page_42.pro
87771f34632f69f8ec18ac1d7befc706
3153644efa1b31278ad444ee1b8094ddcf4e8c8e
4819 F20110217_AAAYDB pineda_r_Page_07thm.jpg
3ebb6a7eb73d06a86472ed9652a8f88d
3e978eee24d125d40bcc975f8eb7158902b6bb67
1051961 F20110217_AAAYCN pineda_r_Page_74.jp2
e633b3665ecb83efa9de3c6f821f6740
30acec0aaad447d2cf9c3197cea65d233a9ab841
32379 F20110217_AAAXXH pineda_r_Page_66.pro
f51070f2d4267823ec4a0b9ce7173631
a20a0ed8e7ae8200f9f7ffc612723cd22743ddd3
875590 F20110217_AAAYBY pineda_r_Page_39.jp2
25df9c483a53a90eb7128f43008ffb90
1d08d0c9d5ee75aca575e088de6d345f4c2a6588
49901 F20110217_AAAXWT pineda_r_Page_44.pro
7d2d999752ce8eef48165b7d8afd0163
cb6d092f99a100550e0143b117a25f3cfc3e2f8b
1302 F20110217_AAAYDC pineda_r_Page_09thm.jpg
1f4b64af9a50f766938ace2af587cad3
ff549775760638092d55e70b232dcc166c9151ae
1051954 F20110217_AAAYCO pineda_r_Page_76.jp2
853d1aca425d9bdcb29de1eed651068b
e4c5a869260eba3431b0838c7d9b567266d6e212
38510 F20110217_AAAXXI pineda_r_Page_68.pro
177524131ceb47b43a5e99b7925124c4
ee68516b6d9c755a66fb5a3788e5bfa4b7d9905d
F20110217_AAAYBZ pineda_r_Page_44.jp2
5f97fa5acbe4b0d9544f41aa91fe7543
2acf30bda90809befa78f3a1bd68dc803552945e
42883 F20110217_AAAXWU pineda_r_Page_46.pro
0cca0533edb03a903478a06ea8946abc
bdeeea17876df48c7086d916c34eb66c461141ed
6512 F20110217_AAAYDD pineda_r_Page_10thm.jpg
42f6ca5a831a7ab4de9630379cf94c28
cb857555a3c3fde62d493436edb7b1217c972c0b
1051944 F20110217_AAAYCP pineda_r_Page_77.jp2
ee322fa15db9b18fed8a7436301c4264
9df81e65e36621dfae1cd3fc0e501ca888ca865d
50742 F20110217_AAAXXJ pineda_r_Page_76.pro
af3084767cd91ab109804426501c66fa
91cb34af103cc820cfd18febabed58be57d7eb0e
51064 F20110217_AAAXWV pineda_r_Page_47.pro
bdf4c4220c137e4b5f253d28ffd251a7
4519b94502e77dabebdcc2fb2369be925c81764f
8278 F20110217_AAAYDE pineda_r_Page_13thm.jpg
fed9c840de4e70e9d2ffc3b840e00c76
0b737adfbd0cb9b2521b7cb2eb12cebc476505a3
1051957 F20110217_AAAYCQ pineda_r_Page_80.jp2
8126454072097db3968a3da47f7bf9ff
93a2d2b7776067d5129b4a5b4f7eba5aa1210b18
52018 F20110217_AAAXXK pineda_r_Page_77.pro
4996a463f5f0fc077402d9c4acf83d59
bd250026412d08b0063eddb46dc45dda868b23fd
52377 F20110217_AAAXWW pineda_r_Page_48.pro
6c2f4a9a0f7232a8ede6878441d27bd0
7869f5488c816c1250a278206719cb6b4bb76714
8512 F20110217_AAAYDF pineda_r_Page_18thm.jpg
855956ea2185097f99506d33527b1a42
9d5d2ac88cf6e411e513cc35f3ecefa2c6228365
1051928 F20110217_AAAYCR pineda_r_Page_82.jp2
f979114d65d6ef6eab148be56255bf16
a2b5011398db9ef1bdec60fa061a3b7f87a196be
50743 F20110217_AAAXXL pineda_r_Page_78.pro
611fabacf868b6aa5c5e2b05c84f9bd2
9843c25f0d59b982eef2d9eb62dbb058a8333589
48866 F20110217_AAAXWX pineda_r_Page_49.pro
c51337b4581814392e9fa3c03b05bfbf
4fad65b035ab5985f52fd9939bb7da3b7fba768a
8525 F20110217_AAAYDG pineda_r_Page_20thm.jpg
05585fc2a233c22ad008dfccfb881514
97236ffa4b5bd8387fb9dabc51021b07c3b7d7b6
82776 F20110217_AAAXYA pineda_r_Page_07.jpg
a66de3fbd4f6cc99f78a8cdabff9af60
1afe4589e566323a0aea67533738042de512b22e
281146 F20110217_AAAYCS pineda_r_Page_83.jp2
84360f97c7a0ef69cbce9ed9e81c52e7
e92156cdc63c30d2717589f7db1bd69df5c212ce
51757 F20110217_AAAXXM pineda_r_Page_79.pro
2c18a1ccbdc105c87d06885d8e8c12d0
87cb4eaa6bdc16cc354fa52d4972731359951378
50771 F20110217_AAAXWY pineda_r_Page_51.pro
00f84bbb50eb4dc3b43f945135bcf910
819696fcfb924b535a6d813b18a3b57ebe168dcd
8426 F20110217_AAAYDH pineda_r_Page_24thm.jpg
76405defe77954f90aba01e238380e0a
fb149188f1d737b2ab285c466199015a0a0e332b
19414 F20110217_AAAXYB pineda_r_Page_07.QC.jpg
1574330d7d125c0067e236179a550b19
e6f1858a05ade62c6d47713b702df8be7ac16270
62362 F20110217_AAAYCT pineda_r_Page_88.jp2
bc839ab6ecc79f5399f5ceaa1e5e2b3e
650d3bddd48727e149e72b252621df06737b2a80
46026 F20110217_AAAXWZ pineda_r_Page_53.pro
35d53294bc61606e7fda15b3bedd37a6
74bada92b903552b524490f81558ce25b9b3aafe
8519 F20110217_AAAYDI pineda_r_Page_25thm.jpg
249545db93c18f080471d4795c1b9354
d3e30f58cd2d0967f3781a10f1509cba16ea1ca6
34610 F20110217_AAAXYC pineda_r_Page_08.jpg
6cd3b347e2006a2005079187f0e06391
2c4786549b55bcd6359a001966353663737a5233
1051945 F20110217_AAAYCU pineda_r_Page_91.jp2
6384c09f164af03c3761a90b5d8964c0
306a462f104eca0a95b0a410e5753a927073255b
48532 F20110217_AAAXXN pineda_r_Page_80.pro
d8bd62c4f699904b28549bd9219678a0
1b2dde78ce197c02d339897eb75fa7dcadcb888f
7816 F20110217_AAAYDJ pineda_r_Page_27thm.jpg
783526c77159bb978930d19698df30c2
db5d4a8dc648cfc058e97dbbaf98f7caa7527c15
12215 F20110217_AAAXYD pineda_r_Page_09.jpg
24f1f4addb51e69dd30fa846fc0954d7
b8135ad068dea620b466a183950eb09d55da2206
1051951 F20110217_AAAYCV pineda_r_Page_92.jp2
e0fce7d0ab22478fc13a7a34dab78217
f47ed2513705c0d4e8429daaf9b7986c4ebdc14b
12693 F20110217_AAAXXO pineda_r_Page_83.pro
ac4e9e52899b2725ee3dfd5281f7eb1a
1e58179c4815ef61a14b2854c1ec876b67bb8ad6
8539 F20110217_AAAYDK pineda_r_Page_29thm.jpg
541bd914d4c581c3ec6a6df429f1573a
e941ca88822c539e8e268cc438bc2dd6677865b9
25746 F20110217_AAAXYE pineda_r_Page_10.QC.jpg
61539737ac831291b0140c87e4e29ce7
5941cba24b29b64c0602bced168b7b7b839bdee4
1051896 F20110217_AAAYCW pineda_r_Page_95.jp2
66f797a1dfda803bdf78bc7c02e92605
8bf65490e6eee1da195a0b2b52765ba3a02dcdbf
10325 F20110217_AAAXXP pineda_r_Page_85.pro
27b6e9c516b232d99ca061072bda24c9
b1924b6c0164bcc7c6f05d745a360854fd6612f9
8458 F20110217_AAAYDL pineda_r_Page_32thm.jpg
185fd732fe9a02965ccd3b3f8c8e5530
e5b1cda5c187c1810ea2bbdfae2b23881df8e028
47950 F20110217_AAAXYF pineda_r_Page_11.jpg
74637a2bd09d97d40737b0987fd88ca2
d05fa5b6b0773c5353236f46e996272ee76dc98e
40208 F20110217_AAAXXQ pineda_r_Page_87.pro
edf64d6f36e097c1c6117533ee7c11d5
eb078a789c7fea0871b7b3b6031f11ed84abf11a
7955 F20110217_AAAYDM pineda_r_Page_33thm.jpg
acb7ecaf846b3552e83676fca81828db
b78595a689b9822b27217d3187ee0ae1ef973ed5
15663 F20110217_AAAXYG pineda_r_Page_11.QC.jpg
845d6e77dd4f1a53bbdad3e19e476cd7
d4b0ead42792cfcf6f083fd2b1ff6e10c46002f5
1051974 F20110217_AAAYCX pineda_r_Page_96.jp2
fb3bf11e95f5647b72d4558e02dd4ca8
47d235d367d3409cb96a770a40db3e40a5414673
2716 F20110217_AAAXXR pineda_r_Page_88.pro
189aa802f4179c7032110eb6547890a1
c71688491033d81ef863d66639a25ebfc59ebe3c
7770 F20110217_AAAYEA pineda_r_Page_64thm.jpg
1b3ef0ac4a3a070cc3f72a6d4698f712
cf58a8ba132e127983e19394369cf996694980f6
8324 F20110217_AAAYDN pineda_r_Page_35thm.jpg
981f275e092c02919cd771df318ce4b9
a4a743c6ba66d4ceaf71d18adfacf58d8f56f8ee
30229 F20110217_AAAXYH pineda_r_Page_12.QC.jpg
7032dd7b5c1c016b5389da6ec3c53e8b
1deb3f03a67810ebac8e0401a555c4e0d7911c22
638 F20110217_AAAYCY pineda_r_Page_02thm.jpg
9996953853a615bfc895de5178622b92
95e85d76cac404f787403c3ec666ad6e8e00fcf7
64502 F20110217_AAAXXS pineda_r_Page_92.pro
096bf224e5cd8536facb294672a18b7f
bcf1dbfc95ee9e1eea1bfd7a6c49a1620d01b425
4202 F20110217_AAAYEB pineda_r_Page_65thm.jpg
dd0dbc30226eeaf22ff991625764137c
d96206748472651b49a1014381de9412c0c976b8
8000 F20110217_AAAYDO pineda_r_Page_36thm.jpg
7764e1fb3ae8f23741c047e8a7792ead
03b103f4cbe10ee89e82732040c7c3bdb51a555c
102493 F20110217_AAAXYI pineda_r_Page_13.jpg
89669085184a2ef56b6c9a4c281fb057
7c998e8b384db6938d965310c4d37bc9c7b1915c
2800 F20110217_AAAYCZ pineda_r_Page_03thm.jpg
8bfbbb6fa82f1d53709e663c5b154b7b
c5205c85553aa2d2396fee4e143ad414ab2a0ef1
27661 F20110217_AAAXXT pineda_r_Page_01.jpg
28d37ea203b80b8c937353758495dd3c
76e80f58888b2b0615de04c3926b1d1156c9b3ea
7345 F20110217_AAAYEC pineda_r_Page_70thm.jpg
35cdfe4d9a8c925e5d72d21b9a2d55e4
5fbc8b8f2caf8d2ee00cb7f1d3d286153425d128
6462 F20110217_AAAYDP pineda_r_Page_39thm.jpg
6bf8b27b6152cf246a7818023c1a2786
7468eef3cb74bdd6e049c3dfe09abb22f09e0d1c
103258 F20110217_AAAXYJ pineda_r_Page_15.jpg
1eccbea1068711739ff635d1f43b2845
33071c847488f6c98b1601c9112e4d8b3b771b57
8612 F20110217_AAAXXU pineda_r_Page_01.QC.jpg
3c8a406f3cced188de8c1500d2e8e05b
56b320064a380c0cb34efe0ab66f470f8e799d7a
7925 F20110217_AAAYED pineda_r_Page_72thm.jpg
3108ca8cc2190f7daed0fad0fc4563e0
2c321fa07852725e17d7b87bc3388af766f76227
8397 F20110217_AAAYDQ pineda_r_Page_40thm.jpg
1818cfd7b35b55da5fc62ce95581267b
d1ecaa05d70115ef384c1c6042ee1a013f68c5e6
101612 F20110217_AAAXYK pineda_r_Page_16.jpg
725f27f3a85f3a74c0fd575b22c58a86
d97612c122e6cad9560dbb2a317892df092bd567
5086 F20110217_AAAXXV pineda_r_Page_02.jpg
c91d48c3402afaed9ccae5f7096c66da
23e18df04e37a7314a90634b0b24f8221ef6ca7c
8516 F20110217_AAAYEE pineda_r_Page_76thm.jpg
5868cf8e540f6cb60fe04863bd45dc58
86e99a976d9b19548aba6b8b32b0a48effdd850c
8611 F20110217_AAAYDR pineda_r_Page_42thm.jpg
a4176667c70d0392c0f2ce07fe4e4e49
ddae576ef350fa035ae9e5a7e30e11132c525697
32445 F20110217_AAAXYL pineda_r_Page_16.QC.jpg
01474c0da304f0b0b9759cbcc5bf6906
e21d0aa326e00b5b84399fe49b508079a8b3c7dd
11914 F20110217_AAAXXW pineda_r_Page_03.QC.jpg
818431e9b4b7a3efff80f4e0efbe1963
f61c95ae2aa73495059033fb51513f8c4e448651
2320 F20110217_AAAYEF pineda_r_Page_83thm.jpg
965c29c731c58fba6f514d26cca0b224
b011d42ce4d04c8e74d9711353690511a481c3c9
29296 F20110217_AAAXZA pineda_r_Page_30.QC.jpg
6c7cbd4eec01f4dc73c9aac435711b1b
10b8ff7e3975b82613ea2784889ed60ae7a6bb8e
8035 F20110217_AAAYDS pineda_r_Page_43thm.jpg
d5c150c18f01b2f3ab6c4847acff1c52
6be373efb48812bd7cc86b075d264b6b53a4dc34
35596 F20110217_AAAXYM pineda_r_Page_17.QC.jpg
137fdda177260ac86e060d21934bee51
6d7f290efab1ebe03b40a855b43e59a2762c2268
30753 F20110217_AAAXXX pineda_r_Page_04.QC.jpg
4e5bfafe37b42e04e4aadc8935a33c78
d4868e78ebafef6ee1f1c1483b0b29c1a6260778
895 F20110217_AAAYEG pineda_r_Page_88thm.jpg
8fee8153f21b8f42b34acf80564e92a2
9f272c9edaec21e8b478d60c93a9706299be98ed
102347 F20110217_AAAXZB pineda_r_Page_32.jpg
c6341fd84af6170edf2024f13e65f5cb
d412a12f20e3113dbcb3146bc8779f90ddf3c6b2
8128 F20110217_AAAYDT pineda_r_Page_44thm.jpg
065c21893b9a1fe34c312f034b2d0940
3a513e8798688aecbe1a94c97373985304a677db
102556 F20110217_AAAXYN pineda_r_Page_18.jpg
0f534bf112a458d8a7c7ed5ef64fef74
213827c654dd86e441c09a30fa4cb12b451c4ec0
9075 F20110217_AAAXXY pineda_r_Page_05.QC.jpg
16914f5609fddf4c4682ceb9a2281964
1ab4fd8a9478aa7efa503049a0cafe5dbeafa5f9
8885 F20110217_AAAYEH pineda_r_Page_90thm.jpg
a3f231709da8fa05b3cba8999487e6a4
f2ef47802ac8544339d40ec06a3363e0ddaee62f
32673 F20110217_AAAXZC pineda_r_Page_32.QC.jpg
2c7a57513d593e3897f1446f2cf4cbc0
c3b2c9b3183e1a5808dc7dd8ffe17e35756c17f1
8371 F20110217_AAAYDU pineda_r_Page_47thm.jpg
5cf2b346bf636e588629685ea6f5f72a
e00c6c90a90bc631d55be56b3624adc573ca3eb7
89264 F20110217_AAAXXZ pineda_r_Page_06.jpg
bc760a5e6cb98971bb79630ec40e90fb
c556b36259fa7b00d24f348a8c0b97e84352bf7e
8795 F20110217_AAAYEI pineda_r_Page_91thm.jpg
00a3040a71a91f86669a7a8c2dbb3b5c
f9768c843921ff3eb052d7016323748c0f2f8f30
31510 F20110217_AAAXZD pineda_r_Page_33.QC.jpg
ac985a4fdc69221801b5387734333473
aa3c98db522dec47cb9f567ba0f9dc7b24938e3e
7876 F20110217_AAAYDV pineda_r_Page_53thm.jpg
9a0ef92568b39bc9711edb70de660e75
84cb62214d595a632950383b13e1f263f0743242
105852 F20110217_AAAXYO pineda_r_Page_19.jpg
42939391cdb628202df1958b612147f6
3e3990d9b16fc8f3085122c5fa857da6e4825af6
8875 F20110217_AAAYEJ pineda_r_Page_93thm.jpg
107519dbe0d71e0607ad9eaf97c2d1c5
4114ffad48a04be4f9ab37de5daf980b3aad643c
101005 F20110217_AAAXZE pineda_r_Page_35.jpg
5e9c7e42ae601f176b68bebaf2fec3d2
18dec0bbfa0fd040b0b316dd73ae9e48a4918b29
7169 F20110217_AAAYDW pineda_r_Page_54thm.jpg
468a9c53719b29fb66f9bb10b973a6bc
f320efe5092dc65aa0fbe5de79d0e8ab6132b253
34862 F20110217_AAAXYP pineda_r_Page_19.QC.jpg
f840b65b23d12d24d4181516c50c2887
dbaa6c903acd8f489108b658363ef14336d97770
7167 F20110217_AAAYEK pineda_r_Page_97thm.jpg
77490f95c808ba561d8e3ab4a373773c
3673461e76aba6c0b257316b32484092067f161c
33303 F20110217_AAAXZF pineda_r_Page_36.QC.jpg
2976cca38618d3141d041c79c58ebd14
55919ac1195e9667fa3a0e1bb3fabaa3b146ed6c
3312 F20110217_AAAYDX pineda_r_Page_56thm.jpg
ef7f9ff9986e2fa311f36fe74ea6695d
cc60a47f188c2bec07576e316c3bf29f391a6e54
34529 F20110217_AAAXYQ pineda_r_Page_20.QC.jpg
5bd1adb741ce59c54bde611f25a89767
19f04005f41954c5f2404931ff73075841a29567
2153 F20110217_AAAYEL pineda_r_Page_99thm.jpg
4d5d510348b436a3961e56f30bf7e4ae
db64717956b1678ee5976d4731adb36167aee637
103585 F20110217_AAAXZG pineda_r_Page_38.jpg
54492aa1b2bff72d81fb329fee0d34aa
32b86122ca0ad05a40e521a2f58fee5d44113d71
103832 F20110217_AAAXYR pineda_r_Page_21.jpg
02b73f32336065296827d8a2549b24fe
f0f24cbd84bdac671ca9ecccaec69e1079f679b3
117238 F20110217_AAAYEM UFE0015659_00001.mets FULL
64a1dcc90e41d96999af27af866c958e
eb40268b34a669d281f1409acae6452edff203f6
81604 F20110217_AAAXZH pineda_r_Page_39.jpg
9e18c7459708a84572957bde639e603e
ea64700298e43c16c8073ac27a233c8d10ad1148
6730 F20110217_AAAYDY pineda_r_Page_57thm.jpg
135a3825ebf6731a0a64213b8e30f153
9b10dd57f8b8fa786e76e8cea176bc66931c4169
33405 F20110217_AAAXYS pineda_r_Page_23.QC.jpg
f10058a09b3b2e247499f3dadeec8a76
ed560f36e92acad1cd0229620dc34338a66bec7b
101832 F20110217_AAAXZI pineda_r_Page_40.jpg
bb431c1963a28036253d7cec6548c0de
3f7b312492ecd5d47cd7e19047b951f9223438d5
7877 F20110217_AAAYDZ pineda_r_Page_61thm.jpg
a925b8bb1b58eb4a561d41dcb2451d2a
94de987fa3b1734f2ad1f7dbceb5039c0deb9cff
103603 F20110217_AAAXYT pineda_r_Page_25.jpg
253285233b2d3b5c304c20cf44f63c08
7e32ff7edca16e03d50c64f87bc1b83b034823ac
30521 F20110217_AAAXZJ pineda_r_Page_41.QC.jpg
fd271e4b88f8f1b1f381024b30147382
c0265bb5c35ef90db56510d242ec3582ca270bc4
34684 F20110217_AAAXYU pineda_r_Page_25.QC.jpg
b9b94608b8368144ef9ba291909d3d0d
3af9d6f97c6643efa92227c915b7a69f1f6f0ab4
108420 F20110217_AAAXZK pineda_r_Page_42.jpg
bac0bc0e02844ceda72b6771356f2e0b
5ff49e448bdbbd799e3af01e7668613e456f9340
105202 F20110217_AAAXYV pineda_r_Page_26.jpg
702a7fcb5b18406d2db1999dece16da2
02e412054aab66f37e6574bd806c68ec39f9b470
31825 F20110217_AAAXZL pineda_r_Page_43.QC.jpg
30331df7c9153a06e382401741496de1
0524aedb2b395967c082e33a9b6579f07e5fc8a8
33916 F20110217_AAAXYW pineda_r_Page_26.QC.jpg
719bd7b2294ef39d755874295dea6509
28e5f5955b46d525019bc1d9df47d09e9b3905ee
32712 F20110217_AAAXZM pineda_r_Page_50.QC.jpg
1e9349ca5af3cb74c309b38c937f611d
d2d41f8cb9155ca98aa0094c2df42adfedce9617
28784 F20110217_AAAXYX pineda_r_Page_27.QC.jpg
dad73956dd4b3dd38a04685223c26a90
7b8edde5d80efb4b79860ee0159a59aeb7e34891
102856 F20110217_AAAXZN pineda_r_Page_51.jpg
2e40b701904cdd4db38ba53fd6523a04
f71c99a86aa9525f41ca7b716ae0c5cbcef9596b
104465 F20110217_AAAXYY pineda_r_Page_29.jpg
94eb9d84c87ebb10c492f09763535ca4
458caafd25e9e0d31411462d80a5ff67df312fd5
39482 F20110217_AAAXZO pineda_r_Page_56.jpg
72d43ce2371b5c52d9324c6aa998e7e3
c84f5c49e38f3c23d091ae3eb6d56e07f9960ab3
90664 F20110217_AAAXYZ pineda_r_Page_30.jpg
148820a32d90bce1777690ab3fe01801
ee4c397f0234f1ba29d1203fc00fb6234789685f
84106 F20110217_AAAXZP pineda_r_Page_57.jpg
12c142ac425b1aaed770e91cef20f14c
ac28b2806218f4c85c9dd6b7e0828e6b950a1e4c
103835 F20110217_AAAXZQ pineda_r_Page_59.jpg
fb173c62d77bf2852383c1264a1fdc6e
cbe1e1b34d6f82cbc8aaf04535529ac35fbad65d
35063 F20110217_AAAXZR pineda_r_Page_59.QC.jpg
798317b70e251a1e4d57260252253ef1
9a7e48162f0e573c0a2ee80071c0544809fd1567
34188 F20110217_AAAXZS pineda_r_Page_60.QC.jpg
4be3c10ecf8a66f4881ad44c88fb83c6
18318cedfc3e5b42e49c07a5a96e485af5a1a36a
96946 F20110217_AAAXZT pineda_r_Page_61.jpg
b7c4f0e162f2e732939f73118dace51e
319f93887bf91e66a20bd8f9f627b871dca5d61a
31485 F20110217_AAAXZU pineda_r_Page_61.QC.jpg
81286a4650660794eba54f04ccea7b90
010a6acdd7be0d0a7fcbb008e0556c30781ea4b6
95750 F20110217_AAAXZV pineda_r_Page_63.jpg
9d067646afc47c4e9e675848e1c4e6f6
7ed8ee6780d3f5c85665a2734e54f555c872a06d
15224 F20110217_AAAXZW pineda_r_Page_65.QC.jpg
229c39868ccc6cf4174ab83b1aec2049
0a58e02f4e473bafe762f9256e830337f028f784
73121 F20110217_AAAXZX pineda_r_Page_66.jpg
d51606c0f4e20e2dca171a0691113b4d
a247ba877d64358edca3ed6ad6658d8f35510f44
73056 F20110217_AAAXZY pineda_r_Page_67.jpg
ea66c57e55a9f2483f869cfba6eca9e1
6dc52d0fedf524970f5ac61dd0e496bb1f998a44
29183 F20110217_AAAXZZ pineda_r_Page_70.QC.jpg
9b75343c152638192de77a027acfc0d3
20b9dbeac28f9dd0e8cd1893d683d1c9331d2719
F20110217_AAAXEA pineda_r_Page_14.tif
5461fd639eb0d9fb6c8d5d73e3f67d96
660881ddd855a5fd98198dcd19766d67a14429e2
F20110217_AAAXEB pineda_r_Page_25.jp2
14d8d4684b19268d32d56f4f432055b4
0427cda308409807f7aae34fa217e487f6f8d41d
1156 F20110217_AAAXEC pineda_r_Page_45thm.jpg
c98bc2a1b95fbbd3a669f549cbabb700
c22b25a9c80bec694c3c649e2cf144a89c1fbbec
51956 F20110217_AAAXED pineda_r_Page_14.pro
ba8338f21a55fa5b019402e532336b78
6400a02722cb02af243f643b0f6e8b1cdc13a23c
27019 F20110217_AAAXEE pineda_r_Page_57.QC.jpg
0f76c2fd3489d176810eec8f0d353032
d827dc977e3f8f6766bdee5dcf3306925a131485
F20110217_AAAXEF pineda_r_Page_48thm.jpg
813b1f50faa19dd17f51b43d7eaebac1
0cedf3b4188e69ba208ccaae50ada7d56e0f12aa
63550 F20110217_AAAXDR pineda_r_Page_69.jpg
53919956886b21af7b8db3adedf09453
4df17cd9a0da0e7fb45cde009f0d8ee66dd9bcca
8398 F20110217_AAAXEG pineda_r_Page_31thm.jpg
53c21d448dc0c778bcac0bf96edd2a79
95b17788d542022c540ffa5717a65a2d82cec807
476 F20110217_AAAXDS pineda_r_Page_01.txt
162803f698c94a114d20d42e23059b95
02760d0155065f3d91272023f8f4dda8b57cc2bb
7270 F20110217_AAAXEH pineda_r_Page_46thm.jpg
6d42ac287c76d5f99b0abe7fc6ea3850
6235fb4e459d00ce3a37c4a92757f8c15a1c2c5a
36044 F20110217_AAAXDT pineda_r_Page_90.QC.jpg
ff5ec372fe12a0dad4483f333792b431
06e13096562bab5fa9f2064fd953ac14ec58f571
103376 F20110217_AAAXEI pineda_r_Page_23.jpg
6e33d3d44d4746c2c2c26576b0d9ae3f
ca98ee14bdd0512cbc45a861a48613f614866374
F20110217_AAAXDU pineda_r_Page_41.jp2
1808df240c79465f7dc1a3f5676a522f
9275c6f1dcc179857e15d0254e9a79f58c74ed44
34064 F20110217_AAAXEJ pineda_r_Page_18.QC.jpg
122a01ec371b50042a1650582d684ed9
d9c08f3e94ac2920cfc9fea8e930c121c8216ef9
32250 F20110217_AAAXDV pineda_r_Page_22.QC.jpg
1960cbe720386b584fe8a510d02eb997
e7a82418ba99a83a009a80666ff19f9c633b67ed
36313 F20110217_AAAXEK pineda_r_Page_96.QC.jpg
dff0f53f4cc1a17dc6dc37dc1133f6fc
8e01ddb5f79f2f0d5048cbb9e589b65d391ac0d8
F20110217_AAAXDW pineda_r_Page_24.tif
95f2ab4e88cfc16b60627ea91e29ca18
d7f4cd145ade2c79406e96c2f524d26c1240e0bf
F20110217_AAAXEL pineda_r_Page_64.tif
7595590c6ae3111ed268a0f404fa359e
2125279513ead2f31eae8c6d9835a659357a8ce1
61828 F20110217_AAAXDX pineda_r_Page_90.pro
abe351e524171f99916ab077e213b24b
54bfcd4eb2c9cf2715ca6f7289325e89dec540a1
F20110217_AAAXFA pineda_r_Page_40.txt
2781d12ae773aa40faca988d46778742
9cbf04c4a6ab0be6cbaea87b84a8deb70986b951
128307 F20110217_AAAXEM pineda_r_Page_96.jpg
b6d710d5d8de439876b3d08d67eaf105
012b86f32452fd90673f71d12728096c2f60daf8
49292 F20110217_AAAXDY pineda_r_Page_71.pro
8d19bdbf78a38fba8cdcfc255fd1305a
107d2b40dbe3afb459c362a092654762735c5cf9
3854 F20110217_AAAXFB pineda_r_Page_09.QC.jpg
3ea7b719fbffd4c72f8039e5327cb7bc
8f61cc8b64988ee2582ebd54d8a963ed09ab3ee3
F20110217_AAAXEN pineda_r_Page_28.tif
f40edfd56919fcfd9d48b2c7dfc3c894
f6ed585b647d9b97d5c2c95cf494f22cd8f9ed61
18604 F20110217_AAAXFC pineda_r_Page_86.pro
f32e6c6454c6ac96e98eb8ca2480fa11
932b2f508487a13db33acc3f28c312899bc7d0f9
105194 F20110217_AAAXEO pineda_r_Page_60.jpg
1b7e59b6fd0e69408fbe37e0278d970d
1c6a19a49e547ca08071937ef48844df55d27a99
2526 F20110217_AAAXDZ pineda_r_Page_94.txt
b8e0bebc59e8a10fda6ab7b84e3a80b0
de97d3195f9f50e207109ed36afefd55b0c29c4c
105538 F20110217_AAAXFD pineda_r_Page_48.jpg
c20d4055cfa8e121ce9fdc20a2c3524d
4c4b078e5d137eb20793a8b5fea05245f2f52fd7
1051946 F20110217_AAAXEP pineda_r_Page_38.jp2
4e9d72e8da09bdd3d1a270c6b247a9b9
871dc94ce8df1e7cb69678179574fb053116ea5b
62550 F20110217_AAAXFE pineda_r_Page_94.pro
1a091660cb8d6052f61b03841c61a537
0faf2062ad3d17329f5e3a705f4d2f2399d12598
7799 F20110217_AAAXEQ pineda_r_Page_63thm.jpg
b3840d4237ebd51921c242079cc38588
05a0b51db41d079a5afe2e85e985d1e02dcc1515
47370 F20110217_AAAXFF pineda_r_Page_97.pro
c4c74d56c69126603ce7fb4a25996c96
4a1600dc6547438a668874ca3f9b80be7819b711
F20110217_AAAXER pineda_r_Page_07.tif
c484bc22c24c526bf5147e407c8f5ca6
6ae27e51eb395a760f67db24b09d119f01768340
20844 F20110217_AAAXFG pineda_r_Page_69.QC.jpg
79ed3c5097baebfa7911910b03ff3da3
4c0f7ecf1674ce81761b73fb6dfe4f4c8f37fbc4
47303 F20110217_AAAXES pineda_r_Page_43.pro
450bcab9d389066b8524085fb8093312
ce39029093dc2c9d2dc920e82bf04f5091b8c228
1051980 F20110217_AAAXFH pineda_r_Page_59.jp2
3ef2e6b403dbf2a538706da2d8e654e0
5e9387b7561cd62cac6c944da308985b6c44bb3f
259594 F20110217_AAAXET pineda_r_Page_01.jp2
bf73e8f164cf16f2bc367b3df7012d0c
5efb1b12714efe80c4b5bdc1fbedd74808dc8d29
1051956 F20110217_AAAXFI pineda_r_Page_20.jp2
39cea165288861c7935cf28080a8c64d
29c1dc88c283fcf6ca21071293f0d00fe17db111
89664 F20110217_AAAXEU pineda_r_Page_70.jpg
29303573964b117c3ff0739beed84f7b
7aef3ed4c045e2a38993cd71325a9b186050796d
1051981 F20110217_AAAXFJ pineda_r_Page_75.jp2
db6cb42ae4e6c5c666ff3d9f0c903899
636e2d5cf5630134bed08092710e79d1fd4a4d69
F20110217_AAAXEV pineda_r_Page_60.jp2
2f8e0acc3c2abcb69c7c60865ac68fba
07d92ad65516ce7986cb39f9379d1afeace88b73
F20110217_AAAXFK pineda_r_Page_77.txt
7f3226a9c2aa4f98a85caab451c87805
b8d7221c128ba143a62b3f8fcbc7693115d88b75
F20110217_AAAXEW pineda_r_Page_35.jp2
1054157b09404ac3521badf2335debd6
1fa4aa7c2a1aa654c3be71d5dc9811fa7d8e793d
10106 F20110217_AAAXFL pineda_r_Page_08.QC.jpg
06826293b83ec293ed183d822e53b635
ea5e7d26a9a197c586882f7dfc4dba170ed1fa36
1979 F20110217_AAAXEX pineda_r_Page_36.txt
c1f4e69e8d3439649538ba67ab360283
7b8d0ae7f460c4e7a4f2f46444cad10ee0b03130
82314 F20110217_AAAXFM pineda_r_Page_68.jpg
7c69e46bbd95ad71fb3d06fadb084fc0
52d960533878e1ed15cfa13dee4f945d2d20ff2d
F20110217_AAAXEY pineda_r_Page_75.tif
05ef8a852e45d317389135c52363b667
be589ad58590ffa2c1f390daf94c1d9b0c123886
F20110217_AAAXGA pineda_r_Page_36.tif
f033ea358e54eacc8fd9915a2b3a4c1a
4ad960f32bd392730f73f1754aebbce3d1f457df
F20110217_AAAXFN pineda_r_Page_96.tif
ff63680b42f21ec1b4a7576e52230e75
65ac8b1387040d77ed963163877ebf0dbdaa8857
8422 F20110217_AAAXEZ pineda_r_Page_51thm.jpg
96b86568f39dc27e5306a435d7b26f43
ba2211ad206b8c414a8ca3391137222a44361888
F20110217_AAAXGB pineda_r_Page_48.tif
527fa33d35041b717ae2971a33cf9ed5
309f22c8264260cc31fe014dabb6817d1b0d7ad7
84215 F20110217_AAAXFO pineda_r_Page_10.jpg
21d9dc61fbb1c431a201c7b00ede8bfd
0798d1e1303621242dd5f882496b1cf87048d33c
596264 F20110217_AAAXGC pineda_r_Page_69.jp2
4b65cb4a455836a77391c6d111a5c67c
940b08c282741475c4400a69d88655c45f462a74
8013 F20110217_AAAXFP pineda_r_Page_73thm.jpg
8fe490aba3f962c1952fddbfc6675be7
8a8367841a630d3608f119ed95710674ae13d763
36736 F20110217_AAAXGD pineda_r_Page_91.QC.jpg
cf7ceaf1b258daf5a592a3071497f487
4698cb1e03968e25a76c7e5d7a828259727b763a
F20110217_AAAXFQ pineda_r_Page_11.txt
f9822863a64b743251c595c41250c8a4
6e67e249df2b1c2b10292663c053e345043f74b0
110797 F20110217_AAAXGE pineda_r_Page_95.jpg
36817f8cc0b40d4f83cc988068c8683b
7bf51bdb26e5a03909440b188aa4256aad3f93f5
91159 F20110217_AAAXFR pineda_r_Page_64.jpg
c8c4d3d909cc557ae6f044ac21fb4e5d
215c024b4889c4a61b987eae50bbbac6dbd6a4cf
F20110217_AAAXGF pineda_r_Page_35.tif
0d77b10a3e2ee287915c96c48cf3f825
2dedf77c40711ff65583c0a547c21535b1deeb9c
63381 F20110217_AAAXFS pineda_r_Page_93.pro
4c8bfa2ab8f5ac5a37a5b9549173a0e3
fdb63579d2242d764e0074d5cb221946f72217fa
F20110217_AAAXGG pineda_r_Page_78.jp2
6110ce3ef53eb5cb4d37794916ed82a5
def374b45675ccfb6c1d96acc974873985f22738
547 F20110217_AAAXFT pineda_r_Page_83.txt
5869fbc2cb778d89addf1dab42f3d51c
da01a00ec27281ae2cdcb1d495095582c464c4f1
94417 F20110217_AAAXGH pineda_r_Page_04.jpg
f631c3673f3dd06b5500c3c3f98940f8
a313c1c845573ab70eff52c2fc9efe0bedcdab04
49917 F20110217_AAAXFU pineda_r_Page_75.pro
114e2501b6e6e2dcb1be98fedb2bfc1f
8fb820c54f6a92daa370e8f4eab72eb3a50c34bb
F20110217_AAAXGI pineda_r_Page_28thm.jpg
2c2202255c45639df175b74b6fab6e4a
84e48a0edc1b2fca21db7081781125e852eb5dbd
1947 F20110217_AAAXFV pineda_r_Page_72.txt
221a7f2db1d8ed93018c006f8cef48cb
553a8d60e965078b36370f9b6411fe0e16f0b377
1875 F20110217_AAAXGJ pineda_r_Page_43.txt
bd930cc9e4cb8a8db43277ba110d79a7
04cf7bc0bde35d0a0af9aa0b61851015453f1922
33727 F20110217_AAAXFW pineda_r_Page_15.QC.jpg
91e795b8444dff72bf196142555266eb
6292eb6b4edf680adf7b5a4fd798180af2551aaa
8045 F20110217_AAAXGK pineda_r_Page_71thm.jpg
1b01838d09c1b24a5c2069785fa8fe98
d2fc2a39ed185142b7af60fc744b635b59769782
44648 F20110217_AAAXFX pineda_r_Page_64.pro
5ef9983b20ef64f2cab5b7961a330a3a
22bab5c643d27ba42908517c5ee7845f5590e4ba
906814 F20110217_AAAXGL pineda_r_Page_10.jp2
3bc64d8893297980ee66c85f60113d04
ebd3a5744bd9a01b8741ec2a46088ed585034a56
8177 F20110217_AAAXFY pineda_r_Page_82thm.jpg
cf54ddb3b276e449ee9717439c918259
e5aa997947f8738f5d1d4a0040cae54cf63d061f
4945 F20110217_AAAXHA pineda_r_Page_06thm.jpg
c60be2d6b24205d166f3e640a9909681
6d0278c771668539009c0eea4066f3b28c22e3a0
22790 F20110217_AAAXGM pineda_r_Page_08.pro
d7d58b1ac05670b2238d7832761f2c73
9f50a1d1bc7ce1ed4d2999c26753e99827231473
8345 F20110217_AAAXFZ pineda_r_Page_77thm.jpg
889559f2d6364c2f5a148e8eab6251d7
9aed6b2d63198e7f1d5ccd24f8153fe054d4e8da
129092 F20110217_AAAXHB pineda_r_Page_92.jpg
f8d9b20ec8ae5ee48d0a123cab5fbaa0
cca3839d498f52df548b2d798d3c0276c0fcb0e8
1356 F20110217_AAAXGN pineda_r_Page_02.pro
41126ddd496d3155945212132434cf8c
0306e2ed1df1cb00fcc32d58d9a8fac0f42b6df2
8517 F20110217_AAAXHC pineda_r_Page_23thm.jpg
9958c9f0e4cb29194cb90c416e4b09a9
849b5c617055e334458afa2d201bbbfb27c02a59
3889 F20110217_AAAXGO pineda_r_Page_84thm.jpg
7efef174b65208f2f6dae7d693907463
719fe711367e110f2d09a06d1df99ef94ef230db
F20110217_AAAXHD pineda_r_Page_24.jp2
2ea6c7e7987a36dc72ed40cd931ce8e6
23d3abf0659121067d5345b1ce05f7efe9490110
953677 F20110217_AAAXGP pineda_r_Page_64.jp2
29e09316746d44e6472969cb35b61187
20548962713cf868d3040580d93f91ed80432606
1607 F20110217_AAAXHE pineda_r_Page_69.txt
0cd6c29d627ae0c3f17835ce87e7d3a2
87226886dc0b0348e9ca97aab73e39351054940f
2260 F20110217_AAAXGQ pineda_r_Page_05thm.jpg
a932d22bba5d797d0a9d77d88bd6cb16
fb3931163c511eba582bdd728b3bf85b8c5f0e59
1640 F20110217_AAAXHF pineda_r_Page_54.txt
35743a3cedd87d93f2c5a923a0585933
ca1150f0c91cc3d6e2ec2fb890eb2a1b92428dc2
8383 F20110217_AAAXGR pineda_r_Page_58thm.jpg
872a11f9c05e897a21183f01d4b8fcaa
6792b099f525b7da414063555f39e57efa38f8aa
8384 F20110217_AAAXHG pineda_r_Page_38thm.jpg
621bb49eb79af2923410d8e4e48d49ae
d07fe5189a7251c620fc9af39a8b595741db406e
248582 F20110217_AAAXGS pineda_r_Page_85.jp2
71250827abbdaa71827581d2a5290010
9823ed6c61ea57df22c991739dead7f310fb563d
32287 F20110217_AAAXHH pineda_r_Page_71.QC.jpg
6dafb309da98ae0276b97bd746c7ac35
45aabcd0b0e8ad59e538a344a8ccfa6e9f442c43
1742 F20110217_AAAXGT pineda_r_Page_66.txt
ef00285641e63748c965d5173f1d8c83
6a53555ab991c74de328ade9acd216efcaa6cd41
34418 F20110217_AAAXHI pineda_r_Page_62.QC.jpg
c0881bd6dbbc63dcb0eb3a70020ea61b
a27ebb374345c8855629e82393eaba60bcec4654
F20110217_AAAXGU pineda_r_Page_23.jp2
32e0afe48b4de823482d9116555b77f2
5ecbe50922988866c2f4d422b8adbed174618863
34063 F20110217_AAAXHJ pineda_r_Page_51.QC.jpg
a73762b2d8dea7a020779a695a94fbc3
343e4c3bded4630e42edb18d2605f0c411f5cfd4
44251 F20110217_AAAXGV pineda_r_Page_70.pro
ec8fb7ce982632477e81606f46059be5
dfbaf445eefbb9743a5a812cf9715a7709f7b2e1
106729 F20110217_AAAXHK pineda_r_Page_17.jpg
1dbeffce0e7cbbaa84c7912f65956f9a
2dd7c0277bf05892f2be79e693298710a11f2409
105712 F20110217_AAAXGW pineda_r_Page_14.jpg
7e2ac6800a8f9a9f5a5becd31f36e3a1
fa588479ad663a0a1ecb1f26ef22082eec1d2767
994947 F20110217_AAAXHL pineda_r_Page_98.jp2
a3ab8d3a501b56047ad309e4453fd8e8
59717b522c3092ab1fde1279a51e4e3d072fb770
34413 F20110217_AAAXGX pineda_r_Page_28.QC.jpg
ab2d634d9c405e71812df8f7ee47db2c
601f4384cf46271c9e3947709f2fdc74c211966c
7378 F20110217_AAAXIA pineda_r_Page_09.pro
9ee121edeb0b2ab6fe8425fbb02b50b7
6d92baa195dd423aa63a5b04064baef8dbaba244
F20110217_AAAXHM pineda_r_Page_32.tif
9e2738e0e5f7d24233204b31c94b6bc6
87c4e39f86895f2ae9239a3dc854d6afad58cc2a
97752 F20110217_AAAXGY pineda_r_Page_43.jpg
f404263f93658e84dc799e916da81705
70c71a7eeecc6d8844e75c6ccdec734ff0f006fb
99933 F20110217_AAAXIB pineda_r_Page_81.jpg
7598892d97e3a8cfdcd7811b8645dcab
2c07384b48da87f1ec70852049e538aa9bf63857
475 F20110217_AAAXHN pineda_r_Page_05.txt
3211c1d649f077d559218d9d209c17fc
323345e49c4b49b9173ad69f7094298785d83b07
F20110217_AAAXGZ pineda_r_Page_42.tif
bd4aaf5c9a270b6fd2e59337837f66a1
09ef7817ef9be0bbc266e46f89700cd6c94df6c3
5915 F20110217_AAAXIC pineda_r_Page_87thm.jpg
441052682456841f5c4f117306a5c5fe
aad468adc615275766052fdf641fd7e5dbb2fdb4
34120 F20110217_AAAXHO pineda_r_Page_31.QC.jpg
33fc367d6714d036f677a1eb066d0d43
387c0a4248aface0fdcd7c87a860df0abcfeeca3
1941 F20110217_AAAXID pineda_r_Page_33.txt
e340e83f5a3b1bc1afc2e3f163227799
27fcf6e05e73fff37c16ef80a4d59f098b6fbc6e
F20110217_AAAXHP pineda_r_Page_78.tif
7e81ed1605e62afae4df0e066ae8b279
857299a4594d1eb263645652afd9dc8ae1187943
21241 F20110217_AAAXIE pineda_r_Page_06.QC.jpg
b31b3972767ecd1115183dc1848dcd9b
c42b9485c048fd0088edce0244a14b241c2b5fb8
7700 F20110217_AAAXHQ pineda_r_Page_89thm.jpg
b7454654abe1e24b4785dbe90c10dfdc
217267f89d7a798d0e6cc03a1796aa7e9603beb2
3728 F20110217_AAAXIF pineda_r_Page_86thm.jpg
e104c9d30224cb300cc5a856c2f0e82a
d3cfb4ffc81ad529172d04d672d25164a0b32dd7
2023 F20110217_AAAXHR pineda_r_Page_26.txt
22c31b37c562bbc3ade607ae4f428a1b
172106f5d2ac4a49ffa829980b9bcfcb3bbebbfb
F20110217_AAAXIG pineda_r_Page_54.tif
d9bcedcbc574a904bf808ab8e42fd7a0
aec6661be2b5e4784156f2896c34a2ee4e382116
1883 F20110217_AAAXHS pineda_r_Page_41.txt
96d9ebe3b0f8959680a7505b7af755c5
3b5c09bf5577622623b6614cc1bbfd79e2114729
8377 F20110217_AAAXIH pineda_r_Page_80thm.jpg
73fefb9aa5f08a372e357ef40abb4693
aab0b2906bd427a5dbce4f9641687056d390db04
F20110217_AAAXHT pineda_r_Page_90.tif
363411525a4450ab011ab913ee7d69ec
7535c234e472066a01b57aa2bae55950c0157f61
2028 F20110217_AAAXHU pineda_r_Page_38.txt
9850f7ea74c8744f1d259f1c6706dfe0
418fa34805a5c2621d0d8a26b0de395e681c0a46
32722 F20110217_AAAXII pineda_r_Page_40.QC.jpg
c8f47751379286d58788631cf38c0c2e
57db3626bb38f352720d964c96ef716daa868656
F20110217_AAAXHV pineda_r_Page_38.tif
e47e2a1caf73304414ce3aaefd2f89bb
5688a5fe1887ef9e75496348d27c8d6730ba8491
102617 F20110217_AAAXIJ pineda_r_Page_20.jpg
f647e8d2e14361702d718c851894a0dd
7f7f8829520e8026c79cf45eb1538a55a59a13dc
828699 F20110217_AAAXHW pineda_r_Page_54.jp2
967c25d50dc7abe42bb25c0ebf2f1a73
fe36e60081c2afed4140fe74865c07aaa8311229
F20110217_AAAXIK pineda_r_Page_45.tif
0bb2fd9ec1a1d0ed1859ad5c42aafdbc
144b20dddf21b4fd6e8f1a0a6e7167e410ff1772
F20110217_AAAXHX pineda_r_Page_91.tif
48a36a479c295a323d18537a7587228a
f503a149ea7e6e532930b9a6ced6dc4973151e07
8015 F20110217_AAAXIL pineda_r_Page_75thm.jpg
d90d90d0596201c7aa8ca4cddb2a0cff
12739a412ea2070e58cb52109e01569177ba791f
49040 F20110217_AAAXHY pineda_r_Page_89.pro
75cac25430c95595d46c3f1c44449d55
952977ae1f5dac781fcd91d003c013a584d38ca3
2084 F20110217_AAAXJA pineda_r_Page_85thm.jpg
3ba381168770701fac6925a8eb3660bb
e8fefea178f29c4cf4ff015c472262a1b11c3489
502010 F20110217_AAAXIM pineda_r_Page_11.jp2
41fec536ebce76a371c1bd0878f3a1ee
c04462f713e41a17a692c4ed843d83cc02b7f4a2
F20110217_AAAXHZ pineda_r_Page_81.jp2
05b863e15ce296b1af60086030643d52
380156dfdec1a2f93490b744e833f105faf88879
F20110217_AAAXJB pineda_r_Page_46.tif
0b775171793bf9db7d916b410df76832
7dae10ff3a729d600e3ee50e8795f05d96d2a6a3
32956 F20110217_AAAXIN pineda_r_Page_24.QC.jpg
fd016c28e25ed79be9c91f8f8e6c8c2c
2c1b121167a6e8048fbcf8e8686cfb3cde0ddf55
95222 F20110217_AAAXJC pineda_r_Page_41.jpg
6ebbb37a9fa8c46f9717ec92bd8306b9
5837134e07a6b8f498d545f71eae135298392feb
F20110217_AAAXIO pineda_r_Page_95.tif
486dfe9be9bc3acc7cc4b1cda95cb8a2
3dada7c5f896bacb6a88f5bc3c9a9bfab8619a8a
898199 F20110217_AAAXJD pineda_r_Page_57.jp2
0b82c0415b8dd3056ea70ba23f1d4c0a
eef1099b3399fe9d854d9be17e8179890c5716fb
F20110217_AAAXIP pineda_r_Page_39.tif
c8d77708305af054845d6b4479f06e8c
c19e30024854b93594f57b24a31c75355776fcf2
49208 F20110217_AAAXJE pineda_r_Page_33.pro
a701c655cc24b3a34f228ef6980d205c
02d99482463462da89a50af47b2aedbc04053b40
49537 F20110217_AAAXIQ pineda_r_Page_73.pro
8138bc0f6da3afbacea32b932d022bd0
ff2a3aa094aa879529ecf02eb9ee0481483f6e4b
8740 F20110217_AAAXJF pineda_r_Page_96thm.jpg
f5b465cc0e9c1ef06916bd9d1d5c9158
391c5a3e11682d69df2f747ee5484c31157925f1
31630 F20110217_AAAXIR pineda_r_Page_72.QC.jpg
6f0788d013679e5de3de57369e72bdc1
4da98a029df380b746e9221fd1f05dcd3b2a3079
51845 F20110217_AAAXJG pineda_r_Page_17.pro
e24a265efc0b24204805d824af329311
1a62baa1664f00db18b38617da220a149877a5c9
47539 F20110217_AAAXIS pineda_r_Page_65.jpg
3e77d6b096a4be72f5609d87aed3389f
600a1b4ca9ea9e3b669c80e7f1d584d0ba7a034e
2597 F20110217_AAAXJH pineda_r_Page_92.txt
7b649f6b753accc7bf48c9731bbaf0ac
170941f8a536ce8cb6a57546271a903b207ebef5
2046 F20110217_AAAXIT pineda_r_Page_14.txt
0ccc0baf1740bcfa04cc39e9b628da8a
23afa0e3cd4ae505c276f64a1294b2651325783c
1051942 F20110217_AAAXJI pineda_r_Page_63.jp2
c0a58067ef40f90f4c25ba053618022e
d68a3a67e184604e71cd3ded0ba9f96f4d4f55be
33346 F20110217_AAAXIU pineda_r_Page_58.QC.jpg
13bbc2fd7c5ab94c07e047baa063ae41
4a83e238f73036a1dea5c9b5752673fd3b0f9c16
31483 F20110217_AAAXJJ pineda_r_Page_44.QC.jpg
53f82aba88616d6e7ddfdbb1279d6121
3462cfd1e07e7ba9e02b0c23467d553273607890
26384 F20110217_AAAXIV pineda_r_Page_05.jpg
6ffb8872bd40572c7171c24a766a12a1
e7fc71624c7f30b8332c1c5f07e86365041da8ea
2424 F20110217_AAAXJK pineda_r_Page_01thm.jpg
659c8a4e5bcd1c4ace19adaafd3eb61f
ab6b57ce0f88c0686b4fad499d1c769d66efb5fd
78844 F20110217_AAAXIW pineda_r_Page_54.jpg
1489ef46a04ede1e39ee181151bc357f
cb6a654cdb08320e32ae5c16bbf7889447adce50
1028450 F20110217_AAAXJL pineda_r_Page_53.jp2
ec165d1b88569ae411e1effa72057433
7d5f95938f8ce75146d363c52f4de8a82de58412
F20110217_AAAXIX pineda_r_Page_53.tif
856418c62c44dee5d9f512906acde10f
9e620e2e9b7ec88ad121990f8f25f69a9ffe459b
F20110217_AAAXKA pineda_r_Page_09.tif
981611bff48dad1e7725f0ffbb7b7d20
16a1cad6b8e4a7d1c84b9b14a3cee73cb7ab87ac
32302 F20110217_AAAXJM pineda_r_Page_73.QC.jpg
8b8febea2f4b7763d7339ad5b6328ed5
88a81bab626703d8c0e2b23e9c7c5b1adbaeb22d
49868 F20110217_AAAXIY pineda_r_Page_36.pro
f2f379df0348103a6e31e8339fdf8302
9d1ae01f71842140512c727e7db7ea7365af60a4
50611 F20110217_AAAXKB pineda_r_Page_35.pro
bf8ab5c53bfd10c7ebd9788fab16d9a6
1205cc8792a2232db160ccd9693f39e3e845ebdf
4097 F20110217_AAAXJN pineda_r_Page_45.QC.jpg
1694142efabbcc601aad4b8762b9833a
928ee0b41697fdd3ebb12a41b53f8ff178210a98
8874 F20110217_AAAXIZ pineda_r_Page_92thm.jpg
5f71d38669506847f491bee6eb6b7efa
486ecf72b9974f69a08df16b02170e60f77371d8
7782 F20110217_AAAXKC pineda_r_Page_55thm.jpg
11c701c99ea6b1aab4d1a3da0d726f0d
e07ab5a1e0820ec628116c6eb7a79ac6b2e1eaac
101792 F20110217_AAAXJO pineda_r_Page_36.jpg
90ec2ec58aafc6b477fffce47b972af0
b3d68ff1f96cf142da8f320a7123f8c106a05eb6
32261 F20110217_AAAXKD pineda_r_Page_35.QC.jpg
598bf7cca4472113b02f238cfa63a106
acde6318b4718eb67c62b4bd90a8b48018e0402f
F20110217_AAAXJP pineda_r_Page_49.tif
e5cd0ec71eb5ad4b0df8f2f9a68cfd49
f6e1f60f1ca7c974046f9bad8a87603620c757c7
2044 F20110217_AAAXKE pineda_r_Page_17.txt
5563f2313e677fc6244699d45b0ad6d3
35db5e751313d36d1fbb389b00c27e9dffff4a63
1749 F20110217_AAAXJQ pineda_r_Page_10.txt
7bebd3f82a99394d4028286c20f00482
c60bd76e5f39af091d25595739e212d3fbe9e29c
1814 F20110217_AAAXKF pineda_r_Page_04.txt
142a6022b67a98bb30fa265e7ff9e31f
0a04a3f9546ac8bcbf972944bdf9121d6cfc0f2e
102662 F20110217_AAAXJR pineda_r_Page_52.jpg
bf8abb59ac5bfe1f207be51345f43ae4
8b4db7d9f22f80dbf38197cf082fb7f325c8b02a
F20110217_AAAXKG pineda_r_Page_71.jp2
b5f16c38ae7452a03dd964eff5976510
dd4184320b7463893546b61196ec23a2dff4051a
128468 F20110217_AAAXJS pineda_r_Page_90.jpg
258ebdd99a536bba72dafbae02625266
400d6808fd3f821bc0e9fc997dd9c855ffe78304
883579 F20110217_AAAXKH pineda_r_Page_87.jp2
68eef8602a1ddbbe0438d3850aee532c
3a040c90eac1bf8cb36ededcefbe92eeea42d9e2
50982 F20110217_AAAXJT pineda_r_Page_52.pro
9c85973bc12e1ec9458172d461b4a8b9
c8f3ca6a929fd8ff4e07cd44166d3078ae5312dc
462 F20110217_AAAXKI pineda_r_Page_99.txt
622ccc85cffffc7ecae70a9bb6dd7d14
1f483f71dcb19b497709063a1559f11a7b8d9696
45131 F20110217_AAAXJU pineda_r_Page_27.pro
8a30c7451a848484d4bcc85ea7c087d3
f291b87471978db66ee38b2f823aa49efcfda1c8
2298 F20110217_AAAXKJ pineda_r_Page_64.txt
de9ef1075102505be216f9111b48ee7d
a24b1247e79c469cebb4d13ac74bacdb7436b672
8593 F20110217_AAAXJV pineda_r_Page_19thm.jpg
a6d06f5e7296809575a08982bcbfee31
7dce75c5e602217032d3747e936af42cc5addfc8
849171 F20110217_AAAXKK pineda_r_Page_07.jp2
f7dd58d70e3845661d6c3bc486399690
cf1a81577ec89459260c8584813fffa5d3113ddf
7917 F20110217_AAAXJW pineda_r_Page_34thm.jpg
81084696b7ab591a2a1375510f318d79
c5144e21b84a4df589ed85d2b74194609b7fb421
51557 F20110217_AAAXKL pineda_r_Page_31.pro
1ee0f97fbb07d8d8db64200ee583c919
2112b5000326a80d333ce3fa8087681aea45a6d5
F20110217_AAAXJX pineda_r_Page_76.tif
22de07e0cb5ca66efa0a2e586e0c4d84
734434212a10c32b6c205d405849c68a308355d9
88716 F20110217_AAAXLA pineda_r_Page_46.jpg
a0cb4c170fda34f9927f50492a604c58
05469a30c75d0c97eaba295c7214a1bdda4938ab
8327 F20110217_AAAXKM pineda_r_Page_59thm.jpg
777cc0b3e77f56050d4acec46d1da201
fdc38a0c61af33992617b961282b44ddaac5c7cf
2081 F20110217_AAAXJY pineda_r_Page_28.txt
f2533775447da3d3638a92bc0f1047ed
300872293b09614d0f35081bb84766a33a4be23b
40146 F20110217_AAAXKN pineda_r_Page_57.pro
f52b8f1c22a3ef3930f17c275a648651
bebff271638349025e42577484e0ddf20ab0ce92
121534 F20110217_AAAXJZ pineda_r_Page_45.jp2
3d18d6dd3347597b0fe739abacc7eb73
23f4f832587d1a60b9c1209eddca5477fcd7792b
F20110217_AAAXLB pineda_r_Page_51.tif
43f1b507bcaa8c6ed18d71da838e34d8
c9c77c7d00e0aaa402b1bae82eeb62a6f07fd5ec
980 F20110217_AAAXKO pineda_r_Page_03.txt
d09f09f33436f7f8ee824cc13d548866
b3d78a39cfde7c30b6692fb820e0ca4f3c92de26
487817 F20110217_AAAXLC pineda_r_Page_84.jp2
0819241c276f29158f7df397b826990f
9ebc3332bfb7054c406c449623eae80beddd9f9f
F20110217_AAAXKP pineda_r_Page_68.tif
bed7f1d71eb9e474dab8773e7047180d
21790af30cbbd70aeadd14f697fd120a72823a5e
1934 F20110217_AAAXLD pineda_r_Page_80.txt
6a3cfa950454c13e5e0a64e987ef3928
04004b21e34639f278288047607e208b5efcb5b6
13019 F20110217_AAAXKQ pineda_r_Page_56.QC.jpg
f70245e829f2a1ea72f4b26f56892bc2
aae1110136467623c7bbe6ef4b74aedb990c5a37
104053 F20110217_AAAXLE pineda_r_Page_47.jpg
d3eee77357ca061dcbdb9f292815a5e9
73299d7c022ab228bef5661b5a9e8cbc273eab97
13670 F20110217_AAAXKR pineda_r_Page_45.jpg
15d3b7f8b2c4195f9d1bdb5db0fac602
d2a49477fbf2d89b4541d3fe8f45d8a7bf2098fd
6185 F20110217_AAAXLF pineda_r_Page_67thm.jpg
1f4cfcd37de1551263f4843b01ff36f4
5c7bd2eaec70cac535e8ecfb0df8c730d113b9f3
27137 F20110217_AAAXKS pineda_r_Page_68.QC.jpg
8946de22d1b488ae3c2ab0e3e840520c
a01f5a0763433a301f8f108100a14ca4fed84916
F20110217_AAAXLG pineda_r_Page_27.txt
d3213ddcc52e6b019eed4288099e6f42
c6962631e566d12dec82f95d4db5d3fc40aa8cf7
50003 F20110217_AAAXKT pineda_r_Page_82.pro
d45eaf8f6287bb9cf18d558d0cfad0d0
29c153925369a523fd04666f2adaef3a14244ca0
F20110217_AAAXLH pineda_r_Page_40.tif
9a64bf351b5e96490bb80802ad869262
e88a1b1d016da66261277cf9cdfb0fb8a10bb972
270 F20110217_AAAXKU pineda_r_Page_45.txt
2efb4e0c4055a39a6be3bcb7a9cdc3a3
94f7b7b471e50a15e9b757580c7741ca3fdeec39
91843 F20110217_AAAXLI pineda_r_Page_55.jpg
a0573caa6c07dee8a9873a2bd1f3ab30
04e6d6992eef71b8dc8ca646ee0b223e03536a6c
F20110217_AAAXKV pineda_r_Page_29.txt
8dc1fae94ce99810eae43daaa8ea4852
50d12ad20c536767c63489b3adb01c6ac760ffb1
237649 F20110217_AAAXLJ pineda_r_Page_99.jp2
81cdfd4ea27519acd5131bd7b09f6129
d1b07e21c642887904634be2bc8920c3adb7db41
47900 F20110217_AAAXKW pineda_r_Page_50.pro
e7972a20a347bae7698d1bad400a37c6
bbc694b1993a331f26069cba4c5d9ebda8176e99
941240 F20110217_AAAXLK pineda_r_Page_46.jp2
045d438455ae46f71236ae1ddc82060a
d93781894b4a38dda7d56368ba65270c3b779c5a
121620 F20110217_AAAXKX pineda_r_Page_94.jpg
a86ef1f64f5bcabd73948acbf04c1500
d353951a41e179ec827516f03a8e83d0f317efab
F20110217_AAAXMA pineda_r_Page_70.tif
abe6eacf066e2ef9e5ed3451a3682129
5a8ccb9d7016be4a8de99cf0e73ebfe4f1ac78f6
5699 F20110217_AAAXLL pineda_r_Page_69thm.jpg
1e9678ee39b3cfababf78a68f1c9da2b
d3bead94aa14b21a59c9f26c7fc837d50ed8d16f
F20110217_AAAXKY pineda_r_Page_52.txt
1bec33242992bdf96c1b2bbbecace0fc
7a9cdfd4776f64219ad391abeb20e205b1539eb5
F20110217_AAAXMB pineda_r_Page_50.tif
57d9df305705470cca3f3fa88d97c185
de012d9fbdbf04c62437da1e7ebd1c9c7f1f49d4
8160 F20110217_AAAXLM pineda_r_Page_22thm.jpg
6ca12e2de4249738b5a1314698d6210f
bcdcdae73da1ff757a7f431f75eb7714b10f2e6c
28626 F20110217_AAAXKZ pineda_r_Page_97.QC.jpg
cc775ce35ad1355afa0d346fd474e05a
c27e64c6462d91667c1efbf9d9b1a8d2ba99560a
33550 F20110217_AAAXLN pineda_r_Page_38.QC.jpg
7b6d355df139b65e98c97aec0aae1ea3
a2fe1a30594839a542b016717036b23dc00530ae
F20110217_AAAXMC pineda_r_Page_89.jp2
b132063cec159ffd9890b135db30bf2b
c1c6642ee812118c68e0bb64bc846bc479123b13
94168 F20110217_AAAXLO pineda_r_Page_12.jpg
f02aa2f6e74478c152da0e13d9dc7206
3889a184d7642b5542df0ef967596fa148b6902b
F20110217_AAAXMD pineda_r_Page_58.jp2
7d8ae7f78223cd455a9cd0518e6f95b8
5334509c4be02095b4e8ab916be166cf8f576160
1976 F20110217_AAAXLP pineda_r_Page_21.txt
333efb827af75d9bb73e51605095b6a6
1b5d458f8b827635654021eae042d8c4693f88a0
469 F20110217_AAAXME pineda_r_Page_85.txt
f14b3ddc785bebd79dc8aeb3437b5605
6215cf69218977b34dacc504a1a29ac278719f70
F20110217_AAAXLQ pineda_r_Page_19.txt
6dfb5378fe6a0eaf1d9ecc38e74e02e3
a0631ff6a5d0f85b565800cc4af691c99ebe3087
F20110217_AAAXMF pineda_r_Page_21thm.jpg
6771f44005320b5685262b56a70bf390
81a36c2a040a4119ebe8fbc40a03d254757effba
34881 F20110217_AAAXLR pineda_r_Page_14.QC.jpg
a1d55c7c2ea293244baf2157c8a372aa
1dcb62722ba5c65cb3e8005591a092778eeb0b72
1051953 F20110217_AAAXMG pineda_r_Page_34.jp2
16d4669efcb44d1ef6bd9cf4849a1657
0eab8f36404cab99ec8c69ebeae63bbc3d0527ef
100229 F20110217_AAAXLS pineda_r_Page_24.jpg
8856d452dc8f834e3a16a0ffce060702
79e4899022886afee9174e5d04eb583a1bb82088
F20110217_AAAXMH pineda_r_Page_87.tif
81c14f84fd761e3323518ce0ff45181f
e5737e1df9bb2a56ee23f2a952a5729c272014d9
30480 F20110217_AAAXLT pineda_r_Page_63.QC.jpg
95b593a10a6ff6a4f865c9203bfd8353
bf1963c286166801ca4db6913838f0f5f7179757
27646 F20110217_AAAXMI pineda_r_Page_46.QC.jpg
eada22a2fa5150871e60b4286f4dbb14
f67f4e6ed5c4ec45214f11561997a16628582f29
F20110217_AAAXLU pineda_r_Page_93.jp2
b9c55ae75d01be30fc27ad79873443f3
76cc3e71b0b4c59629edc841d2754ae593f399d7
97556 F20110217_AAAXMJ pineda_r_Page_97.jpg
1b20e367287ae0e30ebb676778e2d22a
60ec049fc3b15153594843d46621e1bc54072175
51649 F20110217_AAAXLV pineda_r_Page_60.pro
7f345858c52d731a288c12b600f1c7a1
a930d554ff74f895824119837847788b02129199
38722 F20110217_AAAXMK pineda_r_Page_39.pro
2636398bdfbcf81298fb66b3d56427bb
2239e22984fc555d8c4686128440ab0e75c7a448
2554 F20110217_AAAXLW pineda_r_Page_88.QC.jpg
ad9a018eebbfcf181bf84aaaff523ff8
b703e8a5bd5d67247bcbb6de26e68d9c3c940f98
2079 F20110217_AAAXNA pineda_r_Page_31.txt
d40975377502166bd35f1aa778980c08
6615c3ae7d174fdaa66d012d698b237f2ec6570d
8285 F20110217_AAAXML pineda_r_Page_95thm.jpg
c402f93b549763e24626e0bef873f48c
74db2e02d84cf63985313813eb15e7cf8664d53d
F20110217_AAAXLX pineda_r_Page_57.tif
2b5d73e97bb4c0d66369a769e2872603
b74120804f95160daafc90ef79619128ecfa97ce
49445 F20110217_AAAXNB pineda_r_Page_72.pro
65dec642197b6757b7b51ad5fea46b88
f0adaaa57f129ad7391c53466125944ee7770496
F20110217_AAAXMM pineda_r_Page_21.jp2
4035fadb92de2597e133568e64c423db
5d9401125a9584150fb759a6dfd162d38f178d37
1732 F20110217_AAAXLY pineda_r_Page_02.QC.jpg
2d40925e120498bdb67a7058852569cd
1859410cea7cba8ec596f095e51c933f51555764
1866 F20110217_AAAXNC pineda_r_Page_55.txt
09260376104813345010691c89e3b785
ac6b7e49c9d820ae44d9e1373035c4481e35e3b5
F20110217_AAAXMN pineda_r_Page_88.tif
011612c4b86f2bc31a3f675f412a10f2
b71e9d30ec88bc34e926285019b350a389c84a89
7901 F20110217_AAAXLZ pineda_r_Page_99.QC.jpg
f3c91c42884f0f05b3b922e765f6cf02
7ded06b74c70613fc1e05d611bcb01eb40374732
F20110217_AAAXMO pineda_r_Page_84.tif
abd01b303740b199f42e27f8ae9fafa5
f1cde9978b6621898ce60765bdcc21c83fcb3b22
32740 F20110217_AAAXND pineda_r_Page_95.QC.jpg
f706a0d893ddc2353709917437cf4337
0d5af34bea1d05ca1be72efb6a360ee28c9cd8bd
1937 F20110217_AAAXMP pineda_r_Page_22.txt
1bf27bdb3ced83aabdd44b7604a265d5
550de6c81ea98ee548bc56a880ef7495db9698b4
F20110217_AAAXNE pineda_r_Page_71.txt
0cc2aaabae9152806c8488b4c216a2f4
c4f52dfdade8d6265095a558f2a4ad20afa020a2
2657 F20110217_AAAXMQ pineda_r_Page_08thm.jpg
12f8facd3f7cb155aba532e18fb3a981
c021dea137d68830c5785e7d2843e4be0e6e24e6
103482 F20110217_AAAXMR pineda_r_Page_62.jpg
a69bf254953949934fc07fcc14404c20
407205a1d52036c99d70cad0f6c5fdbb9ca4288d
F20110217_AAAXNF pineda_r_Page_31.tif
bf5d79690485cea563512673877025bf
8888da5648a571d8487edbeeded1100bfc621911
1051962 F20110217_AAAXMS pineda_r_Page_79.jp2
2401106b7e73d7ba69b750d2e40d800b
5e52423b3dfe2b42ce0889d5eacd29befb18a272
F20110217_AAAXNG pineda_r_Page_48.jp2
83888ae7dccaff4462612dff8c2d6539
617caf78518966c1f5cbb5b39d7d4042318c36d0
22548 F20110217_AAAXMT pineda_r_Page_11.pro
2d5938e2706aa4f72aad368c802cee7b
e73ebcb03c5ccfffb07e6d854b50e8c53a89230a
50672 F20110217_AAAXNH pineda_r_Page_29.pro
713389bcec2afbc9d10ff3b38bc433d0
447dbdc47f2384dd0f6190ae0019dcc52b25cc36
1973 F20110217_AAAXMU pineda_r_Page_15.txt
3a598a8f1c3bccd43df66cb26cd5c802
e7dfbfde4a9e425facb3255546e24170159930d5
1983 F20110217_AAAXNI pineda_r_Page_32.txt
a99e2863730b8594877a9c199198c8c0
41a128e6c2116bcc0e7838e76f97d9ef08cf6283
1861 F20110217_AAAXMV pineda_r_Page_70.txt
9fd89b4e723e4bdfaf2d26a1eb3304ff
93c7af2984f484568b1120b9ec8ff8b28149b12a
44239 F20110217_AAAXNJ pineda_r_Page_30.pro
eac3f6a36949b42438d7bcb20c44824b
d4847571ae6f156623a75a9a2758aa1ae7b3f2ff
8703 F20110217_AAAXMW pineda_r_Page_79thm.jpg
6bf90448dab51b410e4f63a559af437c
82d64eb41107f56eaee539e4281d56e7f11c9332
F20110217_AAAXNK pineda_r_Page_29.tif
4f4a920647eb6a6cf340dc83b5084d11
6c5fe708200cf2b565fc1e4f94a658c337698f2c
5654 F20110217_AAAXMX pineda_r_Page_45.pro
db394cf4ff0d899342335aee204010f4
90024ff389c3fdb3b703e3291a93dba4df2ddb59
50847 F20110217_AAAXOA pineda_r_Page_23.pro
9b70552d847d48d6bc7fb0c08e037220
c29fdd10ae8a952425fa6ff3b64a0f90f0bad357
7385 F20110217_AAAXNL pineda_r_Page_30thm.jpg
e6fcd87a64797c751d93341e0961d6e8
18ff73bb769ff26484ec6a8a7351f1f53a9bd477
1051963 F20110217_AAAXMY pineda_r_Page_49.jp2
ccdcd4e5d6cb24fb32658bff403f8f78
950ba95bcf9f30b4392c2c58263589b845ca47c2
64359 F20110217_AAAXOB pineda_r_Page_91.pro
8646abbfd715154699f3d52ccf6edbab
548eac4be4ee2d1c900b575436ef619a26ea9ed3
109189 F20110217_AAAXNM pineda_r_Page_09.jp2
a90f49050f12364c2979da9e0000c9f9
b638b2a11b786fe6c3e14c8200eeaecffa5d5ec0
8615 F20110217_AAAXMZ pineda_r_Page_17thm.jpg
c1426b87feb182629415978015114334
4ea36912baf7f02fbb88c59948630c36f3f3ec8e
7938 F20110217_AAAXOC pineda_r_Page_50thm.jpg
452175fe4dba969c1fc1ecd523c43213
d9b072c621eed312d7c3cfc1c7b483617772e716
2669 F20110217_AAAXNN pineda_r_Page_96.txt
af345802f88f6455adec466df1aca2d6
be18e1c0426ac3cc209812126ba8cf6d50814591
27496 F20110217_AAAXOD pineda_r_Page_83.jpg
0a9b38f52e93646c57e77a68e836288c
324f8bb5d978253d1119962b463c06fe058e031c
98218 F20110217_AAAXNO pineda_r_Page_49.jpg
0335c5c52db93f23c02c0fbda0f3e89d
0e9ac31279278fd6a7de524e708734432b78849f
8105 F20110217_AAAXNP pineda_r_Page_52thm.jpg
b86546fb06c639d685877fc16897a8ff
24427ecbfbf42904749c776027deda66f1edd6af
339419 F20110217_AAAXOE pineda_r.pdf
52b6df39c9c965b98febb6fa0e4a91ef
ab395c51494d5959a327958ec7327767420551d5
98912 F20110217_AAAXNQ pineda_r_Page_44.jpg
7799aacad828914df97f4799c4736796
56cbe8fe20db956167014107ae73c98fc6dfa1ca
F20110217_AAAXOF pineda_r_Page_06.tif
3be1a732854aa1438e0eecdb26c7defc
c9e14a5ff0146a52d3135df5bc516b25c2d2c702
49978 F20110217_AAAXNR pineda_r_Page_20.pro
74e6f352e703b11dc507ba3c25429a41
ed3c94e652e8487fabf257393f421d20a482eb02
F20110217_AAAXOG pineda_r_Page_97.jp2
dc1eb405b36702134c9bb713b1657e14
949eb0103723029f16d039ddf83bea65878930ff
1051937 F20110217_AAAXNS pineda_r_Page_94.jp2
2d6676a756e839d627e4b69fef207af3
cd37c41e913e941ed9f51d8a802bc4fdc798963d
1806 F20110217_AAAXOH pineda_r_Page_87.txt
13baf7cd9345ba8cb0350f3ad36095b6
41baa4cf2b2b791b14a18cd7a4efbd9db88884d2
2143 F20110217_AAAXNT pineda_r_Page_42.txt
0fac5e984af732232496139d72b66e99
668c95e6c18248c51d172d8def27e7cb56cc95bd
44681 F20110217_AAAXOI pineda_r_Page_98.pro
4670da9876e861c4206f54336d199e59
4d683531a79987dc84b4ae7f5016c91a743d7f70
1016653 F20110217_AAAXNU pineda_r_Page_55.jp2
efc6ce3dc6aa5f095166b4d647dc5fb0
1c6b18721a230b62db12ad4a3b5207083a30db4d
728 F20110217_AAAXOJ pineda_r_Page_56.txt
064c1d47820386ff6c1f38dc830681e9
6d225b10eec228224ad7d072a829fe8e88624e7e
8117 F20110217_AAAXNV pineda_r_Page_37thm.jpg
c7efe747a06fad61eaa4c54024a1f348
2cb6bb6b42a32f75c9db982e34b660d0b334624a
1943 F20110217_AAAXOK pineda_r_Page_34.txt
47e2f048b623d81578fc4aeebb206f89
756555c602da5d42ebc794f993247ab27e4aff77
31831 F20110217_AAAXNW pineda_r_Page_53.QC.jpg
1d060ee0a24568bfed6f2b3c5d0adb3b
8c88f960ae45a07d11305bd47a8c8d586eb68a87
119049 F20110217_AAAXPA pineda_r_Page_93.jpg
c5080ee5f632ea876ba77d8b8a67844c
e0973a615081bb9718d3026b432ca3a766398fc6
F20110217_AAAXOL pineda_r_Page_25.tif
36daff61d21d11a701ba67737da036c1
e13515812bb6c9df33b8fee19dc44442a07ce247
F20110217_AAAXNX pineda_r_Page_51.jp2
102187fd0ac18c69e840c73ec85afda6
b12140a15d850bb3ef5e0935129d54e5e17c41ea
50048 F20110217_AAAXPB pineda_r_Page_13.pro
982117c82c112d5a07728a482ce76aeb
cb9dc3738b8902ed472fac0b98f1c7ba4908b734
31725 F20110217_AAAXOM pineda_r_Page_37.QC.jpg
eaacbaac75314683e21fdb90efd3812d
6cb0407c267cde4d058067c3a1241a4b71bf0271
F20110217_AAAXNY pineda_r_Page_47.tif
e3c9a6777a0c157510b2ca9eec678cba
c538718e10b9e8abd972bdb3ef623d7ec865db8f
33008 F20110217_AAAXPC pineda_r_Page_49.QC.jpg
b0424c0377bcce89a96b639652158b4e
df819119c28ed5c32130477c657d0c52c248c9b9
36797 F20110217_AAAXON pineda_r_Page_92.QC.jpg
87f5250cfc0ed02222e9438f1d4b1658
6a717843534029b859ddbb4131a848ae5234cf51
F20110217_AAAXNZ pineda_r_Page_80.tif
6b1af977c442061d08f528e845c39c26
1361d8e00c7d43a9b4ecd73203b0e139508c0201
8287 F20110217_AAAXPD pineda_r_Page_14thm.jpg
70f704b07df0a8821a02c52a0ceca3a4
e28f4c34568735c480e01401b2f2dcc005f7e997
35260 F20110217_AAAXOO pineda_r_Page_48.QC.jpg
996fb69acc299c1360df99e3b3367000
69d4d341ef8869eec07c05a5cd08106b510836d3
7482 F20110217_AAAXPE pineda_r_Page_12thm.jpg
1f20242bb8433ebbde78e52e9434a546
0eb1b4970a38fa9b34d54a272e725982a60cca57
8445 F20110217_AAAXOP pineda_r_Page_26thm.jpg
b976f3abe955be99c4175d29345831d4
295f6fc089ca668ed6b09903cd71195a9a2fc56b
8029 F20110217_AAAXOQ pineda_r_Page_16thm.jpg
6f71e2bca089a4b477a957bbfa86dc08
f768f40c7a0e55dcc9fe28749287f87985963d71
7481 F20110217_AAAXPF pineda_r_Page_88.jpg
07a2bcb7beb1e4257f3ded60322a86a6
1cbe1f437c7583f01a8df76011bba7a4b0429bf2
8185 F20110217_AAAXOR pineda_r_Page_15thm.jpg
db7a2df8ce5ca641f3aef91235932430
38e39c6f966a10b475a72728975b04b93a43475f
4016 F20110217_AAAXPG pineda_r_Page_11thm.jpg
168db5a99ee22a0c99633672c793a0f6
87797a569a98b31d7befca35109423f7ea584e6d
F20110217_AAAXOS pineda_r_Page_16.tif
bc9950345abcd80de804353c8874fe8a
055e4b0d9bbc19f474ea6488074ce108abf107a3
104020 F20110217_AAAXPH pineda_r_Page_79.jpg
4009b053d7db7bde372fa3d0d391eef4
32d3f0dc02d5ddb4e16ccc7e08bfdb22c9073229
6914 F20110217_AAAXOT pineda_r_Page_68thm.jpg
eb9e0cea0239917bccfc5f435448522f
54dbdb65b881252b836896b1ffe1c50a4254a107
F20110217_AAAXPI pineda_r_Page_24.txt
6f0fb2f549a2115b6d85b611fa61b441
9f9b88c235cb71404856065f04d8c197cbf8e317
1961 F20110217_AAAXOU pineda_r_Page_61.txt
9d6aae280771da376136660961e99841
66ab4479572e33dbb8a137e1a39a7def94fbd16c
102429 F20110217_AAAXPJ pineda_r_Page_58.jpg
0259e60005c4011e95fb2a2d5a71ba11
440d2819fff117d9538dde32044ec1bd07a1681e
8201 F20110217_AAAXOV pineda_r_Page_49thm.jpg
a983be3da13a2c7b5d14bc0e05a55154
d5a96acae919cc89f0f117a9bc7176d394811cf0
872 F20110217_AAAXPK pineda_r_Page_65.txt
4afa99d2fa443f02f0ea12bb33d3e815
9b88e9c3416f13632fa980bc6219f0ce32bd5cae
30038 F20110217_AAAXOW pineda_r_Page_64.QC.jpg
ef03b6e3029607e9f7a420a013c9c8aa
9f643fd470aafcec45ea700fab36de931c470373
101085 F20110217_AAAXPL pineda_r_Page_73.jpg
24223f4671fabb6deb427d46efe44223
d96fe0a251e5174f1f566e7871293f4cc97aa69e
56671 F20110217_AAAXOX pineda_r_Page_95.pro
89238b66e29380bfc05d54871fc64c59
74f897e8738d96fd768ac2f78ee03fdaf6343d61
8772 F20110217_AAAXQA pineda_r_Page_94thm.jpg
bd4b67f07a9627c6b88cfe00350d97a4
105d5d291a93428b5732c64d33215211ad993119
F20110217_AAAXPM pineda_r_Page_52.tif
3946e7405b9aecd04b51b98508d2c1df
23f3fd3a76b6c7a4659db3a359dd89a3a7400d21
100259 F20110217_AAAXOY pineda_r_Page_22.jpg
fccd8d13df3fbb6ff39b81ef730612e9
f0efd9852d494ccae6c04fa99ef74f2130056ad9
48364 F20110217_AAAXQB pineda_r_Page_03.jpg
b24ce18a6846c1c98c78183c8a9783a6
8d584b6b73f373debd337c8f2582df23cdcd497f
8638 F20110217_AAAXPN pineda_r_Page_01.pro
8e72f6fc14698264c23657b54d243d9c
6f5d4b6192f7addba48f3bc68b3a72ea30339dc0
8225 F20110217_AAAXOZ pineda_r_Page_78thm.jpg
e3b3266a69786f1c8b7cd39197fc941d
f22b4692258f633a259c071f45300850fa539490
104750 F20110217_AAAXQC pineda_r_Page_31.jpg
bda8d4aa9081f9a0398177d08fadb613
ad96ad83aaed279493a427594a6db79d71f40b8d
F20110217_AAAXPO pineda_r_Page_93.tif
8010b478624a2211c72608915867b3c8
51a65e357298e35aacdf5994baf46df1498b4536
24341 F20110217_AAAXQD pineda_r_Page_85.jpg
70cb098b5b239e8cf54aa446ac3e1865
f1e93f71ab78fa6b2b05d84acde1be9e18763305
F20110217_AAAXPP pineda_r_Page_79.tif
422de142fc9a2a404ec495059c558d31
31ca11f622c98adbcb0983279330896b114ef4fc
106263 F20110217_AAAXQE pineda_r_Page_28.jpg
a0f359a31bf089e034eb8b8b226ab051
031f3f44c1f85107f4834e4885f359275abb4d41
18112 F20110217_AAAXPQ pineda_r_Page_56.pro
b63bc9d2eb98a4d4727cec7e3d91fd4c
a7a3ec7c47943186e6fbb722e192ece2874eb345
102222 F20110217_AAAXQF pineda_r_Page_78.jpg
9b576b95835e0fca3d3cede5ab8cf238
32a2ead2d94eac8b136d4520367f43d753c84501
99499 F20110217_AAAXPR pineda_r_Page_34.jpg
7c12b3b8ed8290fe129476918391b291
9eabcceed0abb6805107ce45849efdf94758df53
97315 F20110217_AAAXPS pineda_r_Page_50.jpg
3b9aa12c682070f91ace69bc30b3ff8d
54f6388a5a02ebc041feb48696fad6ce29be67e4
7811 F20110217_AAAXQG pineda_r_Page_41thm.jpg
6b40e7e57a1facd74f2759119be2c0ab
a71b39e64e62e64b6475e258ae4599a94a0ea8df
F20110217_AAAXPT pineda_r_Page_81thm.jpg
d4f2223c134ff25bb77ed55b7c21d76d
708ab8ba45e4d43a213d7750e0a2cef03c59ccf7
23418 F20110217_AAAXQH pineda_r_Page_67.QC.jpg
b4b824394be3abca7b1db5f4a1373933
e0704de297b3074c40cea08efc5b47ed674d6de9
2006 F20110217_AAAXPU pineda_r_Page_18.txt
a5b0995e6735d9aa264c48ad1f13715d
2151fe15f164fbcfac80419dad9e83850e5bc746
34804 F20110217_AAAXQI pineda_r_Page_47.QC.jpg
7a9878cec3aaffebf9baf1ef728e516b
6ad7f97a0df1294b4d4ebf56a8395cf00b5f047c
F20110217_AAAXPV pineda_r_Page_59.tif
a9cb23ce2feff6c06d8fe18457dd4c18
2b06c81837b953ab386d63ee0f0d3e3803322c02
31733 F20110217_AAAXQJ pineda_r_Page_34.QC.jpg
2fddcbccf5a9f846c285044a662a0bd5
6d66de1892230bc326ff80d836f120afeb82a88f
F20110217_AAAXPW pineda_r_Page_74thm.jpg
42350a8da4f38d20b5a8b2a05c036742
1ddb3c7e9160b5d33db7781aa3875bb1ab913846
F20110217_AAAXQK pineda_r_Page_92.tif
18e7fdb56f9db2fbf061084d4a260aa5
f95e763983d6354ccd789f7480f0e6f39582068c
92872 F20110217_AAAXPX pineda_r_Page_53.jpg
53823188f70485cdae6de784a4dd77c0
9aa75fd8ad62e9266a32c548b9329931ee71ba2f
49566 F20110217_AAAXRA pineda_r_Page_81.pro
a1cd45548019961a7c613164e6b9cd31
4ccb8412be94846b382840404615f2f71b8fbf64
42934 F20110217_AAAXQL pineda_r_Page_86.jpg
4e3e45003804a0e9f956df1e2fa5f18e
38b6fb501197553be3d2eb184f5d268a0074868e
32826 F20110217_AAAXPY pineda_r_Page_13.QC.jpg
93d9ba3cf32b31d4ad5174ad88d67f9d
261f4408dee21e6e614afa8b3ed2ba62ae68981d
8326 F20110217_AAAXRB pineda_r_Page_62thm.jpg
64880bcb221de11adbf27705475bdec8
2a41076fdd1035e046e1b7b612e5c3631bc827de
1909 F20110217_AAAXQM pineda_r_Page_12.txt
ae1faf93563b31945af6bf7c71cf3978
a8119ea32d99d9bfdb11164d51cf342818b85ff1
8716 F20110217_AAAXPZ pineda_r_Page_60thm.jpg
bd158f06bee44ab592afe6cc3c8f078f
6c2fb8169bae2893092baed3a577bba5100ecbee
34180 F20110217_AAAXRC pineda_r_Page_29.QC.jpg
8a02f44e327d902902e35ef8cc570b01
4de35b7d9bace2c6fedf12185ad46d64ab4dc45e
2000 F20110217_AAAXQN pineda_r_Page_58.txt
349889d24e4abb2b6ada1cdb807ab99e
d573d03f4899bc47e532592e69c7c99e4c502e2f
F20110217_AAAXRD pineda_r_Page_14.jp2
f77f1b3dff2cb7a2894a17bee479e106
02fbd9ba4aa13fcfca4606404b509c78be57c62d
21107 F20110217_AAAXQO pineda_r_Page_84.pro
ad09d54fac2dde95740d8d13ee918ee5
ac5b51f6b5f7ca5c2edfbd6742255664e883a599
F20110217_AAAXRE pineda_r_Page_86.tif
a3021e0f3f36ff997e7d14d5aa68ee3f
cdba7bf1485230843b7e0cc92b65ae26fe812737
47361 F20110217_AAAXQP pineda_r_Page_63.pro
49f5340bf766d95e41a0e7bf228162dc
68caae9cd7ec873378e9210f12e04ac98af9d4a0
F20110217_AAAXRF pineda_r_Page_23.tif
5eb79877102264ae7c99dfca0f8640f4
0ab24f1123931c690126aca54ac884fe2fa138af
33542 F20110217_AAAXQQ pineda_r_Page_67.pro
58a635b8e45a89d326e785f20970e593
3420bf2876ea47cbb1471cd61dbe58ef5461a173
51214 F20110217_AAAXRG pineda_r_Page_74.pro
39d1909bcb047540a6f7126b9ccc096c
82f2fe6070c1310d13302ec912f268c23d3a016d
1895 F20110217_AAAXQR pineda_r_Page_37.txt
85b9e9eca8679870d94a5c0e297b2cbf
5be35eeff2cfd211c4976da6a89727ec04af149b
25241 F20110217_AAAXQS pineda_r_Page_54.QC.jpg
53c85336916dc89aa558f610e7547c47
03d73eed50a0962aa0a5fa658cb6fdae03912016
F20110217_AAAXRH pineda_r_Page_13.txt
a09e541d3ece3a89c527ddb1b6032b69
e0b419c0d2b9c6aa27584e88eaedf372c6bd7922
F20110217_AAAXQT pineda_r_Page_63.tif
7ebe8e13e6707bc11e6bbb87cec261c7
391d7410986f1c8439a0560a63f7cfa45d471ff1
F20110217_AAAXRI pineda_r_Page_34.tif
55900d273ebc291dae2755ed4e521ca8
d88f55c4deb94ebc431d1ee279875d117e743118
445842 F20110217_AAAXQU pineda_r_Page_86.jp2
82fafaa2496c190a4c1391bc4c6dc128
6251181c5d9a29a51db6eec90fdcd0a766982221
104346 F20110217_AAAXRJ pineda_r_Page_74.jpg
983d277b52766132058e69661e6cd48c
a388548c1bc80c9e28d8fdb2c016f2187daf44f1
1051972 F20110217_AAAXQV pineda_r_Page_40.jp2
2d2bd754483cdc776fb6dae7c2b3a16c
308259d415df3c9afaec0ddadbad85ff4ae1e764
36190 F20110217_AAAXRK pineda_r_Page_42.QC.jpg
533dee3942ac56d5d3b1e79a28c6a5a7
55c8066669cc704723167ace70ec77bae9ed1ee4
23913 F20110217_AAAXQW pineda_r_Page_87.QC.jpg
41a821236f648b4cbc1fa62493f40b72
595749c0987ddf51f47f995aaad533c2aa5e7f69
F20110217_AAAXSA pineda_r_Page_73.tif
b6a8e0e813b63c8657af5deb81c8add8
189a8c46ef17ca2b54c61ea3c66acf796ea36730
10572 F20110217_AAAXRL pineda_r_Page_99.pro
fc2ac03840ef6862fcd65dc87178093b
072de4b5cd33ee85342aacfe91a101830dfae86b
F20110217_AAAXQX pineda_r_Page_43.jp2
5488b74aada659802300b1eea2aff343
4c3105a2a761293f7217ae606f341bf2da6aa444
6174 F20110217_AAAXSB pineda_r_Page_66thm.jpg
9562b7069d95f07ada5479e4b631a55b
50f0f64f2674f245deec042b09e54d32a1346df6
23716 F20110217_AAAXRM pineda_r_Page_66.QC.jpg
236b7f55d8bae3eea7e6c03c57039f03
b22ac090dd1bd3114fd332c92c4aadba5387b5a7
25513 F20110217_AAAXQY pineda_r_Page_39.QC.jpg
b7da00f7c6a495cbd9fb7ae3130db993
a06d72f481c9a046ef0bdffcabdc370a5458ad05
F20110217_AAAXSC pineda_r_Page_90.jp2
0f9473b7406c9353695bd8eb9b3c0816
daa1da83028cf69d1689233677546efe853fe791
76309 F20110217_AAAXRN pineda_r_Page_06.pro
56dcae751bda7c8d75455d0e8dbef1f9
49836d757679961a5612278821cfabdf1dadc4e8
98637 F20110217_AAAXQZ pineda_r_Page_33.jpg
e267f57300201dd6316b47eb1dce2333
d44a5b8e77d97f56c62c161dd394d792a0cd9ffd
97647 F20110217_AAAXRO pineda_r_Page_80.jpg
e5ae1659b31b6f43fcb8301b4bc4d539
45d1d6e0646e578f64ee17b918c2d96b08df94a9
1801 F20110217_AAAXSD pineda_r_Page_98.txt
616484cbff27224e6415a493780f7eb7
53e72b776b60b01d4992dd48e8b822136e58c3dd
26177 F20110217_AAAXRP pineda_r_Page_69.pro
a6f0530d7969ad441cba99ee45797b7e
c0a99b174db60c1315334b849168781aad7e174c
F20110217_AAAXSE pineda_r_Page_42.jp2
a4475e2e462df54fdff2c5f579d7ad5c
878b64f9c2fcf1257aa3f88c2934db9e678a02cb
90205 F20110217_AAAXRQ pineda_r_Page_27.jpg
b1f12cbe30079fc83fa7bea6de6a1830
d1dd774828cb1ecd72f2a6874780bd728377cc46
1898 F20110217_AAAXSF pineda_r_Page_53.txt
10b69f1c3c5e700426777f558f7ac925
d697facf03a4a6b390c0b96ea9bd4525c2f82a1d
F20110217_AAAXRR pineda_r_Page_81.tif
3665dc8e6eb07029edd41a8ca86e4fce
e9e8254abdee296125c573bd656e948ba7ec13d4
F20110217_AAAXSG pineda_r_Page_02.tif
c011550d3f1ab20e5925957d22323f75
7c4307f05efd0e9f2c0d63d075144d9434187eb4
33468 F20110217_AAAXRS pineda_r_Page_74.QC.jpg
f3188437f657375635ae1616a2fe1054
99c61abe4c1e960469a26c2792a8503f14e63c6a
1051986 F20110217_AAAXSH pineda_r_Page_37.jp2
b863eb1f9c594a36273222444ae3ebdf
b7e69324c7a0d97f4c03a606f554d1d9f61638e5
F20110217_AAAXRT pineda_r_Page_36.jp2
c826e127bbfadc3f53a1323ef2cdf3a6
ff1efaa676a74bc6d774b20bd9a879985466f0d6
34010 F20110217_AAAXRU pineda_r_Page_52.QC.jpg
60c1ff7692b3f30b4cb652914211e71c
f1466f149b2ee678cfe1b0e86609c0e672b95e8b
7646 F20110217_AAAXSI pineda_r_Page_98thm.jpg
92e78badc61c3b4affb755b110fb1d6e
ae6175fbbbe2d3980359813554d905d1e1efcb55
97945 F20110217_AAAXRV pineda_r_Page_37.jpg
80f06b3e01488face713e21e5706bf1a
e1dd24580eb51a21cb39836b1acca908822f82f7
33620 F20110217_AAAXSJ pineda_r_Page_21.QC.jpg
26001c99669e73045ee833247af5e4a5
a0126b5a098ba57c70e010b566653925522b4f0b
30285 F20110217_AAAXRW pineda_r_Page_55.QC.jpg
f3da0e81433c16c9fd2696bf48b9ad39
3bf3addc5f6263499c24e1b1d563b579fc5f9d44
159932 F20110217_AAAXSK UFE0015659_00001.xml
b4cd20eaa097d999fbae18de59fc436c
5db72f699f9596784691f32e65cc2feac43c2d60
1989 F20110217_AAAXRX pineda_r_Page_89.txt
2529ae32c6d78226d949c9e4c841fc9a
16782e9ab012a59cc9569fba42bad2bc4924a9dd
F20110217_AAAXTA pineda_r_Page_20.tif
8892d27efb31bb864c53788eaf53ab9e
dc1b956ba1af86d30ebb7d086c4e4ca0e2377bf8
66110 F20110217_AAAXRY pineda_r_Page_96.pro
67418359dd0f5068083ccca1a82040e4
1f1ed15e71f6a91bdae413f6bd94a2537d514b83
F20110217_AAAXTB pineda_r_Page_21.tif
eaddeda124d3b609fdf12a846ff28655
971593d498ddabef494c13d6a0de6362ab7ebbec
45275 F20110217_AAAXRZ pineda_r_Page_04.pro
5643f37bd9695edeaffe7d6799562f92
658db284a440477dbaeaea14a0dd55312a4a8886
F20110217_AAAXTC pineda_r_Page_22.tif
6bcaf372ab702ffac5ebca183e35426e
297f5ce2f4233d6b718575ec9d0f1b3dad70f6d6
F20110217_AAAXSN pineda_r_Page_01.tif
6c54c1e80d1c343a77ef998bf1026f26
25297454f318890f9abaeef4a33ac902087a95f5
F20110217_AAAXTD pineda_r_Page_26.tif
1f54ae2c9d8bf3974b59f10e2a389983
5a961419a9a8cb84c09e72daf349b317f70f4cd8
F20110217_AAAXSO pineda_r_Page_03.tif
24cba5684109291fc16eb57f9739bbfb
a8faf9c9f8beb69fc415c831b4ea52a2d9548119
F20110217_AAAXTE pineda_r_Page_27.tif
cac3bd0706e9f1b43e42f509c89e9654
50441f96fb4d20f414b37aa9cfadce54bf47e517
F20110217_AAAXSP pineda_r_Page_04.tif
9c797c9941805178f78373f56c968377
162925a91b8397c94775a0d6bc64c8613ed25d1e
F20110217_AAAXTF pineda_r_Page_30.tif
049e58abcdfbaf8884bd38d465a6c012
f67e305d0b12626ba01dfbc64044b39611f8cc57
F20110217_AAAXSQ pineda_r_Page_05.tif
f772506d7ccf346d1bd3cf3ddc05051a
da77f4e9a19f42f0e17833d67f2e96f4f5a1773d
F20110217_AAAXTG pineda_r_Page_33.tif
b8d1d2f7ac7fdb168fa1d2fa3e0cc37d
8c7dae851f5d23fd4efc07362af4f851b3d9dff3
F20110217_AAAXSR pineda_r_Page_08.tif
73bf4a1c1e1345913b8c88a0c68c939f
7dc8de5ec407f66da96a76a514dda688958eaa40
F20110217_AAAXTH pineda_r_Page_37.tif
a66d92244cf19c70dd2874d415b8839d
5f8d33303de64897b0ec47b5a6c59efdca2df04d
F20110217_AAAXSS pineda_r_Page_10.tif
9f0be64abda4dcafc5f623755c5ca042
447eaacdeee68d5a029333927ae44b699b97f06f
F20110217_AAAXTI pineda_r_Page_41.tif
1f500e32b7e3fa38df1be20b2525ca4f
22f3db551bb73acbeea92af8e70b183cee25e079
F20110217_AAAXST pineda_r_Page_11.tif
fad96542e25310e3db5c3a880618523f
5e6f450b8acb102e923da28dd350bbda3454978f
F20110217_AAAXSU pineda_r_Page_12.tif
eb86c607f0047ca6a667fc29672a9683
c4bc631554473ba35f7a2e53b1a03651f9a7ac3e
F20110217_AAAXTJ pineda_r_Page_43.tif
565b3a8ae6bbfcfdee3f25183de2862f
38f62a92a0436355775ed4027517fa8279c4ae92
F20110217_AAAXSV pineda_r_Page_13.tif
5e47c99fb3f26ec4ba72a302c39ae056
7d1cfaee4fd1299b4118f206dac97fccd2daa6b3
F20110217_AAAXTK pineda_r_Page_44.tif
c8e7cdaecef0a5cce250f96a7d313632
94942fbcd2934d8f9e5450cc543e6bee0a09f3ea
F20110217_AAAXSW pineda_r_Page_15.tif
729e315c265ba86e3d9e91ba68285ea9
ef04b647e3254eee65bfc05106a93a9a8860c454
F20110217_AAAXUA pineda_r_Page_83.tif
b6c34c870df2d1f0e0e18ec619f052ad
5cc4745ebe2460a8927e956396b67c34a92756aa
F20110217_AAAXTL pineda_r_Page_55.tif
bd9f39058fd0668fbcb7b3bb7edda6f2
c741e46f2b6465285e05ceafa0f89611bc92e5b7
F20110217_AAAXSX pineda_r_Page_17.tif
fa27c236c3783e5be6d1d0f2f72a7df6
5f4e1e93a8c92bd66a8d2abb93b6584e6c47a79b
F20110217_AAAXUB pineda_r_Page_85.tif
a95a5ececf9108e69d8d79fb65f22d22
7b5511988ff9b12d9a3e30e0aa86e3ae025fa05e
F20110217_AAAXTM pineda_r_Page_56.tif
a3e9bd0d48b81b781e0eaf6e766f6d79
3b5e9577d5e0f8c694788c90c24997867c86f2f5
F20110217_AAAXSY pineda_r_Page_18.tif
c0687ec6e1b4a092409b17c9097b3062
f4d4c1da3bec081421c9c48ee1e4254694d92bd8
F20110217_AAAXUC pineda_r_Page_89.tif
8941aa626e9f6e18b901e73ea235982c
dd985679f1d6227d314f27ab59f038be36ddefb5
F20110217_AAAXTN pineda_r_Page_58.tif
26df394d2783ecfbb29047bd99ed6f44
20568ca95a6e6ab9ef97524992b03b6fc2bd0153
F20110217_AAAXSZ pineda_r_Page_19.tif
a806188bf028a93e60228a733dd9d1dc
71e37e99ca4c971291173c1b4d9d1b64f5b4c2c8
F20110217_AAAXUD pineda_r_Page_94.tif
5fd13c7e85d870ad1e337803607d6353
882ff49868f0d662fcc54b36e61b8cb079464b3d
F20110217_AAAXTO pineda_r_Page_60.tif
16eb0a6cda621881a08875a0a4784859
1b7b37670e49a27a3e3ec58cde26d40873821e29
F20110217_AAAXUE pineda_r_Page_97.tif
d22070c868e66ca393990b57bd0655a1
cbd969a7662e1bbcc2e98f129ee697c342e5d238
F20110217_AAAXTP pineda_r_Page_61.tif
c9b6885d90d9fac29d7b65349fb2c837
91737c3ae5ee1650458e163e911e6d08a73537bf



PAGE 1

BREASTFEEDING PRACTICES IN THE NEONATAL INTENSIVE CARE UNIT BEFORE AND AFTER AN INTERVENTION PLAN By ROBERTA GITTENS PINEDA A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2006

PAGE 2

Copyright 2006 by Roberta Gittens Pineda

PAGE 3

This dissertation is dedicated to all the mothers who have premature and medically fragile infants in the neonatal intensive care unit (NICU). It is hoped that this and other works with infants and mothers in the NICU will give you the hope, courage, and information needed to “mother” in the co mplex environment of the NICU, during your infant’s first precious days. This dissertati on is also dedicated to my husband, Jose, for his endless source of love and inspiration. It is also dedicated to my children, Alan and Marissa, whose early birth ma de me realize the importance of education and support for mothers, as well as to my daughter Abigail, whose premature birth in the middle of this research gave me the extra steam to see it through. This dissert ation is especially dedicated to my mom, Barbara Gittens Vale ntine, whose expertise with mothers and babies was critical during my own son’s hospitalization.

PAGE 4

iv ACKNOWLEDGMENTS This research would not have been possi ble without the supp ort and guidance of Dr. Lorie Richards, who has been my advisor, mentor, and friend. I want to thank Lorie for having faith in me and inspiring me to do my best. I would lik e to thank the nurses and health care professionals at Shands Ho spital who participated in this research endeavor. In particular, I give special th anks to Annmarie Brennan, who enabled this research project to occur in the neonatal intensive care unit (NICU) at Shands and supported the project every step of the way. I also would like to thank Cammy Pane, the co-author of the Educational Module; Ste phanie Meeks for your hours of work on “A Mother’s Gift”, and other members of the Lactation Committee at Shands who helped with my research: Elayne McNamara, Sandra Sullivan, Brenda Owens, Sheila Walker and Jeannette Sexton. I want to give special thanks to Susan Frazier from Medela for your support at the inservices. I also want to thank all those who provided donations as incentives for participation: Sonny’s Barb eque, Atlanta Bread Co mpany, Scholotsky’s Deli, and TGIF. I want to thank Dr. David Bu rchfield, the medical director of the NICU at Shands, for assisting with this project. I thank Sarah Boslaugh for guiding me through the statistics and for all y our patience from the many que stions that came up along the way. I would also like to thank my comm ittee for sticking with me through the years, and the move to St. Louis and the addition of the new baby. I a ppreciate your endless patience, high expectations and sincere enthus iasm for my interests and work. I want to thank Drs. Richards, Foss, Krueger, Seung, and Rosenbek!

PAGE 5

v I would finally like to thank my parents who always showed unc onditional love and always motivated me to strive to do better. I extend special thanks to my husband, Jose, for always being there when I needed you mo st and giving me patience and love every step of the way. You enabled me to go back to school and were there when it came to crunch time. You have made this all possibl e and I am eternally grateful for your love and support.

PAGE 6

vi TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES...........................................................................................................viii LIST OF FIGURES...........................................................................................................ix ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 The Importance of Breast Milk and Breastfeeding.......................................................2 Health Benefits of Breastfeed ing for the Full Term Infant...................................3 Health Benefits of Breastfeed ing for Premature Infants.......................................4 Long Term Benefits of Breastfeeding...................................................................5 Developmental Benefits of Breastfeeding.............................................................5 Benefits of Breastfeeding for the Mother..............................................................6 Current Breastfeeding Recommendations....................................................................7 Why More Women Are Not Giving Their In fants the Benefits of Breast Milk...........8 General Breastfeeding Barriers.............................................................................9 Barriers to Breastfeeding Premature Infants.........................................................9 Health Care Professionals Can Hinde r the Breastfeeding Process in the Neonatal Intensive Care Unit...........................................................................14 Treatments to Foster Improved Breastfeeding Rates..................................................16 Need for an Educational P ackage for Health Care Professionals and Mothers of Infants in the Neonatal Intensive Care Unit............................................................19 Synactive Theory and Breastfeeding Interventions in the Neonatal Intensive Care Unit..........................................................................................................................2 0 Theory Governing the Behavior of Health Care Professionals..................................25 Transtheoretical Model of Behavior Change and Methods of Education..................31 Summary and Research Questions.............................................................................33 2 METHODOLOGY.....................................................................................................35 Participants.................................................................................................................35 Research Interventions................................................................................................36 Intervention 1: Breast Pump Loaner Closet.......................................................36

PAGE 7

vii Intervention 2: Health Prof essional Education Initiative...................................37 Intervention 3: Br eastfeeding Guideline............................................................38 Intervention 4: Educational Pam phlet for New Mothers of Neonatal Intensive Care Unit Infants..............................................................................38 Intervention Plan Modification...................................................................................39 Design......................................................................................................................... 39 Procedures...........................................................................................................40 Program Evaluation.............................................................................................41 Data Collection...........................................................................................................42 Data Analysis..............................................................................................................42 Hypotheses..........................................................................................................43 Adjusting the Alpha Level...................................................................................44 3 RESULTS...................................................................................................................46 Intervention Implementation......................................................................................46 The Sample.................................................................................................................48 Inter-Rater Agreement................................................................................................50 Demographics.............................................................................................................50 Investigation for Selection Differences......................................................................52 Results Per Research Question...................................................................................52 4 DISCUSSION.............................................................................................................59 The Effect of the Interventions on Br eastfeeding Practices in the Neonatal Intensive Care Unit.................................................................................................59 Limitations..................................................................................................................64 Recommendations for Further Research....................................................................69 Conclusions.................................................................................................................71 APPENDIX A OUTLINE OF THE EDUCATION MODULE..........................................................73 B OUTLINE OF ITEMS ADDED TO TH E INDIVIDUALIZED CARE PLAN.........75 C OUTLINE OF THE EDUCATI ONAL BOOKLET FOR MOTHERS......................76 LIST OF REFERENCES...................................................................................................78 BIOGRAPHICAL SKETCH.............................................................................................87

PAGE 8

viii LIST OF TABLES Table page 1-1 Stages of change in which particul ar processes of change are emphasized.............28 2-1 Hypothesis testing accordi ng to dependent variable................................................43 3-1 Demographics of the pre-interventio n and post-intervention groups with test statistics for selection differences.............................................................................51 3-2 Breast milk feeding initiation rates...........................................................................53 3-3 Comparison of rates of breastf eeding after 30 we eks gestation................................55 3-4 Rates of ever breastfed in the neonatal inte nsive care unit.......................................56 3-5 Rates of breast milk feedings at discharge................................................................57

PAGE 9

ix LIST OF FIGURES Figure page 3-1 Number of times breastfed per day after 30 weeks gestation..................................54 3-2 Proportion of the stay that breast milk was provided...............................................58

PAGE 10

x Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy BREASTFEEDING PRACTICES IN THE NEONATAL INTENSIVE CARE UNIT BEFORE AND AFTER AN INTERVENTION PLAN By Roberta Gittens Pineda August 2006 Chair: Lorie Richards Major Department: Rehabilitation Science The benefits of breastfeeding for both mother and infant ar e cited extensively in the literature. Premature infants hospitalized in the neonatal intensive care unit (NICU) have a great need for the benefits that breast milk offers, due to their fragile health states. However, mothers of very low birth weight infants hospitalized in the NICU have magnified barriers to th e breastfeeding process due to the complexity of medical conditions that warrant admission to the NICU and the separation of the infant from the mother to enable medical care. Studies ha ve cited lack of edu cation about lactation among health care professionals and discrepanc ies in education dissemination to mothers as a major barrier to the breastfeeding proce ss. A three-part intervention within the NICU was implemented that consisted of an educational initiative for health care professionals who instruct and support mother s, modifications to th e individualized care plan that included a new breastfeeding path way, and an educational booklet for mothers with infants hospitalized in the NICU. Cha nge in breast milk feeding initiation rates,

PAGE 11

xi breastfeeding rates, breast milk at discharge rates, and propor tion of the hosp ital stay that breast milk was provided was investigated be tween pre-intervention and post intervention groups. Results indicated general positive tre nds in all variables, but only one variable achieved statistical significance. The percen tage of infants who were ever breastfed while in the hospital increased from 25.9% before the interventi on to 44.4% after the intervention, and this reached statistical significance with a p value of .025. Full implementation of strategies l earned in the interventions wa s questionable. This study provides partial support of the three-part intervention in facilitating breast feeding in the NICU. Possible reasons for lack of change across all variables, as well as other possible interventions that could aff ect change, are explored.

PAGE 12

1 CHAPTER 1 INTRODUCTION Breastfeeding is an important part of the occupation of mothering. However, mothers of infants admitted into the neonatal intensive care unit (NICU) are not able to function in the traditional role of mother. They are usually separated from their infants, and the role of caregiver shif ts to health care professiona ls. In addition, many infants may be attached to life-saving or monitori ng equipment, which can be intimidating for new parents. Even more intimidating is that many of these infants are fragile or lack neurological maturity, which a ffects how the mother will in teract with and care for her infant. This environment presents significan t barriers to the pr ovision of breast milk, including the fragility of the infant, the separation of the in fant from the mother, and the behavior of the health care professionals who are focused on the medical interventions necessary for these infants. This is unfortunate because the established benefits of breast milk may be even greater in these medically fragile and matu rationally immature infants. The rate of breastfeeding in the United St ates, despite repeated advertisement of its benefits, is only 71.4% (Li, Darling, Maurice, Barker, & Grummer-Strawn, 2005). Unfortunately, due to the many barriers to br eastfeeding in the NICU environment, this percentage is significantly lower for infants discharged from the NICU, with breast milk feedings in premature infants reaching only approximately 50% (Espy & Senn, 2003). However, despite the medical complexities of the NICU and the shift of care to health care professionals, with adequate circumventi on of barriers, mothers can be supported in the occupation of moth ering through support of breastfeeding.

PAGE 13

2 Studies have identified that health care professional support is predictive of success with breastfeeding (Swanson & Power, 2005). However, health care professionals must be given the tools to foster breastfeeding in the complex NICU environment. Therefore, the aim of this study was to test the efficacy of an intervention to support breastfeeding practices in the NICU. The intervention centered on health care professional behavior change through an educational initiative for health care professionals, modifications to the individualized care plan (ICP) with a breastfeeding protocol, and educational materials for mothers with infants in the NI CU. It was hypothesized that the intervention plan would foster change in health care pr ofessionals, which would then enable positive changes in breastfeeding pr actices in the NICU. The Importance of Breast Milk and Breastfeeding Breast milk can be provided to the infant either directly through infant suckling at the breast (breastfeeding) or by having the mother express the breast milk with a pump and providing the milk via enteral feedings or bottle (breast milk feedings). The health benefits of breastfeeding for the infant are cited in the literatu re extensively (Wolf, 2003). Breast milk has a protective effect against many childhood health problems. Breast milk differs from formula in that it has unique in gredients that are difficult, if not impossible, to duplicate. Important components of breas t milk are IgA antibodies, which aid in preventing infection by creating a non-inflammatory response in body cells. This enables a more active immune system, which demonstr ates better defense against infection. Other factors in breast milk, such as lactof errin and oligosaccharides have also been isolated and are believed to prevent mucous attachment, the origin of most infections (Hanson, 1998; Hanson et al., 2002).

PAGE 14

3 Infant formulas continue to strive to be similar to breast milk and have become nutritionally advanced in the la st decade, however, research c ontinues to illustrate that breast milk is far superior to formula (A gostoni & Haschke, 2003; Baker, 2003; Wold & Adlerberth, 2000). Thus far, formula companie s have been unable to replicate the exact ingredients of breast milk. Perhaps predom inantly due to the IgA antibodies found in human milk, breastfed infants have superi or protection from many ailments that compromise health and pr event optimal functioning. Health Benefits of Breastfeeding for the Full Term Infant When comparing babies who are fed breas t milk to those who are formula fed, there is a significant reduction in resp iratory infections, di arrhea, necrotizing enterocolitis, meningitis, sepsis, urinary tract infections, atopic dermatitis, celiac disease, and inflammatory bowel disease in the breas tfed babies (Dai & Walker, 1998; Hanson, 1998; Hylander, Strobino, & Dhanireddy, 1998; Laubereau et al., 2004; Marild, Hansson, Jodal, Oden, & Svedberg, 2004; Wold & Adlerberth, 2000). Although preliminary studies have not been conclusive, it is also suggested that allergie s and asthma are also diminished among breastfed babies (Kem p & Kakakios, 2004; Oddy et al., 2004). Breastfed babies have a diminished risk of sudden infant death syndrome (Alm et al., 2002; McVea, Turner, & Peppler, 2000), as well as a significantly lower risk of mortality after the neonatal peri od (Chen & Rogan, 2004). Because it is associated with less infant illness, breast feeding may cut medical expenses for the infant. Ball and Wright (1999) addressed excess medical costs for 3 common childhood illnesses: gast rointestinal infection, resp iratory tract infection and otitis media among breast fed versus formula fed infants in the first year of life. There was evidence that children who were never breast fed incurred significantly more office

PAGE 15

4 visits, hospitalizations, prescr iptions and subsequently had higher health care costs (Ball & Wright, 1999). Thus, the health advantages associated with breas tfeeding create less financial burden as health care costs diminish (Ball & Wright, 1999) and, more importantly, they improve the quality of lif e and health status among mother-infant dyads. There have been a multitude of studies th at have also investigated health and developmental benefits of breast milk for premature and high risk neonates (Callen & Pinelli, 2005). The fragile health states of these infants make them more susceptible to infection, gastrointestinal probl ems, and life threaten ing illnesses than full term infants (Lanari et al., 2001; Lugo-Vicente, 2003). Ther efore, breast milk is perhaps more important in this fragile population, because it diminishes the risk of multiple medical problems, which can complicate the medical co urse and put them at a higher risk of developmental sequelae. Health Benefits of Breastfeeding for Premature Infants Breast milk fed infants from the NICU di ffer significantly from formula fed infants in incidence of infection and diagnosis of sepsis/meningitis (Hylander et al., 1998), necrotizing enterocolitis, and retinopathy of prematurity (Hyl ander et al., 1998; Hylander, Strobino, Pezzullo, & Dhanireddy, 2001; Scha nler, Hurst, & Lau, 1999). Breast fed premature babies have been noted to expe rience less stress than bottle fed infants as evidenced by fewer episodes of oxygen desatu ration and temperature instability (C. H. Chen, Wang, Chang, & Chi, 2000). Breastfeeding has been cited as an intervention that has lasting, long term benef it beyond discharge from the hos pital (Harrold & Schmidt, 2002), and studies have detected significant reductions in le ngth of stay among breastfed premature infants (Gomez, Acosta, Sevillano, Curbelo, & Alvarez, 1997).

PAGE 16

5 Long Term Benefits of Breastfeeding More recent studies are sugge sting that the effects of breast milk extend beyond the period of infancy and early childhood, and pr omote long term immunity and protection from chronic diseases. Lower risk of de veloping childhood cancers, obesity, type I diabetes, and cardiovascular disease have been cited as long term benefits of breastfeeding (Davis, 2001; Hanson, 1998; Schack-Nielsen & Michaelsen, 2006; Singhal, Cole, Fewtrell, & Lucas, 2004). Studies of long term effects of breast milk on premature infants have also found benefits with lowe r blood pressure readings in adolescence (Owen, Whincup, Odoki, Gilg, & Cook, 2002). Despite concerns that breastfeeding results in suboptimal growth in infancy, studi es have demonstrated an increased growth velocity in late childhood in breastfed groups (Schack-N ielsen & Michaelsen, 2006). Additionally, improved parental attachment in the teenage years has been linked to breastfeeding (Fergusson & Woodward, 1999). Developmental Benefits of Breastfeeding Research also points to the importance of breastfeeding on infant development. Breastfeeding results in improved oral motor development and orthodontics (Page, 2001), with early weaning increasi ng the risk of malocclusion, mouth breathing, dysfunctional oral motor development and subsequent s uboptimal speech development (Neiva, Cattoni, Ramos, & Issler, 2003; Viggiano, Fasano, M onaco, & Strohmenger, 2004). Breastfed infants have improved visual motor skills (Bir ch et al., 1993), have better responses to pain (Gray, Miller, Philipp, & Blass, 2002) with improved neurobeha vioral organization (Hart, Boylan, Carroll, Musick, & Lampe, 200 3) and have demonstrated improved scores on mental functioning (Gomez-Sanchiz, Canete, Rodero, Baeza, & Avila, 2003).

PAGE 17

6 Premature infants have a greater risk of poor neurological outcome, which suggests that breast milk may be critical to enable optimal developmental functioning. Research has demonstrated improved cognitive and motor functioning scores among premature infants who had breast milk feedings (Lanar i et al., 2001; Schanler et al., 1999). Studies demonstrate improved cognitive scores and inte lligence quotients that continued to be evident through middle childhood among breastf ed infants (Lucas, Morley, Cole, & Gore, 1994; Lucas, Morley, Cole, Lister, & L eeson-Payne, 1992; Morley, Cole, Powell, & Lucas, 1988; Smith, Durkin, Hinton, Bellinger, & Kuhn, 2003). Benefits of Breastfe eding for the Mother In addition to the benefits given to th e baby through breastfeeding, there are also benefits for the mother. Women who succeed with breastfeeding comment on the special bonding experience (Torgus, Gotsch, & La Lech e League International., 1997). Women who breastfeed have less postpartum bleed ing (Chua, Arulkumaran, Lim, Selamat, & Ratnam, 1994) and have a faster rate of pregnancy related we ight loss (Dewey, Heinig, & Nommsen, 1993). Women who breastfeed al so postpone ovulation (Rea, 2004), and breastfeeding has been demonstrated to serv e as a natural and effective birth control method in the postpartum period ("How breast-feeding postpones ovulation," 1985; "What is best birth control to use after ha ving a baby?," 1989). In addition, women who succeed with breastfeeding lower their risk of osteoporosis (Chantry, Auinger, & Byrd, 2004), obesity (Rooney & Schauberger, 2002), ov arian cancer, breas t cancer (MikielKostyra, 2000), diabetes and rheumatoid arthritis (Rea, 2004). Mothers of preterm infants have additiona lly reported an improved sense of well being, as they feel that they are actively contributing to the health of their babies (Schanler et al., 1999). Having an infant in the NICU is a difficult challenge. Mothers

PAGE 18

7 may feel shut off from their in fant as the nurses take on the role of primary caregiver. Being able to provide the best source of nutrition can be one task that embraces the mother in her role and fosters parental involvement, as it is something only she can do for her baby. Current Breastfeeding Recommendations The health benefits of breastfeeding for mother, baby and health care systems are evident and extensive. Therefore, the American Academy of Pediatrics (AAP), as well as the American Dietetic Association, have res ponded to the benefits of breastfeeding for mother and baby by recommending exclusive br eastfeeding for the first 6 months with breastfeeding and supplemental solids until the in fant is 1 year old ("Breastfeeding and the use of human milk. American A cademy of Pediatrics. Work Group on Breastfeeding," 1997). The World Health Orga nization recommends breastfeeding for at least 2 years ("The optimal duration of exclusive breastfeeding: results of a WHO systematic review," 2001). However, breastf eeding statistics conti nue to demonstrate a gap between these recommendations and how the general population of mothers in the United States chooses to feed th eir infants (Li et al., 2005). Some women never breastfeed, some br eastfeed exclusively, some supplement breastfeeding with bottle feed s of human milk, some supplement breastfeeding with bottle feeds of formula, some bottle feed fo rmula only, some bottle feed breast milk only, and some women start out breastfeeding and completely wean once formula is introduced. Statistics from the year 2003 indicated that 71.4. % of women in the general population initiated breastfeeding while in th e hospital, and 35.1% of mothers were still breastfeeding when their babies turned 6 m onths of age. At one year of age, 16.1% continued to provide some breast milk for thei r infants (Li et al., 2005) Variable rates of

PAGE 19

8 breastfeeding have been reporte d for infants in the NICU. Th e rates for infants receiving some breast milk at some point range from 50% to 83% (Byrne & Hull, 1996; Espy & Senn, 2003; Meier, Engstrom, Mingolelli, Mira cle, & Kiesling, 2004; Smithers, McPhee, Gibson, & Makrides, 2003; Yip, Lee, & Sheehy, 1996). However, studies have found that the rates of breast milk feeds at discharge ar e 64%, with the rate of breastfeeding being 38% (Yip et al., 1996). One study found that at 4 months of age, only 24% of infants born at less than 33 weeks gestation continue to re ceive some breast milk feedings (Smithers et al., 2003). Subsequently, breastfeeding rates at hospital discharge for infants born prematurely are significantly lo wer than those of full term, healthy infants (Yip et al., 1996). To understand the suboptimal breastfeedi ng rates for premature and high risk neonates, it is beneficial to investigate the barriers to breastfeeding. By understanding the barriers to breastfeeding, appropriate interventions can be developed and implemented to facilitate im proved breastfeeding practices. Why More Women Are Not Giving Their Infa nts the Benefits of Breast Milk Maternal demographics are st rong predictors of breastfeed ing. Women with higher socioeconomic status, more education, prev ious children but smaller family size, Caucasian race, and women who are marri ed are more likely to succeed with breastfeeding (Bueno et al ., 2003; Kronborg & Vaeth, 2004; Mitra, Khoury, Hinton, & Carothers, 2004). However, perinatal medical condition is also an important predictor of successful breastfeeding (Espy & Senn, 2003; Powers, Bloom, Peabody, & Clark, 2003). Scott (2006) discovered that the infant bei ng admitted to the intensive care unit was the strongest predictor of not bei ng exclusively breastfed at di scharge (Scott, Binns, Graham, & Oddy, 2006). Other studies have concluded that having a cesa rean section, as well as

PAGE 20

9 having a low birth weight infant, makes a woman less likely to breastfeed (Hwang, Chung, Kang, & Suh, 2006). Demographic factor s as well as medical condition and type of delivery have been shown to be strong in fluences on the decision to breastfeed and the success of breastfeeding. General Breastfeeding Barriers The barriers to breastfeeding full term, healthy infants include lack of family and spouse support and perceptions of lack of support; (Arora McJunkin, Wehrer, & Kuhn, 2000; Matthews, Webber, McKim, Banoub-Baddour & Laryea, 1998; Scott et al., 2006), social withdrawal and isol ation (Stewart-Knox, Gardiner & Wright, 2003), perceived inconvenience (Zimmerman & Guttman, 2001) perceived inadequacy to provide adequate nutrition (Arora et al., 2000; Matt hews et al., 1998), early supplementation or first feeding of formula (Wheeler, Chapman, Johnson, & Langdon, 2000), lack of appropriate education (Arora et al., 2000), functional probl ems with the process of breastfeeding; (Bick, MacA rthur, & Lancashire, 1998), intent to return to work (Arora et al., 2000; Matthews et al., 1998; Piper & Parks, 1996; Ryan, Wysong, Martinez, & Simon, 1990), and maternal illness (Black & Hylander, 2000; Riskin & Bader, 2003). Barriers to Breastfeeding Premature Infants Breastfeeding challenges are stronger and even more numerous for the high risk neonate, despite these babies having an even greater need for human milk. Mothers of infants who are born prematurely have unique challenges to succe ssful breastfeeding. One barrier to breastfeeding the premature in fant is that when an infant is born prematurely and warrants admission into the NICU, the mother is separated from her baby (Black & Hylander, 2000). The time after bi rth is very different for these mothers compared to those with full term infants. Ther e is usually not a period of being able to put

PAGE 21

10 the baby to breast immediately after birth, and breastfeeding may not be possible for several weeks or months, depending on the in fant’s level of prematurity and medical instability. When visitation is possible, mothers may vis it their baby in the intensive care unit. Here, they may have difficulty with the transition to motherhood as the doctors and nurses make decisions related to the care of the baby, including whether or not the mother may hold her new baby (Holditch-Davis & Miles, 2000; Lupton & Fenwick, 2001). The machines and equipment present and being utilized by the baby in the NICU can be overwhelming for many parents (Wheeler et al., 2000), and this environment is very different from the quiet, home -like environment one would typically envision during the first days of the baby’s life. An additional barrie r is that the ability to achieve let down, in which breast milk begins to flow during in fant feeding and pumping, is hindered by the inability to relax in this stressful envi ronment (Beresford, 1984; Nyqvist, Ewald, & Sjoden, 1996; Wheeler, Johnson, Collie, Sutherland, & Chapman, 1999). Many low birth weight infants are unable to breast feed for several weeks or months following birth (Hill, Andersen, & Ledbetter, 1995). Their gastrointestinal systems are immature and feedings can be da ngerous or life threaten ing. During the first days, a baby may be fed intravenously or th rough an orogastric or nasogastric tube, in which feeds may be slowly introduced and adva nced. When the gastrointestinal system is ready for bolus feeds direc tly into the stomach, the ba by’s immature central nervous system may not enable consistent presenta tion of sucking and swallowing responses to enable safe oral feeding (Nyqvist, Sjoden, & Ewald, 1999; Ziemer & George, 1990). Although breastfeeding may not be possible initial ly, breast milk can be expressed by the

PAGE 22

11 mother with a breast pump, and the infant can be advanced on gastric feeds with breast milk. Just as the first feeding by breast is a good predictor of sustained breastfeeding in full term infants, timely pumping for those mothers who are unable to put the baby to breast is an important predicto r of sustained breastfeeding in the premature baby (Jaeger, Lawson, & Filteau, 1997). Women of premature babies may express their breast milk and supply it to hospital staff so that the baby ma y be tube fed with human milk instead of infant formula (Meier & Brown, 1996). Add itionally, this process establishes and maintains a milk supply so that the mother will not have diminished or absent milk supply, when the baby is stable enough to engage in the breastfeeding pr ocess. Barriers to breastfeeding related to this early process include incr eased amounts of stress (Docherty, Miles, & Holditch-Davis, 2002; Miles, Funk, & Kasper, 199 2) and time constraints placed on these new mothers, difficulty in acq uiring hospital grade br east pumps for milk expression, lack of special bonding and emoti onal feedback received from using a pump, delayed initiation of milk expression, se paration from the infant, reliance on medical technology to feed the baby, and psychological adju stment to the idea of not being able to breastfeed for weeks or even months (Byrne & Hull, 1996). With the mother experiencing stress associated with coping w ith her sick baby (Miles et al., 1992) and a shift of care from the mother to the baby afte r the birth, there may be delayed initiation of pumping and lack of accessibility of hospita l grade pumps to promote milk supply in an efficient manner. New studies are highlighting the importance of investig ating barriers at different time periods during an infant’s hospitalizati on (Callen & Pinelli, 2005). If a mother

PAGE 23

12 successfully overcomes the chal lenge of maintaining her milk supply, there are additional challenges as an infant approaches discharg e from the hospital. Poor central nervous system maturity may initially prevent complete success with breastfeeding, and dysphagia is common in this population (H ill, Hanson, & Mefford, 1994). The literature cites problems with the mechanics of breas tfeeding a premature baby as a barrier to breastfeeding (Kavanaugh, M ead, Meier, & Mangurten, 1995). Once discharge is approaching, there frequently is little time to enable a mom and baby to achieve successful breastfeeding (Meier & Brown, 1996). Bottle feeding is often preferred as it allows nurses to orally feed the baby when th e mother is not present and the exact amount ingested can be accurately measured (McG rath & Braescu, 2004). Additionally, infants can be fed more passively with bottle f eeding compared to the active process of breastfeeding. Although this can have negati ve side effects of desaturations and bradycardic events as well as increased risk of gastroesoph ageal reflux, it is frequently preferred because of the efficiency of or al feeding. However, breastfeeding can be achieved in this population despite the preferences of health care staff and the challenges that must be overcome. Infants in the NICU are fed according to a schedule, typically every 3 to 4 hours, and may be fed via bottle, tube or breast to optimize the nutritional status. The inability of a preterm baby to breastfeed on demand in an environment with scheduled feedings via different modes is a significant barrier to breastfeeding (Black & Hylander, 2000). It undermines the typical procedures associated with breastfeeding a full term infant which involves feeding a baby when he/she s hows hunger signs and not supplementing until breastfeeding is well established. This allows for the infant to ingest a smaller feeding

PAGE 24

13 and thus become hungrier and to have a more rigorous, larger feeding for the next one. However, scheduled feedings of specific am ounts can affect the transition to active breastfeeding in the NICU. If the infant typi cally receives a prescr ibed amount of breast milk by bottle or nasogastric tube and the mo ther attempts to breastfeed, not knowing the exact amount of breast milk ingested by br eastfeeding may result in the health care professional doubting if there was adequate intake. Thus supplementation frequently occurs, which inhibits the next breastfeed ing session, decreases the demand for breast milk produced by the mother and diminishes milk supply, and thus becomes a cyclic problem. Diminished milk supply is cited extensiv ely in the literatu re as one of the significant barriers to breastfeeding in th e NICU (Callen & Pine lli, 2005). Among the earliest of premature infants, the average dur ation of providing breast milk is 4-5 weeks (Byrne & Hull, 1996). Lack of ability to enga ge in active breastfeeding due to the health status of the infant, lack of presentation of sucking and swallowing capabilities of the infant and the need for the mother to demons trate consistent milk expression via a breast pump to establish and maintain a milk supply all contribute to diminished milk supply in mothers of infants hospitalized in the NICU. Infants who are born prematurely have diffe rent nutritional need s than full term infants. Thus, there are premature infant form ulas that are utilized in the neonatal period and many are used until one year of life. When gastric feeds are being established, physicians are concerned with establishing a good weight gain trend. If an infant is not gaining weight as desired, the physician may increase caloric density or add lipids to infant formula or expressed breast milk to fo ster weight gain. Fre quently nutrients and

PAGE 25

14 calories are added to human milk by the way of human milk fortifiers (Chan, 2001), which promote establishment of a good weight ga in curve. However, this is a barrier to breastfeeding as the mother perceives that the composition of her breast milk is not adequate to promote the health of her child. She may perceive that formula or fortified breast milk by bottle is essential to enable the appropriate milk composition (Kavanaugh et al., 1995). However, studies suggest that mother’s milk of premature babies differs from that of full term infants with the mo st notable differences evident between 4-6 weeks after delivery (Gross, David, Bauman, & Tomarelli, 1980). Additionally, the use of hind milk, the milk at the e nd of a breastfeeding se ssion that is very high in fat content, has been shown to facilitate weight gain in premature babies (Slusher et al., 2003). Research is identifying that there are fact ors in the hospital setting that influence breastfeeding decisions. The site of care is a strong predictor of c hoice and success with breastfeeding (Powers et al., 2003) In addition, literature is highlighting the important role of health care professionals on the deci sion to initiate and continue breastfeeding (Nyqvist, Sjoden, & Ewald, 1994; Swanson & Power, 2005). Health Care Professionals Can Hinder the Breastfeeding Process in the Neonatal Intensive Care Unit There are many inconsistencies in what parents are educated about and many disparities in what parents are instructed to do by health care professionals, and this can be confusing and frustrating for new mothers (Byrne & Hull, 1996; Nyqvist et al., 1994). One study identified that 48% of mothers reported receiv ing conflicting advice about breastfeeding in the NICU (Jaeger et al., 1997). Mothers rely on health care professiona ls in the NICU to provide accurate, complete, and consistent information about br eastfeeding their high risk infant. Many of

PAGE 26

15 the mothers of preterm infants have not had an opportunity to fully prepare for motherhood before the birth of their ba by. Some may have planned on taking a breastfeeding or parentin g class, but the early arrival dampened these plans. In addition, the NICU is a medically complex environm ent, and parents need guidance on how to function in their role as mother with the environmental constraints. The literature suggests that there is a lack of health care professionals who are tr ained in lactation and breastfeeding with premature babies, and th at many health care professionals have incorrect knowledge and negative beliefs about lactation (Berens, 2001; Pantazi, Jaeger, & Lawson, 1998; Register, Eren, Lowdermil k, Hammond, & Tully, 2000; Spicer, 2001). Yet, it is the health care professionals in the NICU, despite lack of education, who are teaching and instructing these new mothers on breast milk feedings and breastfeeding. Health care professionals can influence breastfeeding behaviors, and their own values and beliefs concerning breastfeeding can have supporting or damaging results on the breastfeeding process (Ekstrom, Matth iesen, Widstrom, & Nissen, 2005). Studies have identified that education and traini ng can affect attitude s and knowledge about breastfeeding (Bernaix, 2000; Siddell, Marinelli, Froman, & Burke, 2003; Swanson & Power, 2005). However, to date, there are no st udies that have invest igated the indirect impact of health care professionals’ behavi or change with acqui sition of knowledge and attitude change on breastfeed ing outcomes in mothers and infants in the NICU. The American Academy of Pediatrics issu ed a statement in February 2005 that stated that breastfeeding or human milk feedings are recommended for all healthy, premature and high-risk infants for wh om breastfeeding is not specifically contraindicated. It further st ates that health care professi onals should provide complete,

PAGE 27

16 current and accurate information to parents on the benefits and techniques involved with breastfeeding (Gartner et al ., 2005). However, to date there has been no specific, standard set of tools devel oped and utilized to achieve education of health care professionals to enable consistent info rmation dissemination to parents. Treatments to Foster Improved Breastfeeding Rates The United States Surgeon General, Davi d Satcher, identified breastfeeding as a national health priority and released the “Health and Hu man Services, Blueprint for Action on Breastfeeding” in October 2000. In response to this, The World Health Organization in conjunction w ith UNICEF is promoting breastfeeding through the baby friendly hospital initiative. To be designated as “baby friendly,” the hospital must follow the ten steps to successful breastfeeding: Every facility providing maternity services and care for newborn infants should: Have a written breastfeeding policy that is routinely communicat ed to all health care staff. Train all health care staff in skills necessary to implement this policy. Inform all pregnant women about the bene fits and management of breastfeeding. Help mothers initiate breastfeedi ng within half an hour of birth. Show mothers how to breastfee d, and how to maintain lact ation even if they should be separated from their infants. Give newborn infants no food or drink other than breast milk, unless medically indicated. Practice rooming-in (i.e., allowing mother s and infants to remain together) 24 hours a day. Encourage breastfeeding on demand. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.

PAGE 28

17 Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF statement published by the World Health Organization These ten steps specifically involve how h ealth care professionals and the hospital system will deal with mother-infant dyads on regular maternity floors within a hospital. Once these ten steps are put into practice, the hospital may apply for designation as a baby friendly hospital. Hospitals that have been through the pro cess of baby friendly designation have demonstrated improvement with breastfeeding ra tes (Philipp, Malone, Cimo, & Merewood, 2003). For example, Bo ston Medical Center was designated as baby friendly in 1999, with increased breastf eeding rates of 58% in 1995 to 86.5% in 1999. Breastfeeding rates were maintained at this high rate from 1999 to 2001. Although the baby friendly designation is sp ecifically for the maternity floors of a hospital system and not designed for the unique needs of the high risk population, there have been positive effects on breastfeeding practices in the NICU following designation (Vannuchi, Monteiro, Rea, A ndrade, & Matsuo, 2004). However, a program specifically designed for the high risk population with its si gnificant barriers to breastfeeding, could have the potential for greater enhancement in breastfeeding rates in the NICU Premature infants are a unique populati on and warrant individualized breastfeeding strategies and interventions (Kavanaugh et al., 1995; Meier, 2001) Many hospitals have implemented pract ices that will educate and promote breastfeeding practices for infants within the NICU. However, only a few have evaluated their programs for effectiveness. The Rush Mother’s Milk Club has proven to be effective in increasing breastf eeding rates (Meier et al., 2004) by enabling free access to

PAGE 29

18 hospital grade breast pumps, by offering lact ation support 24 hours a day, by use of cue based feeding when an infant consumes at l east 50% of feeds orally, and by providing of breastfeeding peer support. Ot her studies have found positive increases in breastfeeding initiation with the introduction of counseling as well as contact with lactation consultants among mothers with low birth weight infant s (Pinelli, Atkinson, & Saigal, 2001; Sisk, Lovelady, Dillard, & Gruber, 2006). A workbook pr ogram introduced at 2 different time periods during the hospital stay was also s hown to have positive effects on breastfeeding with premature infants in one hospital setting (Jang, 2005). Many papers have documented specific prot ocols to instruct mothers and promote breastfeeding (Isaacson, 2006; Premji, Paes, Jacobson, & Chessell, 2002; Spicer, 2001), but no research has been conducted to determine the effectiveness of such recommendations. Although studies have shown increased knowledge acquisition by health care professionals in the NICU followi ng an education plan (Siddell et al., 2003), there are no studies that have investigated the effect of education of health care professionals coupled with protocols and st andard written information for parents on changes in breastfeeding pr actices in the NICU. Of all interventions for breastfeeding with the high risk neonate, the Rush Mother’s Milk Club is probably the most well known. The health care providers in the NICU at Rush University have an increased level of knowledge regarding breastfeeding in the NICU. With this knowledge, they are able to implement advanced strategies, such as putting breast milk in a centr ifuge to modify the fat cont ent to promote weight gain (Meier, 1998). Many studies have been conduc ted to evaluate the effectiveness of the Rush Mother’s Milk Club with positive resu lts (Meier et al., 2004). However, the high

PAGE 30

19 level of education about breastfeeding among health car e professionals at Rush University likely underlies the capability to im plement the more advanced interventions. For many hospitals, basic education on lactati on with high risk infants is lacking. In addition, many interventions that have proven to be effective, includ ing the use of free access to pumps and accessibility to lactation counseling, have associated costs, which many hospitals do not have budgets to support. Need for an Educational Package for He alth Care Professionals and Mothers of Infants in the Neonatal Intensive Care Unit Breastfeeding and human milk feedings ar e possible and benefi cial in the NICU, however, there is sign ificant support and education that must occur to enable success among mothers in the NICU (do Nascimento & Issler, 2004). Education and treatments should be based on research with premature a nd high risk infants, as they have unique needs in the breastfeeding pr ocess (Meier, 2001). The use of developmental care practices can drive the unders tanding of appropriate breastf eeding interventions based on infant readiness cues (Karl, 2004). Although there have been many articles and books written on the subject of breastfeeding with the high ri sk neonate, there was no up to date, comprehensive, evidence based education packet with comp lementary information for both parents and health care professionals available on the market. By understanding each of the challenges to breastfeeding the medically frag ile infant and the specific developmental and nutritional needs of the high risk infant, an education initiative can be developed and then evaluated for efficacy.

PAGE 31

20 Synactive Theory and Breastfeeding Interv entions in the Neonatal Intensive Care Unit While investigating, developing and im plementing appropriate interventions targeted to improve breastfeedi ng rates, it is important to cons ider the vulnerability of the special population in the NICU and the imp act of environmental stressors on this population. One theory that can be used to guide appropriate interv entions in the NICU is the synactive theory, which identifies the process of neurobehavioral maturation of the infant. Breastfeeding interventions should be individualized, based on infant readiness cues and tailored to the responses of th e infant (Blackburn, 1998). Review of the synactive theory and its app lication to breastfeeding should be part of any education initiative for health care prof essionals who serve the vulnera ble infants in the NICU. The synactive theory was developed by Heidelese Als in the early 1980’s (Als, 1982). The process of developmental care, rela ted to the synactive theory, is intended to facilitate a well organized, stable infant who may optim ally grow and develop. Developmental care has been instituted in many neonatal intensive care units around the country as a developmental care initiative. It provides a framework for interacting with these fragile infants without jeopardizing health. The synactive theory of development describes the process of neurobehavioral matu ration related to an infant’s internal and external environment. As the infant attempts to interact with the external environment, a dynamic process occurs internally among 5 di fferent subsystems. The dynamic process among the 5 subsystems can explain the be haviors and responses exhibited by the premature infant and can guide appropriate interventions. The 5 distinct, yet interdependent subsystems ar e physiological or autonomic, motor, state organization, attention and inte raction, and the state regulation subsystems.

PAGE 32

21 These subsystems are believed to impact th e functional organization of the infant’s system in an ordered fashion. The subsystems are not hierarchical, but they are believed to be ordered and interdepe ndent (Als, 1982; Als, 1994). The physiological subsystem is considered the core of the system. It is the foundation for which all of the other systems ga in stability. This physiological subsystem allows the infant to have control over autonomic functions such as voiding, breathing, maintaining steady vital signs and processing nutrition. The motor system provides control over movement, muscle tone, and postu re. The state subsystem gives the infant control over his/her level of consciousness. It enables the infant to move through identifiable states and move smoothl y from one state to another. The attentional/interactive subsystem enables control over functional responses to stimulation in the environment and governs the ability to interact. The stat e regulation subsystem gives the infant the ability to balance environmental stresso rs and recover by modulating all the other systems (Als, et al, 1982). While the autonomic subsystem serves as the foundation of the system, the state regulation s ubsystem serves as the gate keeper and is achieved with increasing maturity. A cone shaped diagram is used to represent the complex development of the infant as it relates to the five subsystems (Als, 1982). The cone has its tip at the bottom with the funnel going upward. The five subsystems can be viewed at the top of the open cone. At the smallest center is the physiological subs ystem with the remaining (motor, state, attentional/interaction) forming layers out side the center, much like an onion. The youngest fetus is represented at the bottom of the cone and has with it only components (not yet a fully developed system) from the autonomic subsystem. This indicates that

PAGE 33

22 infants who are born early are unable to inte grate the higher order systems. Stressors within the system interfere w ith the physiologic capabilities of the infant. Subsequently, early premature infants are incapable of a ny interaction and need all their energy to maintain homeostasis of the system to sustai n life. There is also instability in the physiologic system, which is why prematur e infants frequently have medical or physiological problems when born early and have to contend with the stressful environment. With the earliest fetus at the bottom of the cone, increasing gestational age is associated with increasing maturity spreading out to the other layers of the system. With increasing gestational age and thus maturity, the infant may extend its control out to the next level, the motor subsystem. The infa nt may demonstrate improved muscle tone and postural control. This concept parallels th e literature, which demonstrates improvement in muscle tone and reflex development with increasing gestational age (Allen & Capute, 1990). Further maturity may extend the infant ’s control out to the state subsystem enabling the infant to demonstrate some aw ake periods and to smoothly transition from one state to another. As maturity continue s, the infant may be able to achieve some attention and interaction with caregivers and the environment. Lastly, as the infant approaches term and achieves more maturity, he/she will be able to tolerate stressors, cope with them, reorganize and continue interaction without being knocked down to functioning at the lower subsystems. The term synaction refers to the relati onship between all the subsystems and how instability in one system has the potential to affect all the other subsystems and thus the integrity of the child’s health and well-being (Als, 1982). On the right side of the cone

PAGE 34

23 are gestational ages that reflect the increasi ng maturity of the system (dependent on the subsystems) with increasing gestational age. On the left side of the c one are influences of the environment on the maturation of the syst em, with a break in the intrauterine and extrauterine environment before term to i ndicate the premature birt h, thus representing the role of environmental stresses before full maturity occurs. With earlier birth and more stressors from the environment, there will be a resultant decrease in neurobehavioral maturity. When an infant is stressed from the environment, he/she may initially demonstrate stress reactions based on the predominant leve l of neurobehavioral maturation. If he/she is primarily functioning in th e physiological state, he/she may demonstrate bradycardic events, oxygen desaturations, hicc ups, stooling, or spitting up. If he/she is primarily in the motor state, he/she may demonstrate gr imacing, arching, saluting, finger splaying, or sitting on air. If he/she is in the state s ubsystem he may shut down or move to a light sleep state. If he/she is in the attenti onal/interactive subsystem, he/she may avoid interaction by turning away. The infant has th e capability to re-ach ieve organization with time outs or specific strategies designed to he lp him cope. Interventions designed to help infants cope with stressors include pr oviding boundaries, swaddling, positioning in flexion, bringing hands to mouth, minimizi ng environmental stimulation, non nutritive sucking, and enabling grasping. Infants addi tionally will demonstrate approach signals such as smiling, mouthing, ooh face, cooing, quiet and alert state, and soft and relaxed facial expressions when they are ready fo r interaction (Hussey-Gardner, 1996). Once reorganized and demonstrating approach signals the stressor may be reintroduced slowly.

PAGE 35

24 The synactive theory defines the subsys tem along with stress and coping signs consistent with each of the subsystems to enable caregivers to identify and respond to behaviors appropriately. Wh en stress signs are recogni zed, the caregiver can then withdraw the stressor th at contributed or help facilitate the infant to cope. Once a time out is given and the infant reorganizes, the treatment or interacti on can continue. This “give and take” enables the infant to func tion optimally within the environment and allows him/her to continue to benefit from interaction and stimulation, including breastfeeding, as he/she tolerate s. The synactive theory proposes an approach for each individual child that is adapted to fit the needs of that infant. It promotes infant development to occur as normally as possi ble, despite medical complications and immaturity brought on by an early birth. Infants born at earlier gestational ages and with decreased neurobehavioral maturation are not capable of handling envir onmental stressors typically experienced by newborns. When interventions for these neurobehaviorally immature infants are done without respect for readiness cues the infant is at risk for regressing to one of the more primitive states, putting them at risk of developmental and medical sequelae. Breastfeeding is an environmental stressor. Without observing infant readiness cues and introducing breastfeeding at the appropriate ti me individualized for each infant, optimal responses to the environment as well as op timal neurological ma turation are delayed. Therefore, breastfeeding cannot be introduced at a prescribed time or introduced in the same way that it would be for a full te rm infant, but it must be based on the neurobehavioral maturation of the infant and advanced according to stress and readiness cues. These concepts need to be in any educational program fo r both health care

PAGE 36

25 professionals and for mothers of infants in the NICU to help them implement the best breast milk feeding program for these infants. While the synactive theory defines the appropriate time and way to introduce interventions, it also assists with underst anding that many extremely low birth weight infants and low birth weight infants are t oo neurologically immature and fragile to engage in any breastfeeding. Subsequently, mothers of infants in the NICU need equipment that will enable them to achieve and maintain a milk supply, in the absence of infant suckling at the breast, until the infant is appropriate for nut ritional brea stfeeding. Hospital grade breast pumps that will enable long term milk expression are necessary for mothers with infants in the NICU to mainta in adequate milk supplies while they are waiting for their babies to become medica lly and developmentally stable enough to engage in feeding at the breast. Understanding the synactive theory and implementing develo pmentally supportive care can instruct and guide interventions and NICU practices as they relate to breastfeeding the premature infant. One cas e study in the literat ure highlighted the significant benefits of a developmentally s upportive plan on the breastfeeding process in a premature infant (Nyqvist et al., 1996) The synactive theo ry should guide the development of any educational module and in service for health care professionals who serve infants in the NICU. Theory Governing the Behavior of Health Care Professionals Studies have identified that there is a lack of education about la ctation and lack of consistent support and instruction about breas tfeeding among health care professionals in the NICU (Ekstrom, Widstrom, & Nissen, 2005; Pantazi et al., 1998) Having educated health care professionals will not necessarily impact breastfeeding practices. It is how

PAGE 37

26 those health care professiona ls respond and utilize that education to execute new interventions that will foster change a nd subsequent improvement in human milk feedings. The behavior of health care prof essionals in the NICU needs to change to support the breastfeed ing process. Studies have shown that behavior change is much more successful when interventions are matc hed to the stage of readiness to change (Prochaska, Prochaska, & Levesque, 2001). The transtheoretical model (TTM) provides a description of how the indi vidual’s state of readiness to change translates into behavioral change. The premise of the TTM is that there are several stages associated with behavior change. Individuals go through these stages on their way to making a change. They may start anywhere along the con tinuum of the 5 stages and they may move forward or backward or skip stages, but there is some progression through the stages on their way to behavior change. The TTM has been used to describe many health behavior changes, such as use of sunscreen, use of condoms self examination breast checks, smoking cessation and initiating an exercise plan. Appr opriate interventions can be tailored to the stage of readiness to change. The five stages of the TTM are prec ontemplation, contemplation, preparation, action and maintenance. Each stage identifi es if the individual has an intention of changing behavior and identifies how significan t the intention to ch ange behavior is (Prochaska & DiClemente, 1983). Someone in the precontemplation stage does not intend to take action within 6 months. A pe rson in the contemplation stage intends to take action within the next 6 months. Someone in the preparation phase intends to take action in the next 30 days. The action stag e refers to persons who have made obvious

PAGE 38

27 changes less than 6 months ago. The maintena nce stage refers to individuals who have made significant changes more than 6 months ago. Interventions that are impl emented to enable behavior change should be conducted in such a way that the intervention matches the stage an individual is in, or should be tailored to how ready the person is for change Ten fundamental proc esses that can affect change have been identified along with interven tions that can be matched to the stage of readiness to change (Table 1-1) (Prochaska et al., 2001). Certain interventions will only be effective if they are appropriate for the st age of readiness for behavioral change of the individual. For example if someone is in the precontemplation stage, interventions should be focused on educational ini tiatives and strategies to pr omote reflection about how the change may impact the person’s situation and how it will benefit others, while interventions for the person in the contemplative stage s hould be about supporting and motivating the person to actually initiate th e intended behavioral change. These latter interventions provided to the precomtemplate r would not be effective because the person has not yet formed the conviction that change is needed or desire d and could actually create significant resistance and prevent be havioral change from succeeding (Prochaska et al., 2001). By enabling stage matched inte rventions, education and strategies can be implemented to foster movement across stag es to enable successful change. The TTM has been used to address beha vior change within organizations by targeting employees. By providing stage matc hed interventions, all employees can be given opportunities to participate in the change process. Although stage matched interventions have been show n to facilitate movement toward action, not all employees may achieve action. Change at the organizati onal level should include interventions that

PAGE 39

28 are stage matched to each stag e of change to give all employees the opportunity for participation in the ch ange initiative (Prochas ka et al., 2001). Table 1-1. Stages of change in which part icular processes of change are emphasized Stages Precontemplation Contemplation Preparation Action Maintenance Process Conscious Raising, Dramatic Relief, Environmental Reevaluation Self Reevaluation Self Liberation ContingencyManagement, Helping Relationship, Counter Conditioning, Stimulus Control To foster behavior change regarding support and information dissemination about breastfeeding within the NICU, the TTM can be utilized to structure an intervention program. By matching breastfeed ing interventions to stages of readiness to change, all health care professionals can ha ve the opportunity to participat e in the change process. By introducing interventions that can target health care professionals in each stage of readiness to change, a meaningful intervention plan can be implemented to foster change at the organizational level. A breastfeeding intervention for the NICU with 4 parts could theoretically target individuals in all of the stages of readiness to change. For those health care professionals in the pre-contemplation stage, there is no intention of making a behavior change. Health care profes sionals in the contemplation stage intend to make a change within the next 6 months. Both of these stages describe

PAGE 40

29 individuals who are not yet rea dy for action, and interventions fo r those in either of these stages would be the same. Interventions for those in these stages should be two-fold. One intervention, education, would be aimed di rectly at the health care professional. With education, conscious raising can be foster ed. With it, it is hope d that health care professionals will have the resources needed to become aware of the need for breastfeeding support in premature infants and will start to see solutions to the problem. However, because those in the pre-contempl ation stage have no intention of making a behavior change, there would be no motivation to participate in an educational initiative. Likewise, those in the contem plation stage also may need incentives to push them to participate. Therefore, incentives on annual review, food, prizes and continuing education units could serve as motivati on for participation among those who lack motivation to attend without some perceived pe rsonal benefit. With the participation in the educational initiat ive, they would be exposed to content of the education that highlights the great benefits of breast milk and the need for support and education among mothers. With this increased awareness of the problem and possible solutions, behavior change could be fostered. The other intervention shoul d be aimed at achieving some level of support and education for the mothers. Materials that provide consistent a nd thorough information could be issued to all new parents in the NICU to ensure that all mothers receive information about initiating and sustaining br east milk feedings in the NICU. Although this intervention would serve to enable educ ation of mothers, it also may serve as a conscious raising effort for the health care professional, who may be asked for guidance and support by the mother on information contai ned in the educational materials. The

PAGE 41

30 health care professional may then better understand the problem and the need for behavior change to facilitate succ ess with the breastfeeding process. Individuals in the preparati on phase intend to make a change in the next 30 days. These individuals are ready for action orie nted interventions. Therefore, clinical pathways or protocols could fo ster change in how they deal with breastfeeding mothers. Protocols or pathways, which become a part of required paperwor k, could theoretically facilitate professionals to make a commit ment to change by giving protocols that necessitate action. Those in the action and maintenance stag es have already made changes. The mother’s positive experiences could serve as motivation from the environment, and there could be other motivators for continued compliance from within the organizational structure, such as acknowledgement on the a nnual review and identification as one who has expertise in breastfeeding with high risk infants. Those in the action and preparation phase also may take an active part in motiv ating others and facilitating more positive change related to breastfeeding in terventions in the NICU. Thus based on the TTM, an educational initiative that includes educational materials to parents, opportunities for e ducation with incenti ves for health care professionals, and protocols or pathways of car e could be effective in facilitating change in breastfeeding practices in the NICU, and each is theoretically matched to all of the stages of readiness to change. Although the primary focus of the interven tion for this research is health care professional behavior change, in terventions structured to enab le change in breastfeeding practices also must target be havior change in the mother s. Theoretically, developed

PAGE 42

31 interventions for the health ca re professionals can also be matched to mothers in each stage of readiness to change. An educa tional booklet for new mothers could enable conscious raising for mothers in the prec ontemplation and contemplation stages. A breast pump loaner closet as well as milk expression guidelines and a breast milk log (that could be included in the educational booklet) could be appropria te interventions for those in the preparation and act ion stages. Appropriate interv entions for those mothers in the action and maintenance stages would include concepts such as the first feeding being at the breast and enabling breastfeeding while in the hospital to support continued breast milk feedings in the presence of the d ecision to initiate breast milk feedings. Interventions targeted at health care pr ofessional change can be structured to move mothers to decide to br eastfeed and help them maintain that behavior once they start. Theoretically, interv entions including a breast pump loaner closet, an educational booklet for new mothers, a breastfeeding pathwa y, and an educational initiative for health care professionals can support behavior change in two different gr oups, the health care professionals as well as the mothers. The health care professiona l group functions as a primary support for the mothers to initiate and sustain breastfeeding. Transtheoretical Model of Behavior Change and Methods of Education Equally important with providing stage matched interventions for health care professionals is consideration of what mode of learning to uti lize for the conscious raising strategy. Self learning modules can be considered easy to implement and enables staff to participate in the learning initiative s at their own pace, enables them to take modules home if work responsibilities preven t participation during working hours, and is rather inexpensive when compared to othe r modes. The literature reflects good success with self-directed learning modules, with good performance on post tests and learning

PAGE 43

32 retention (Coleman, Dracup, & Moser, 1991). When compared with lecture-discussion formats, self learning methods were compar able in achieving the educational objectives being targeted within the nursi ng field (Nikolajski, 1992). Computer based training is another method of education gaining increased acceptance and use in the last several years w ith the increasing capab ilities of technology. Harrington and Walker (2004) discovered that, although both groups significantly improved their post test scores a group of individuals who engaged in computer based training did significantly better th an individuals in an instructor led course on fire safety (Harrington & Walker, 2004). Research and e xperience are beginning to define computer based learning as a viable option for e ducational purposes. However, the access to technology and to the people who format and de sign the computer systems is a significant barrier to widespread use of such learning practices today. Not all individuals have the same learning style. While some may prefer self paced methods, others may be more motivated a nd embraced in a face to face lecture and discussion with peers. Goldrick, Gruende mann, and Larson (1993) found that 64% of nurses in a pediatric intensive care unit had an abstract lear ning style and preferred self learning modules. However, there remained 36% who preferred more traditional methods (Goldrick, Gruendemann, & Larson, 1993). Self directed learning, through an educatio nal module, is an effective form of educating health care professionals. Howeve r, not all individuals possess the learning style necessary for successful completion of self learning modules and prefer lecturediscussion formats. By providing both forms of educational opportunities, more health

PAGE 44

33 care professionals could be encouraged to pa rticipate in an educational initiative. Computer based training could also be effec tive if access to technology can be achieved. Summary and Research Questions The provision of breast milk has important be nefits to infants, especially those in the NICU who are less healthy and less mature at birth than full term infants. Yet significant, but not insurmount able, barriers to breast milk feedings and breastfeeding exist in the NICU. Health care professi onals are a powerful influence (Swanson & Power, 2005). It is proposed that change fr om the health care professionals can enable mothers and infants to overcome many of the barriers to breastfeeding, and subsequently, positive changes in breastfeeding practices can occur in the NICU. Therefore, in this study, the effect of a 4-pronged educati on and support interv ention to promote breastfeeding in the NICU, based on the synac tive theory and transtheoretical model of behavior change, will be explored. The four parts of the proposed intervention are a breast pump loaner closet, a breastfeeding pa thway on the individualized care plan, an educational booklet for mothers, and an educational initiativ e for health care professionals who work with infants and moth ers in the NICU. The research questions are Is there a significant difference in breast milk feeding initiation in very low birth weight (VLBW) infants admitted to the NICU before and after implementation of the intervention plan? Is there a significant difference in the rate of breastfeeding in the hospital among women with VLBW infants hospitalized in the NICU before and after the implementation of the intervention plan? Is there a significant difference in breas t milk feedings at discharge in VLBW infants admitted to the NICU before and after the implementation of the intervention plan?

PAGE 45

34 Is there a significant difference in the pr oportion of the hospital stay that breast milk is provided in VLBW infants admitted to the NICU before and after the implementation of the intervention plan?

PAGE 46

35 CHAPTER 2 METHODOLOGY The purpose of this study was to test the efficacy of a 4-part intervention on improving breastfeeding practices in the ne onatal intensive care unit (NICU). The overall goal was to attempt to develop an effective intervention to assist mother-infant dyads in the complex NICU environment. Participants Very low birth weight (VLBW) infants (< 1500 grams) were included in the study if they were 1) admitted to the Level II or II I nursery at Shands Hospital during the study periods and 2) had a length of stay greater than or equal to 7 days, 3) were admitted to the NICU within the first 3 days of life, 4) were hospitalized less than 4 months, 5) achieved full gastric feeds during their stay, and 6) had a hospital stay that di d not cross over from the pre-intervention group time period into th e education initiative time period. Very low birth weight infants were exclude d from the study if they 1) ha d a length of stay less than 7 days, 2) were transferred to Shands Hosp ital after the third day of life, 3) were hospitalized greater than 4 m onths, 4) did not achieve full gastric feeds during the hospital stay, 5) had a hospital stay that crossed over from the pre-intervention group time period to the education plan time fram e, or 6) had conditions that would make breastfeeding contraindicated as established by the physician. Power indicates the probability of rej ecting the null hypothesis, if a condition exists. With a power of 80%, which is freque ntly used in the literature, there is a 20% chance of failing to reject the null hy pothesis when it should be rejected.

PAGE 47

36 Prior to conducting the study, a power an alysis was conducted to determine the appropriate sample size. The mean and st andard deviations of breast milk feeding initiation were unavailable from other studies to compute an effect size and subsequently a sample size. Therefore Cohen’s Criteria wa s utilized to make sample size estimations (Cohen, 1988). According to Cohen, a .2 standard deviation change is a small effect, a .5 is a medium effect, and a .8 is a large eff ect. For the purposes of this study, a medium size effect was selected. By using Cohen’ s criteria and determining the sample size necessary with a power of 80%, alpha of .05, and looking for a medium size effect of .5, Cohen’s Criteria indicated a needed sample size of 82 per group. Th erefore the research plan consisted of intent to conduct quota sa mpling with participants enrolled from the beginning study dates for both the pre-interv ention and post-interv ention groups until 82 were achieved in each group. The planned pre-intervention group consisted of all very VLBW infants admitted to Shands Hospital NICU from April 15, 2004 forward until 82 participants were enrolled in the study. The intervention started on March 1, 2005 with conclusion of the educational initiative on April 15, 2005. The planned pos t-intervention group cons isted of all very low birth weight infants admitted to Shands Hospital NICU after implementation of the intervention plan, from April 15, 2005 until 82 were admitted into the study. Data from participants were collected from the same time of year to account for seasonal confounds. Research Interventions Intervention 1: Breast Pump Loaner Closet Intervention 1 consisted of the developmen t of a breast pump loaner closet for use by mothers with infants hospitalized in the NICU Hospital grade breast pumps could be checked out by mothers who had infants in the NI CU to enable them to express their milk

PAGE 48

37 the recommended 8 to 12 times per 24 hour period. This would enable a supply of expressed breast milk for initiation of breast m ilk feedings in the infant and would enable the mothers to establish and maintain a m ilk supply until the infant was able to go directly to breast. Intervention 2: Health Prof essional Education Initiative Although there are many different recomm endations and published articles about breast milk feedings and breas tfeeding in the NICU, there was no up to date, available educational plan that could be utilized for staff education. Therefore, an education initiative encompassing key areas of educati on on breastfeeding special care babies was developed to educate as many of existing staff in the NICU as possible. The initiative consisted of education to staff on breastfeeding to enable health care providers to have the education and tools to support mothers in the breastfeeding process. The education was offered through completion of a self st udy educational module on breastfeeding in the NICU or through attendan ce at an inservice on breas tfeeding in the NICU. Education topics contained in the self st udy module and discusse d in the inservice included the benefits of br eastfeeding, the barriers to breastfeeding, the physiology of lactation, use of breast pumps, pre feeding interventions based on the synactive theory and breastfeeding interventions that acknowledge the readine ss of the infant. All the information contained in the module was base d on an extensive literature review to represent evidence based practice and was desi gned to foster success with breastfeeding in the high risk neonate population while acknowledging their un ique needs. The educational module was reviewed by two individuals considered to be experts in the area of breastfeeding for establishing validity of information provided. Minor adjustments were made to the education plan based on the expert feedback. Refer to the outline of the

PAGE 49

38 educational module, appendix A, or contact the author for further details. The successful completion of the health prof essional education was defined as completion of the module or attendance at one of the inservices and a passing score of at le ast 80% on a post test that was identical for either form of the education. Intervention 3: Breastfeeding Guideline Each medical chart contains an individua lized care plan (ICP) for documentation by nurses. This ICP was modified to al so have a pathway of care for providing breastfeeding support to new mothers (a ppendix B). This ICP necessitated documentation of education and support by nurse s at critical times in the breastfeeding process. The guideline called attention to and necessitated documentation on specific key points that were identified in the literature to be predic tive of success: achieving and maintaining a milk supply, timely pumping, skin to skin contact, and first feeding being at the breast. It also included areas to check off, date, and sign at the following critical times in the breastfeeding process: within 6 hou rs of delivery, issue a nd instruct in proper pumping and breast milk storage techniques; within 24 hours, ensure proper pumping and storage technique; on day 3 to 5, ensure that the milk has come in and trouble shoot any problems; weekly, foster continued pumping a nd skin to skin care; first oral feeding, ensure that it is a breastfeeding session; 10 days, monitor milk supply and make referrals as appropriate. Intervention 4: Educational Pamphlet fo r New Mothers of Neonatal Intensive Care Unit Infants An educational pamphlet, “A Mother’s Gift”, for mothers who had an infant admitted to the NICU was developed. The outline of the educ ational booklet (see appendix C) addressed the following key poi nts: benefits of breastfeeding, how to

PAGE 50

39 express and store human milk, pre-breastfeed ing strategies, and cu e based breastfeeding interventions. The back of this pamphlet also included a place for mothers to document breast milk production to facilitate communi cation with nurses about their milk supply. This educational pamphlet was developed to en sure that all mothers received a standard set of educational points dur ing their infant’s hospitaliza tion, and that the information contained in it was consistent with the e ducation that the health care professionals received. Intervention Plan Modification The original intervention plan consisted of 4 parts: a breast pump loaner closet, an education module and inservic ing, changes to the individu alized care plan and an educational booklet. Prior to the initiation date of March 1, 2005, it was learned that external funding for the breast pump loaner clos et could not be obtai ned. Therefore, this prong of the intervention had to be deleted from the intervention program. The study was then conducted with the followi ng being the intervention/educ ation plan: the education initiative, the mother’s edu cational booklet, and the breastf eeding pathway addition to the individualized care plan. Design This study was a quasi experimental, ma tched through cohort controls, design (Shadish, Cook, & Campbell, 2001), investigat ing indirect changes in breastfeeding practices following a 3-part breastfeeding in tervention in the NICU. Through this design the pre-intervention group consisted of a group of VLBW infants hospitalized in the NICU before the implementation of the interv ention plan. This group was then compared to the post-intervention group, which consisted of a group of VLBW infants who were hospitalized in the NICU after the im plementation of the intervention plan.

PAGE 51

40 The independent variable was the implemen tation of the intervention as described above. Dependent variables included 1) breast milk feeding initiati on rate (was breast milk ever consumed/breast milk feeds initiated? (yes/no)), 2) br eastfeeding rate (number of times the infant was put to the mother’s breast after 30 weeks ge station divided by the number of days hospitalized after 30 weeks gest ation), 3) breast milk feeding at discharge rate (did the infant continue to have breast m ilk feedings at discharge? (yes/no)), and 4) the proportion of the hospital stay that breast milk was provi ded (total number of days into the hospitalization that breast milk wa s provided divided by the length of stay). Procedures The educational intervention was imple mented March 1, 2005 to April 15, 2005 with opportunities for health care professionals to complete the self study educational module or participate in an in service. “A Mother’s Gift ”, the educational booklet for mothers was issued to all new mothers with infants admitted to the NICU on or after March 1, 2005. Last, the modified individualized care plan was used in the medical chart on all new admissions after March 1, 2005. To promote completion of the educational in itiative, incentives were given to those who participated in the br eastfeeding education initiativ e by way of food, prizes, continuing education credits and docume ntation on the annual review of their performance. Following the six week educational initiative, completion of the self study educational module on breastfeeding in the NICU became part of the orientation process to enable the same education for those sta ff who were not employed at Shands Hospital during the six week educa tional initiative. The educational opportunities during the initiative date s included a self study module and/or inservices. A breastfeeding module was available for health professionals

PAGE 52

41 to check out and complete at home or wor k. Food and prize incentives as well as 2 continuing education credits were awarded for those who completed the educational module. For those who preferred lectur e-discussion formats for learning, 1 hour inservices were offered at least one time per week throughout the education initiative period. Those who attended the inservices were educated on the same information contained in the education m odule, however in a condensed amount of time. Therefore one continuing education credit, in addition to food and prizes, were awarded to those who attended an inservice duri ng the initiative dates. The booklet entitled “A Mother’s Gift” was issued to mothers with infants admitted into the NICU after March 1, 2005. There was a central location at the reception desk where nurses who had new admissions could acce ss and issue them to mothers. Nurses were instructed to issue these booklets during staff meetings through the monthly bulletin and in the breastfeed ing inservice that occurred over the six week period. The modified individualized care plan w ith the breastfeeding pathway replaced the old ICPs and were placed in the chart as ro utine paperwork as of March 1, 2005. Nursing staff were instructed to use it by way of a m onthly written bulletin. It was also discussed in staff meetings and further reminders were given to document on it during the breastfeeding inservices that occurred over the six week period. Program Evaluation The desired impact of this program wa s increased breastfeeding in the NICU. However, the intervention strategies used in the current study can only be effective if they are implemented. The full implemen tation of the 3-pronged intervention was evaluated in four ways. All the educational tools (the educational module, the inservice, the educational booklet for he mothers and the m odified ICP) stressed that the first oral

PAGE 53

42 feeding should be at the breast. Therefore the primary outcome measure to determine implementation of the intervention was whether the first oral feeding was at the breast. Second, attempts were made to track the percen tage of mothers of infants newly admitted to the NICU to whom educational booklets we re issued to determine if, in fact, most mothers were being issued th is educational booklet. Last, weekly communications with the nursing administrator indicated the degree of compliance with educational key points based on her monthly experiences as a bedside nurse, in which she worked directly with mothers and their babies in the NICU. Data Collection Participants were recruited by way of a data base containing all admissions and discharges from the NICU during the two different time periods. For each infant admitted to the hospital during the applicable time periods, an extensive retrospective chart review was conducted. Each identified chart was fi rst investigated to ensure that the infant did not have any exclus ion criteria. Given that incl usion criteria were met, the dependent variables as well as demographics were collected and recorded on a laptop computer. Inter-rater reliability was determined in 3 different participants to ensure that accurate variables were collected from the charts. This occurred by having another researcher collect data on the same particip ants following data coll ection by the principal investigator and comparing if the variable s collected by the two different researchers were in agreement. Data Analysis Retrospectively, charts were reviewed and data was analyzed for significant differences in the proportion of mothers who in itiated breast milk feedings, the number of

PAGE 54

43 times per day the mother breastfed after 30 weeks gestation, the proportion of mothers who provided breast milk at discharge, and th e proportion of the hospital stay that breast milk feedings occurred. Table 2-1 su mmarizes the dependent variables and null hypotheses. Table 2-1. Hypothesis testing acco rding to dependent variable Group Breast milk feedings initiated (yes, no) The Number of Time s the Mother Breastfed Per Day After 30 EGA Breast milk provided at discharge (yes, no) Proportion of the hospital stay that breast milk was provided -------------PreIntervention Group --------------A1 ---------------B1 --------------C1 --------------------------------D1 -------------Post – Intervention Group --------------A2 ---------------B2 --------------C2 --------------------------------D2 Hypotheses The following hypotheses and data an alysis plan guided this study. The rate of breast milk feeding in itiation will be higher in the post intervention group (A2>A1). Data Analysis Plan : A Pearson’s Chi Square was us ed to test two proportions for significant differences between the two groups. The number of times per day that an infant is breastfed after 30 weeks gestation will be higher in the post-intervention group (B2>B1). Data Analysis Plan: A one-way analysis of va riance (ANOVA) was not possible secondary to a violation of the assumption of normality. Therefore, the nonparametric Mann Whitney was used to test for differences between the 2 groups.

PAGE 55

44 The rate of breast milk feedings at discharge will be higher in the post intervention group (C2>C1). Data Analysis Plan : A Pearson’s Chi Square was us ed to test two proportions for significant differences between the two groups. The proportion of the hospital stay that breast milk was provided will be higher in the post intervention group (D2>D1). Data Analysis Plan : A one-way analysis of va riance (ANOVA) was not possible secondary to a violation of the assumption of normality. Therefore, the nonparametric Mann Whitney was used to test for differences between the 2 groups. In this study, the pre-intervention group and post-intervention group were compared for significant differences in four different variables. For the purposes of this study, an alpha level of .05 was chosen, which is standard throughout the literature. Adjusting the Alpha Level There are no statistical procedures that can simultaneously test multiple outcomes, some of which are continuous and some of which are dichotomous. Therefore, the significance levels of the i ndividual tests were adjust ed by the ranked Bonferroni adjustment. There has been criticism of th e standard Bonferroni adjustment being too conservative and that, in theory, if many test s were run, the level of significance would be so low that no differences c ould be detected. The ranked Bonferroni adjustment was preferred over a standard B onferroni adjustment to enable maximum power in initial comparisons, by adjusting the alpha level w ith each additional comparison to prevent inflation of the type I error rate. This would help to prevent the researcher from rejecting the null hypothesis inappropr iately while minimizing inappropriate stringent p value

PAGE 56

45 constraints (Benjamini & Hochberg, 1995). Fo r this study, the questions were ranked in order of importance. The first question, whet her or not there was a difference in breast milk feeding initiation, was tested at an al pha of .05. The second question, whether or not there was a difference in number of tim es breastfed after 30 weeks gestation, was tested at an alpha of .025 (.05/2). The th ird question was tested at an alpha of .017 (.05/3). The fourth question was tested at an alpha of .013. Each statistical analysis was conducted as a one sided test as it was assumed that trends would be toward increased rates of br eastfeeding with the interventions that were implemented.

PAGE 57

46 CHAPTER 3 RESULTS Intervention Implementation One hour inservices were conducted 1 to 3 times per week for a total of 10 inservices during the intervention pe riod of March 1, 2005 through April 15, 2005. General attendance at each inse rvice was low with approximately 2 to 5 participants at each one. Self-study modules were also availa ble for check out during this time. Overall response to complete the self-study modules was also low in the month of March. Therefore, in April, the researcher started directly asking health care professionals to complete the modules and offered food prizes for those who did. It appeared that directly requesting participati on was beneficial in promoti ng participation by the health care professionals. There were 11 health care professionals who completed the self study education modules from March 1 through Ma rch 31, 2006, and there were 45 health care professionals who completed the educatio nal module from April 1 through April 15, 2006. The total number of health care professionals who partic ipated in the educational initiative was 88, which was 63% of health care professionals working in the neonatal intensive care unit (NICU). The total number of nurses who participat ed in at least one of the methods of education was 75, which was 77% of all nurses who care for infants in the NICU. There were 3 rehabilitation ther apists (100%), 1 nurse practitioner (9%), 2 neonatologists (20%), 2 social workers (100%), 1 respiratory therapist (10%), and 5 other

PAGE 58

47 health professionals (83%). All those who participated in the education achieved a passing score of 80% on a post test. Nursing managers reported variable levels of compliance with the new strategies presented in the educational in itiative, contained in the educational booklet for mothers, and on the modified individualized care plan (ICP). Starting on March 1, 2005 the nurses initiated use of a new, revised individualiz ed care plan (ICP) for documentation. The revised ICP was supposed to replace the old one. However, in mid April, it was realized that some old stores of the previous ICP, that did not include th e breastfeeding pathway, had been pulled from the shelf and were being utilized. Acco rding to the nursing manager, this problem was resolved with full use of the new ICP by May 1, 2005. Although all nurses were expected to fo llow the established guidelines on the breastfeeding pathway, during da ta collection it was observed that the new ICP was not utilized fully. One example of the lack of full implementation of the new pathway concerned whether the first oral feeding was at the breast. On the breastfeeding pathway, all mothers should have been encouraged to have the first feeding at the breast with documentation accordingly or documentation stating why care deviated from the pathway. However, the first feeding being at the breast occurred in only 25% of mothers in the post intervention group, and with full implementation it should have approached 100%. Although it is possible that mothers were encouraged, but declined to participate in the first feeding at breast, it is more like ly that there was lack of full compliance with the educational key points and the modi fied individualized care plan. Starting on March 1, 2005 “A Mother’s Gift ”, the educational booklet for mothers, was available to be issued to new mothers wi th infants in the NICU. Initial “Mother’s

PAGE 59

48 Gift” educational booklets were tracked to be able to determine if the number of booklets that were issued matched the number of admissions. Not all mothers were given the pamphlet over the first few weeks of the inte rvention. There were reports of running out of the booklets and not being able to find them. Multiple copies of these were distributed during and after the educational initiative, bu t they became impossible to track as they were frequently misplaced, redirected to the maternity floor rather than remaining in a central location in the NICU, and others outside of the research initiative made copies of the booklet for distribution. Nursing managers reported variable levels of compliance with the new strategies presented in the educational initiative, contained in the educational booklet for mothers and on the modified ICP. One nursing administ rator, who would func tion in the role of bedside nurse approximately once a month a nd would work directly with mothers and their babies during this time, reported certa in personnel to be imp lementing strategies while others, even those who par ticipated in the educational in itiative, to be consistently ignoring the pathway of care contained in th e medical chart. The nursing administrator’s occasional role of bedside nurse revealed th at there were mothers who never received the educational materials and that ICPs in the medical chart had inadequate documentation. The Sample The pre-intervention sample data was obtained before the education plan implementation using quota sampling from th e beginning study date of April 15, 2004. The post-intervention group was obtained afte r the intervention pe riod implementation from April 15, 2005 onward. Eighty one part icipants were obta ined for the preintervention group from April 15, 2004 through discharges on December 7, 2004. Data collection in the preintervention group was stopped at 81, because the subsequent 2

PAGE 60

49 admissions crossed into the treat ment period. Data from only fift y four participants in the post-intervention group was collected fr om April 15, 2005 through discharges on November 29, 2005. There were no discharges from the NICU of participants who met inclusion criteria from November 29, 2005 to December 7, 2005. This sample included all admissions of VLBW infants admitted during the preintervention study dates except for 17 infant s who did not meet inclusion criteria. Among the 17 infants who were excluded, 13 of them were extremely low birth weight and expired shortly after birt h, thus never achieved full gast ric feeds. Two of them did not achieve full gastric feeds before being tran sferred to another hospi tal, and 2 of them had a length of stay that ex tended into the treatment peri od. The pre-intervention group consisted of 83% of all admissions of VLBW infants admitted to the NICU at Shands during the study dates. The sample include d all admissions of VLBW infants admitted during the post-intervention study dates exce pt for 11 infants. Among those 11 infants who were excluded were 9 infants who neve r achieved full gastric feeds and expired shortly after birth and 2 who had genetic disorders that made eventual oral feeding contraindicated. The post-int ervention group also consisted of 83% of all admissions of VLBW infants admitted to the NICU at Shands during the study dates. The data collection period was not exte nded in order to capture the remaining 17 participants for two reasons: the first is that a long period of tim e had passed since the intervention plan, and new interv entions were scheduled to be implemented in the NICU. These would have introduced significant additional conf ounds into the study. Secondly, a new power analysis based on actual effect sizes of this partial sample indicated a need for data from an additional 124 participants in the post-intervention group and 95 in the pre-

PAGE 61

50 intervention group to achieve 80% power b ecause of the already high breast milk initiation rate (74.1%). Continuing data co llection to enroll 82 in each group based on the original research plan would have incr eased power from 38.6% to 45.6%, an increase that was considered to not be feasible gi ven the potential confounde rs listed above, or likely to change the statistical outcomes. Inter-Rater Agreement To ensure accurate documentation of the re search variables, inter-rater agreement was tested on the chart review procedures. Another researcher c onducted data collection on 3 charts that the principal investigator had already coll ected data from. There was 100% agreement in 2 out of 3 of the charts. However, one chart revealed agreement of 92%, for a total inter-rater ag reement of 97% for this study. The principal investigator reviewed the chart that did not have complete agreement to find 100% agreement with her initial findings. Demographics Table 3-1 includes sample demographics and p values for statistical tests to rule out selection differences. All demographics we re collected as continuous or dichotomous variables, with the exception of race. Race in the medical chart was classified as White, Black, Asian, Hispanic or Other. Theref ore, race is documented with the same classifications. The pre-intervention gr oup was 4% Hispanic, 42% Black, and 54% White. The post-intervention group was 2% Asian, 3% Hispanic, 49% Black, 42% White and 4% with undocumented race in the medical char t. Due to the majority of participants being Black or White, with minimal representa tion of other racial backgrounds, and due to Black being a known predictiv e factor in the literature, race was dichotomized into Black and not Black for statistical purposes to rule out selection differences.

PAGE 62

51 Table 3-1. Demographics of the pre-interv ention and post-interven tion groups with test statistics for selection differences Low SES Race (Black) Maternal Age Marital Status (not married) Transferred Instead of DC Home Length of Stay Birth Weight EGA No. of Sibs PreIntervention Group .775 .42 25.46 .56 .432 50 1074 28.57 1.01 PostIntervention Group .70 .49 25.62 .57 .327 54 1114 28.7 .86 p Value to Investigate Selection Differences .339 .256 .899 .860 .225 .534 .368 .762 .297 There was a large percentage of participan ts of low socioeconomic status (77.5% in pre-intervention group a nd 70% in the post-intervention gr oup), Black race (42% in the pre-intervention group a nd 48% in the post-intervention group), and unmarried mothers (56% in the pre-interventi on group and 57% in the post-in tervention group). Average maternal age in the pre-in tervention group was 25.46 and in the post-intervention group was 25.62 years. The average birth weight in the pre-intervention group was 1074 grams, and the average birth weight in the post-i ntervention group was 1114 grams. The average gestational age (abbreviated EGA) at bi rth was 28.57 weeks gestation in the preintervention group and 28.7 week s in the post-intervention group. The average number of siblings (abbreviated No. of Sibs) in th e pre-intervention group was 1.01 and in the postintervention group was .86. Eighty four percen t of the pre-interv ention group consisted of single births, and 83.3% of the post-intervention group consisted of single births. In the pre-intervention group there were 43.2% of participants who were transferred to another hospital instead of discharge home, and in the post-intervention group there were 32.7% who were transferred to another hospita l. Average length of stay in the preintervention group was 50 days and in th e post-intervention group was 54 days.

PAGE 63

52 Investigation for Selection Differences Due to the matching through cohort controls research design, it was important to first determine if there were selection diffe rences in the two groups being compared. Socioeconomic status was categorized in to Women, Infants and Children (WIC) or Medicaid eligibility or not WIC/Medicaid eligible. Difference in this variable between the two groups was investigated by use of a z test for 2 proportions. Hypothesis testing of two proportions with a z test was used to test for group differences in maternal race, which was dichotomized as Black or not Black. Group dissimilarity based on maternal age was investigated through an independent sa mples t test, while differences in marital status (married, not married) and sex of the infa nt were investigated by use of a z test for two proportions. Gestational age at birth, bi rth weight and number of siblings was investigated by use of an independent sample s t test. Discharge status was investigated with a z test of 2 proportions a nd length of stay with an i ndependent samples t test. By testing each of the demographic variables at an alpha of .05, none of the demographic variables were significan tly different between the two groups (see table 3-1). Subsequently, having no selection differences supports the ability to use the matching through cohort controls design. Results Per Research Question The primary aim of this study was to im plement a breastfeeding intervention that would improve breastfeeding practices in th e NICU. The results of this study are provided per research question. Is there a significant difference in breast milk feeding initiation in very low birth weight (VLBW) infants admitted to the NICU before and after implementation of the intervention plan?

PAGE 64

53 Table 3-2 summarizes breast milk feeding initiation results. The breast milk feeding initiation rate in the pre-interventi on group was 74.1%. The breast milk feeding initiation rate in the post-i ntervention group was 85.2%. This represents an increase of 11.1%. However, through a Pearson’s Chi Squa re Test of 2 proportions, the p value is .124, indicating no significant difference between groups when tested at an alpha of .05. The odds ratio of breast milk feeding initiati on is 2.013 with a confid ence interval of .818 to 4.952. Table 3-2. Breast milk feeding initiation rates Was Brest Milk Ever Provided? Total Test Statistic No Yes Count 21 60 81 Pre-Intervention % within subject 25.9% 74.1% 100.0% Count 8 46 54 Group PostIntervention % within subject 14.8% 85.2% 100.0% Count 29 106 135 Total % within subject 21.5% 78.5% 100.0% Pearson’s Chi-Square Significance .124 Odds Ratio 2.013 Odds Ratio Confidence Interval .818 to 4.952 Is there a significant difference in the rate of breastfeeding in the hospital among women with VLBW infants hospitalized in the NICU before and after the implementation of the intervention plan? For the continuous variable of number of times breastfed per day after 30 weeks estimated gestational age (EGA), see figure 3-1. The graph is clearly skewed toward 0. Due to the violation of normality, a Mann Whitn ey nonparametric test was used to test significance of this variable. Interpretation of this graph a nd variable is difficult as the

PAGE 65

54 rate of breastfeeding in the NICU is si gnificantly low at .059 in the pre-intervention group, which is once every 17 days, and .139 in the post-intervention group, which is once every 7 days (see Table 3-3). This va riable proved to be significantly different between the two groups with a p value of .011. Figure 3-1. Number of times breastf ed per day after 30 weeks gestation

PAGE 66

55 Table 3-3. Comparison of rates of breastfeeding after 30 weeks gestation subject Number of Times Breastfed Per Day After 30 EGA Test Statistic Pre-Intervention Group Mean .0593937 N 81 Std. Deviation .18818812 Post-Intervention Group Mean .1389242 N 54 Std. Deviation .24433376 Total Mean .0912059 N 135 Std. Deviation .21513898 Mann Whitney Significance .011 To enable easier interpretation of this va riable, it was dichotomized into whether a mother ever participated in breastfeeding while in the hospita l. In the pre-intervention group, there were 25.9% of mothers who ever breastfed their infa nt in the hospital. In the post-intervention group, there we re 44.4% of mothers who ever breastfed their infants in the hospital (see Table 3-4). This represen ted an increase of 18.5%, which achieved a p value of .025 through a chi-square test of 2 pr oportions. Therefore, there were significant differences in proportion of wo men who ever breastfed in th e two groups, using an alpha of .025. The odds ratio of ever breastfed in the hospital was 2.286 with a confidence interval of 1.1 to 4.750.

PAGE 67

56 Table 3-4. Rates of ever breastfed in the neonatal intensive care unit Was the Infant Ever Breastfed While in the Hospital? Total Test Statistic Frequency No Yes Count 60 21 81 PreIntervention % within subject 74.1% 25.9% 100.0% Count 30 24 54 Group PostIntervention % within subject 55.6% 44.4% 100.0% Count 90 45 135 Total % within subject 66.7% 33.3% 100.0% Pearson’s Chi Square Significance .025 Odds Ratio 2.286 Odds Ratio Confidence Interval 1.1 to 4.750 Is there a significant difference in breas t milk feedings at discharge in VLBW infants admitted to the NICU before and after the implementation of the intervention plan? There were 35.8% of infants who were pr ovided with breast milk at the time of discharge in the pre-intervention group. There were 40.7% of infants in the postintervention group who were provided with breas t milk at discharge. This 4.9% increase resulted in a p value of .562 through a chi-sq uare test of 2 pro portions, indicating no statistically significant difference among groups. The odds ratio was 1.233 with a confidence interval of .607 to 2.502.

PAGE 68

57 Table 3-5. Rates of breast milk feedings at discharge Was Breast Milk Provided at Discharge Total Test Statistic No Yes Count 52 29 81 PreIntervention % within subject 64.2% 35.8% 100.0% Count 32 22 54 Group PostIntervention % within subject 59.3% 40.7% 100.0% Count 84 51 135 Total % within subject 62.2% 37.8% 100.0% Pearson Chi-Square Significance .344 Odds Ratio 1.233 Odds Ratio Confidence Interval .607 to 2.502 Is there a significant difference in the pr oportion of the hospital stay that breast milk is provided in VLBW infants admitted to the NICU before and after the implementation of the intervention plan? Looking at figure 3-2, both groups have peaks at 0 and 1. However, there is a larger peak at 0 in the pr e-intervention group. The variab le, proportion of the hospital stay that breast milk was provided, did not achieve the assumption of normality as the graphs are u-shaped. Therefore, an ANOVA co uld not be run on this variable without violating assumptions. The nonparametric Ma nn-Whitney test was used to test for significant differences. This test indicated that the p value was .108, therefore there were not significant differences between the two gr oups in proportion of th e hospital stay that breast milk was provided.

PAGE 69

58 Figure 3-2. Proportion of the stay that breast milk was provided To look at effect size in a variable th at does not have a normal distribution, the proportion of the hospital stay was dichotomi zed into breast milk provided for most of the hospitalization or not. This variable represented whether breast milk feeds were supplied to the infant more than 50% of the length of stay not. Th ere were 51% of the pre-intervention group who provide d breast milk for most of the hospital stay, and there were 57% of the post-intervention group who provided breast milk for most of the hospital stay. This gives an odds ratio 1.219 with a confidence interval of .608 to 2.444 for breast milk feeds being provided for most of the hospital stay.

PAGE 70

59 CHAPTER 4 DISCUSSION The Effect of the Interventi ons on Breastfeeding Practice s in the Neonatal Intensive Care Unit This research investigated if a three-pa rt intervention plan designed to promote increased breastfeeding in premature infant s would have an effect on breastfeeding practices in the neonatal intensive care un it (NICU). The three-part intervention consisted of opportunities for education of health care professionals over a 6 week educational initiative, an educational booklet for new mothers in the NICU, and modifications to the individualized care plan (ICP) with a pathway of care for breastfeeding. This interven tion did have an effect on br eastfeeding practices in the NICU, but it did not result in changes across all breastfeeding variab les as hypothesized. Evidence of improved breastfeeding practi ces was that rates of breastfeeding (mothers putting their infants directly at the breast) in the NICU improved following intervention. The number of times infants were breastfed per day after 30 weeks gestation was significantly greater in the post-interv ention group than in the pre-intervention group. Mothers in the pre-intervention group breastf ed their infants after 30 weeks gestation .059 times per day, and in the post interven tion group they breastfed .139 times per day. This works out to an average of once ever y 17 days in the preintervention group and once every 7 days in the post intervention group. Although a stat istically significant increase was observed following the interventi on, the resultant rate of breastfeeding in the NICU remained low. After dichotomizing this variable, it was noted that there were

PAGE 71

60 25.9% of mothers who ever breastfed their infa nt in the hospital in the pre-in tervention group. In contrast, there were 44.4% of mothers who ever breas t fed their infants in the post intervention group. This represented a si gnificant increase of 18.5%. This provides some support that the program had a positive effect with increase d participation in breastfeeding among mothers in the NICU. However, the ov erall rate of breastfeeding participation remains low in the NICU. The variable of ever breastfed while in the hospital is an important one, as it requires active participation by the mother and infant. Diminished milk supply is cited as one of the most significant barriers to breastf eeding in the NICU population. Maternal stress has been linked to inhibition of oxyt ocin, which is responsible for the let down response during pumping and breastfeeding (Lang, 1996). However, physiologically, oxytocin is facilitated with in creased mother-infant contact an d environments that foster breastfeeding ("How brea st-feeding postpones ovulation," 1 985). Mothers with infants in the NICU typically experience high leve ls of stress and anxiety and many are overwhelmed by the NICU environment (Nyqvi st et al., 1994). Many also comment on the loss of control of their infant to othe rs during stays in the NICU (Lupton & Fenwick, 2001). Close contact, as in skin to skin, as well as breastfeeding, are important in maintaining bonding in a difficult environment, promoting the milk supply and providing some control over care for mothers (Kirsten, Bergman, & Hann, 2001). This direct interaction of the mother and infant can be assumed to be critical to the other breastfeeding outcomes. Although positive trends in favor of the post-intervention group were observed across all variables, the inte rvention did not have a str ong enough impact to result in

PAGE 72

61 significant changes in breast milk feeding initiation rates, breast milk feeding at discharge rates and proportion of the hospital stay that breast milk was provided. This could be due to lack of a strong enough impact of the intervention with a need for a more extensive list of interventions or adjustment of the interv entions proposed in this study, need for consistent compliance with the rese arch interventions to promote change, or a different time frame for the study to detect changes. The breast milk feeding initiation rate (was breast milk ever provided) in the preintervention and post-intervention groups app ears to be fairly comparable to other research findings, which have documented rate s of breast milk feeding initiation in the NICU at 64% (Byrne & Hull, 1996), 72.9% (Mei er et al., 2004), a nd 83% (Yip et al., 1996). Although breast milk feeding initiation failed to reach statistical significance, there was an increase in breast milk feed ing initiation of 11.1%, which was a positive change in the right direction as more infants received some breast milk following the intervention. Scientists are beginning to refer to breast milk as medicine and have initiated discussing breast milk in terms of a dose (Meier et al., 2004). Thus following the intervention, 11.1% more infants in the post-intervention group re ceived breast milk at the most critical stage of their recover y. However, this va riable did not achieve statistical significance, which c ould indicate that the impact of the interventions was not strong enough or that there wa s not enough compliance with th e interventions to promote change. It is important to note that breast m ilk feeding initiation re flected whether breast milk was ever provided and not if breastfeeding ever occurred or if br east milk continued to be supplied after the 2nd day of life or at discharge.

PAGE 73

62 Although the rate of breast milk feedings at discharge (was breast milk provided to the infant at discharge) increased slightly by 4.9%, this difference failed to reach statistical significance. Succeeding with breast milk feedings until discharge in the NICU population is a significant challenge for mother s with infants in the NICU. Discharge for many of these infants did not occur until they were 1 to 4 months old. This supports other research findings that state that so me of the strongest predictors of not breastfeeding by discharge is being low birt h weight, having decrea sed gestational age and being admitted into the NICU (Hwang et al., 2006; Li et al., 2005; Powers et al., 2003; Scott et al., 2006). The findings of th is study in both the pre-intervention (35.8%) and post-intervention (40.7%) groups are compar able to other research findings, which document breast milk feedings at discharge to be 38% (Yip et al., 1996). The low rate of breast milk feeding in the NICU at discharg e gives some insight into the significant challenges that women encounter with succeeding with breast milk feedings through a NICU hospitalization. However, to enable moth ers with this process, it is critical that strategies to promote long term success are implemented. Although lack of full implementation and compliance with intervention strategies may have factored into this research study, these results suggest that th is 3-pronged intervention was not sufficient to enable mothers to overcome the barriers to maintaining breastfeeding until the time of hospital discharge in this complex and challenging environment. There was no difference between the groups in the proportion of the hospital stay that breast milk was provided. These re sults again highlight the importance of determining strategies for long term success to enable mothers to succeed with the

PAGE 74

63 breastfeeding process fo r a larger proportion of the hospita lization. Such strategies could enable breast milk feedings until discharge and beyond. This study complements conclusions from other studies that attention to and education about lactation affects health car e professional knowledge and support of the breastfeeding process (Siddell et al., 2003). Many studies c ite lack of health care professional education as a significant barrie r to the breastfeeding process in the NICU (Register et al., 2000). Although improvement in breastfeeding rate s in the NICU was observed in the post education group, there is no way to de termine which part of the intervention plan may have had an effect on th is variable. Other studies have concluded that health care professionals play a signi ficant role in breastfeeding practices in the NICU (Swanson & Power, 2005) as does in creased knowledge about breastfeeding among mothers in the NICU (Bernaix, 2000). However, because all the interventions were implemented together as a 3-pronged a pproach, it is unclear if the educational materials for mothers, the educational in itiative, or the modifications to the ICP/breastfeeding pathway resulted in th e effect on breastfee ding in the NICU. According to the transtheoretical model of behavior change, change is a process and sometimes requires multiple approaches th at are stage matched in addition to the passage of time. The real impact of the e ducation perhaps could not be fully observed in assessing the indirect impact on breastfeeding practices am ong mothers and infants. By assessing the indirect impact of the education interventi on on breastfeedi ng strategies without measuring the knowledge and behavior change of th e health care professionals, it cannot be determined if there was a change in the health care profe ssionals and what the magnitude of such a change was. This calls into question whether the educational

PAGE 75

64 initiative did what it was intended, which was to change health care professional behavior. With knowledge of a change in health care professional behavior, the true impact of education and inte rvention strategies on breastf eeding outcomes in the NICU could be assessed. In addition, there were 2 behavior changes that could have been assessed, the health care professional as we ll as the mother. Further measuring the mothers’ behavior change, in the presence of education from the health care professional, would have provided useful information on whether the intervention was strong enough to elicit positive changes in the mothers. Although positive changes are evident, the re ported compliance with strategies and follow through of education key points was called into question by the nursing administration. Other studies have determined that education about breastfeeding has had an effect on breastfeeding knowledge and s upportive behaviors (Ekstrom, Widstrom et al., 2005). This research study di d not measure the behaviors of health care professionals following education. Therefore, it could be that the 3 part intervention plan was not strong enough to elicit changes in health ca re professional behavior that not enough time passed post intervention to enable successful change or that the health care professional change elicited following the intervention was not enough to result in positive outcomes across all proposed breastfeed ing variables. Subsequently, this study provides only partial support for positive changes in breas tfeeding practices in the NICU following the 3 part intervention. Limitations This study is not without limitations. Limitations included inadequate implementation of all the intervention strategi es by the health care professionals, lack of methods to determine behavior change and im plementation by health care professionals,

PAGE 76

65 lack of ability to give ample time for ch anges to be implemented without introducing other confounds, lack of participation by key decision makers in the NICU, the inability to control for other changes in the NICU environment, lack of a more comprehensive breastfeeding intervention plan, and lack of a randomized sample. An important limitation of this study was the questionable full implementation of the strategies learned in the educational in itiative as well as inconsistent use of the modified ICP and inconsistent distribution of “A Mother’s Gift”. Although there was a high health care professional par ticipation rate in the education initiative of 63%, health care professional behavior change and attitude s were not measured. Therefore, there is no way to know the direct effect of the edu cation and placement of the modified ICP in the medical chart on health care behavior and attitudes. It can be assumed that although there was good participation in the educational initiative by bedside nurses and the breastfeeding pathway on the ICP was added to the medical record, there was a lack of movement to action among many health care professionals based on the observations by nursing administration as well as by the first f eeding at the breast variable remaining low in the post-intervention group. Despite education about promoting br eastfeeding in the NICU and how to introduce such practices, there remained a la rge percentage of women (56%) who never breastfed while in the hospital. This demons trates that although the education may have occurred, change was not fully embraced and implemented. Health care professionals care for infants, including caring for nutriti onal feeds, in the NI CU 24 hours a day, and parents are visitors to the NICU when they come to see their infant. Breastfeeding is typically something that hea lth care professionals would en able, and thus its low rate

PAGE 77

66 could be attributed to low hea lth care professional support of the breastfeeding process. This study investigated breas tfeeding outcomes in the natu ral NICU environment in which health care professionals may have ha d other priorities, may have had negative beliefs about breastfeeding in th e NICU, may have had control issues that interfered with promoting a feeding method that they eventua lly cannot participate in, or may have been suffering from burn out. However, without the intermediate meas ure of health care behavior, it is difficult to determine if the in tervention could be effective if health care professionals demonstrated an appropriate beha vior change and were called to action. According to the trantheoretial model of behavior change (TTM), change is a process with people moving through different stages of readiness to change (Prochaska et al., 2001). The intervention plan was desi gned to provide interventions that are appropriate for individuals in each stage of readiness to change. However, the educational initiative and interventions were introduced with data collection occurring in the post intervention group 6 s hort weeks later. This may not have been a long enough period of time to enable individuals to re spond to the intervention and move them to action. According to the TTM, those in the pre-action stages are the precontemplators (no intention of making a change), the contem plators (intention of making a change in the next 6 months) and those in the preparation stage (intend on making a change in the next 30 days). Theoretically a six week period may not have been enough to enable movement through the stages of change to promote action toward increasing breastfeeding support and implementing strategies learned in the educ ational initiative. In contrast, other confounds were being intr oduced in the NICU in the months following the conclusion of this study, as more inte rventions were set to be implemented.

PAGE 78

67 Therefore, this study could not account for th e possible inadequate time frame due to the potential introduction of confounds th at could bias the results. Another limitation was the weak partic ipation in the education modules by physicians and nurse practitioners, who are ke y decision makers in the NICU. Prior to the educational initiative dates, they participated in a short, general inservice about breastfeeding to f acilitate discussion and direction. Due to this recent meeting, it was difficult to get them to participate in the research educational in itiative. Therefore, participation was low with only 20% of neona tologists and 9% of nurse practitioners attending an inservice or co mpleting the self study edu cational module. Although the researcher did meet with the physician medical director of the unit to discuss key points of the educational initiative, the initiative ma y have been much more successful if the neonatologists and nurse practiti oners had higher levels of pa rticipation. Nursing staff and parents look to physicians and neonatal nu rse practitioners for direction, and their lack of participation was a signi ficant limitation to this study. The NICU is a constantly changing environm ent that can not be fully controlled in a study like this, where all infants during a sp ecific time frame are being enrolled. This study does not account for other changes that may have occurred, such as staff changeover, other education that health care professionals may be receiving and implementing, and changes made to the physical NICU environment. Cosmetic changes were made to the NICU environment duri ng the course of this study, and it was impossible to determine if this may have had an effect on the results. The lack of optimal resources that may facilitate breastfeedin g may also pose a limitation to this study. During the early stages of planning this res earch project, funds

PAGE 79

68 were applied for to provide a breast pump loaner closet that would provide a needed resource for long term maintenance of the m ilk supply (Meier et al., 2004). These funds were not achieved, making it impossible to pr ovide this resource to enable long term success with maintaining the milk supply, and subsequently with addressing the idea of providing breast milk all the way until the in fant was discharged from the NICU. Providing breast milk or breastfeed ing at the time of discharge would be the goal, as this would indicate that a mother succeeded w ith providing milk during the hospitalization and would enable breastfeeding at discharg e home. Without the funding, women were left to find their own resources to access a hospital grade pump for milk expression. Some may have accessed one for use at home while others may have used store bought pumps or self expressed. This study is a cohort study. Due to lack of randomization, there is the possibility that there are unseen differences in the two groups that lead to differences or similarities in breastfeeding practices that cannot be attributed to the in tervention. Results from this study can only give conclusions about the popu lation of infants being studied at Shands Hospital. In addition, the small sample si ze limited the ability to achieve adequate power, which can affect being able to detect si gnificant differences, if they exist. Based on the utilized sample size, 38.6% power was ac hieved on the primary variable of breast milk feeding initiation. This indicates that the probability of finding a difference in the two groups was only 38.6%. The already high br east milk feeding ini tiation rate in the pre-intervention group, 74.1%, ga ve less room for improvement in this variable. Although comparable with other ra tes reported in the literature, the rate in this unit was expected to be lower due to lack of lactation se rvices in the unit a nd the large population

PAGE 80

69 of Black mothers, mothers with low socioec onomic status and single mothers, which are all predictive of decreased br eastfeeding behaviors (Powers et al., 2003). The nature of the population may have been a limitation, in th at perhaps the effect of the intervention would be different given a diffe rent demographic presence in the NICU. Given the effect of the current intervention, a larger sample si ze would be needed to determine if there are significant differences in the pre-interventi on and post-intervention groups. Such sample size was not feasible during the study pe riod given the number of admissions and discharges. Prolonging enroll ment was not feasible give n the risk of introducing potential bias. To Recommendations for Further Research Women with infants in the NICU face unique challenges to the breastfeeding process. These barriers result in decreased breastfeeding initiation rates and breast milk feedings at discharge from the hospital. Howe ver, these fragile infants are at an increased need for the benefits of breast milk. Ther efore, further studies looking at trends in breastfeeding and looking at in terventions that can assist mothers in overcoming barriers is necessary. Future research could investigate the e fficacy of educational interventions that measure the intermediate effects of the inte rvention on health care professional behavior as well as the effect on breastf eeding outcomes. With similar findings as this study, this would make it easier to interpret if the educat ional interventions did not cause health care professional behavior change and thus did not affect breastfeeding outcome or if the educational interventions did affect health care professi onal behavior but that the resultant effect of this was not strong enough to result in positi ve breastfeeding outcomes.

PAGE 81

70 Future studies addressing an educationa l initiative for health care professionals with more time to enable change would be appropriate to run in this population. If change takes time to occur, a longer period be tween the intervention a nd the start of data collection in the post interven tion group would help identify ch ange that occurred over a longer period of time following the interventions. However, such a study would require close control of the environment to preven t other confounds from being introduced as time from the education initiative elapses. Although an intervention w ith many parts that addre sses milk expression and breastfeeding over the course of hospitalization ma y be optimal in promoting breastfeeding practices in the NICU, a look at intervention sp ecific studies could help to declare which interventions are successful and which are not. Such a study, although it may require a much larger sample size and perhaps random assignment to groups and a multi-center trial, could assist with understa nding which, if any, and in what combination, treatment(s) have an effect on brea stfeeding practices in the NICU. Further research could also investigat e the specific results, amount of milk expression and success with breastfeeding am ong women who had a nurse who was in an action oriented stage of beha vior change regarding support for lactation compared to those receiving traditional NICU care. The effects of support and education for the mother could further be investigated by in cluding success and failure with breastfeeding among mothers who demonstrated compliance wi th strategies in “A Mother’s Gift” compared to those who were not fully compliant. With the paucity of breastfeed ing (putting the infant to breast) in the NICU, it is of great interest to determine the predictive e ffect of breastfeeding on breast milk feedings

PAGE 82

71 at discharge, milk production, amount of breast m ilk feedings in the hospital, as well as the effect on maternal and child health. Likewise, it would be of great interest to determine if there are any nega tive effects of not enabling brea stfeeding on the ability to maintain the milk supply, success of breastfeeding at discharge and beyond and the ability to transition from breast milk feeds to direct breastfeeding. Conclusions This study investigated change in breastf eeding practices following implementation of an intervention plan with 3 parts; an educational booklet for new mothers, an educational opportunity for health care profe ssionals who serve mother-infant dyads in the NICU, and changes to the individualized care plan that necessitate breastfeeding practice documentation by nurses. There we re general positive trends across all variables, which make this type of interven tion have some promise for affecting positive changes in breastfeeding practices in the NICU given the limitations of this study and the difficulties that can be expected in the complex NICU environment. There were statistically significant differe nces between groups in the rate of breastfeeding, with infants in the post-intervention group being more than twice as likely to be breastfed in the hospital. While health care professionals may play a significant role in the breastfeeding process, perhaps an educational plan and breastfeeding pathway as well as complementary educational materials for mothers is not enough to promote full participation and optimal breas tfeeding practices in the NICU This study demonstrated limited, but encouraging, support for an in tervention plan focused on education to facilitate change in breastfeeding wi thin the NICU, but perhaps a multifaceted intervention plan, including hospital grade br east pump allocation may optimize positive

PAGE 83

72 changes in breastfeeding practices. An important limitation of this study was lack of full implementation of the intervention strategies. Future studies can be designed to better measure compliance with educational interven tions as well as the individual effect of each intervention and the additive effect of multiple interventions implemented together. Randomized multi-institutional studies will enab le larger intervention trials as well as generalization of findings.

PAGE 84

73 APPENDIX A OUTLINE OF THE EDUCATION MODULE Breastfeeding in the Neonatal Intensive Care Unit An Educational Module for H ealth Care Professionals Introduction Benefits of Breastfeeding for the Full Term Infant Health Benefits Developmental Benefits Financial Benefits Benefits for Preterm or High Risk Infants Benefits for the Mother Barriers to Breastfeeding Full-term infants High-risk infants Contraindications Breast Milk Composition Transition to Mature Milk The Breast and Lactogenesis Anatomy Neuroendocrine control Sucking pattern General Interventions for Supporting Breastfeeding Appropriate Timing of Interventions Interventions in the NICU Interventions Prior to Active Breastfeeding Breast pumps Maintaining a milk supply Kangaroo Care Non-nutritive suckling

PAGE 85

74 Early initiation of direct breastfeeding Monitoring Physiologic Responses Transition to Direct Breastfeeding Interventions for Supporting Breastfeeding Privacy Positioning Timing Special Techniques Determining Adequacy of Intake Conclusion Post-test References For further information, contact the authors: Roberta Gittens Pineda : jopineda@pol.net Cammy Pane: cam92460@yahoo.com

PAGE 86

75 APPENDIX B OUTLINE OF ITEMS ADDED TO TH E INDIVIDUALIZED CARE PLAN Breastfeeding Guidelines: Within 6 hours of delivery: Mom is given “A Mother’s Gift” Within 24 hours: Ensure proper pumping (w ith hospital grade pump) and storage 3 to 5 days of life: Assess Mom’ s milk production. Address problems 10 days of life: Mom’s milk supply should be at least 350 ml per 24 hours With each parent contact: Offer support and discuss any problems Kangaroo care is encouraged as soon as possible First oral feeing is at breast Mom is encouraged to breastfeed at each visit with supplementation only when medically indicated At discharge: Encourage tr ansition to full breastfeedi ng while monitoring weight gain

PAGE 87

76 APPENDIX C OUTLINE OF THE EDUCATI ONAL BOOKLET FOR MOTHERS A Mother’s Gift Breastfeeding and Pumping for Your Baby in the NICU Breast milk is the best food for your baby’s start in life Each mother’s milk is prefect for her baby Babies who drink breast m ilk are healthier and smarter This makes breast milk even more important for premature babies Breastfeeding is healthy for the mother too! Providing breast milk for your baby is something very special you can do to help your child It is important to begin expressing your milk as soon after delivery as possible, and to keep pumping Pumping may seem complicated at fi rst, but it is worth it for your baby During pumping, relax and enjoy gentle thoughts about your baby At first, you may not get any milk, or only a few drops Here is how to store your milk Every mother wants to know -“Am I making enough milk” In order to maintain a good milk supply… Most mothers really want to hold their babies Kangaroo care is good for your baby Kangaroo care is good for parents too Privacy is more important to some than others… Suckling at the breast is the best way to nourish your baby… and it takes practice Positioning during breastfeeding will become easier with practice… Is my baby really, really, really getting enough milk Please take extra care of yourself too! If you are taking medications Making milk for twins or more… Please ask if you have questions or need help How to obtain a pump for home use… Chart for tracking milk production

PAGE 88

77 On-line resources For more information, contact: Roberta Gittens Pineda : jopineda@pol.net

PAGE 89

78 LIST OF REFERENCES Agostoni, C., & Haschke, F. (2003). Infant formulas. Recent developments and new issues. Minerva Pediatr, 55 (3), 181-194. Allen, M. C., & Capute, A. J. (1990). Tone and reflex development before term. Pediatrics, 85 (3 Pt 2), 393-399. Alm, J. S., Swartz, J., Bjorksten, B., Engstra nd, L., Engstrom, J., Kuhn, I., et al. (2002). An anthroposophic lifestyle and in testinal microflora in infancy. Pediatr Allergy Immunol, 13 (6), 402-411. Arora, S., McJunkin, C., Wehrer, J., & K uhn, P. (2000). Major factors influencing breastfeeding rates: Mother's perception of father's attitude and milk supply. Pediatrics, 106 (5), E67. Baker, R. (2003). Human milk subst itutes. An American perspective. Minerva Pediatr, 55 (3), 195-207. Ball, T. M., & Wright, A. L. (1999). Health care costs of formula-feed ing in the first year of life. Pediatrics, 103 (4 Pt 2), 870-876. Berens, P. D. (2001). Prenatal, intrapartu m, and postpartum support of the lactating mother. Pediatr Clin North Am, 48 (2), 365-375. Beresford, H. J. (1984). The success of breast feeding. IPPF Med Bull, 18 (5), 3-4. Bernaix, L. W. (2000). Nurses' attitudes, subj ective norms, and behavioral intentions toward support of breastfeeding mothers. J Hum Lact, 16 (3), 201-209. Bick, D. E., MacArthur, C., & Lancashire, R. J. (1998). What influences the uptake and early cessation of breast feeding? Midwifery, 14 (4), 242-247. Birch, E., Birch, D., Hoffman, D., Hale, L ., Everett, M., & Uauy, R. (1993). Breastfeeding and optimal vi sual development. J Pediatr Ophthalmol Strabismus, 30 (1), 33-38. Black, K. A., & Hylander, M. A. (2000). Breas tfeeding the high risk infant: implications for midwifery management. J Midwifery Womens Health, 45 (3), 238-245. Blackburn, S. (1998). Environmental impact of the NICU on developmental outcomes. J Pediatr Nurs, 13 (5), 279-289.

PAGE 90

79 Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding. (1997). Pediatrics, 100 (6), 1035-1039. Bueno, M. B., de Souza, J. M., de Souza, S. B., da Paz, S. M., Gimeno, S. G., & de Siqueira, A. A. (2003). [Risks associated with the weaning process in children born in a university hospital: a prospective cohor t in the first year of life, Sao Paulo, 1998-1999]. Cad Saude Publica, 19 (5), 1453-1460. Byrne, B., & Hull, D. (1996). Breast milk for preterm infants. Prof Care Mother Child, 6 (2), 39, 42-35. Callen, J., & Pinelli, J. (2005). A review of the literature examining the benefits and challenges, incidence and duration, and barrier s to breastfeeding in preterm infants. Adv Neonatal Care, 5 (2), 72-88; quiz 89-92. Chan, D. K. (2001). Enteral nu trition of the very low bi rth weight (VLBW) infant. Ann Acad Med Singapore, 30 (2), 174-182. Chantry, C. J., Auinger, P., & Byrd, R. S. (2004). Lactation among adolescent mothers and subsequent bone mineral density. Arch Pediatr Adolesc Med, 158 (7), 650-656. Chen, A., & Rogan, W. J. (2004). Breastfeeding and the risk of postneonatal death in the United States. Pediatrics, 113 (5), e435-439. Chen, C. H., Wang, T. M., Chang, H. M., & Chi, C. S. (2000). The effect of breastand bottle-feeding on oxygen satu ration and body temperature in preterm infants. J Hum Lact, 16 (1), 21-27. Chua, S., Arulkumaran, S., Lim, I., Selamat, N., & Ratnam, S. S. (1994). Influence of breastfeeding and nipple stimulati on on postpartum uterine activity. Br J Obstet Gynaecol, 101 (9), 804-805. Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, N.J.: L. Erlbaum Associates. Coleman, S., Dracup, K., & Moser, D. K. (1991). Comparing methods of cardiopulmonary resuscitation instru ction on learning and retention. J Nurs Staff Dev, 7 (2), 82-87. Dai, D., & Walker, W. A. (1998). Role of b acterial colonization in neonatal necrotizing enterocolitis and its prevention. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi, 39 (6), 357-365. Davis, M. K. (2001). Breastfeeding and ch ronic disease in chil dhood and adolescence. Pediatr Clin North Am, 48 (1), 125-141, ix. Dewey, K. G., Heinig, M. J., & Nommsen, L. A. (1993). Maternal weight-loss patterns during prolonged lactation. Am J Clin Nutr, 58 (2), 162-166.

PAGE 91

80 Diaz Gomez, M., Ramos Acosta, C. L., Rico Sevillano, J., Robayna Curbelo, M., & Alvarez Alvarez, J. (1997). [Breast feeding and length of hospitalization]. Rev Enferm, 20 (231), 11-14. do Nascimento, M. B., & Issler, H. (2004). [Breastfeeding in premature infants: inhospital clinical management]. J Pediatr (Rio J), 80 (5 Suppl), S163-172. Docherty, S. L., Miles, M. S., & Holditch-D avis, D. (2002). Worry about child health in mothers of hospitalized medically fragile infants. Adv Neonatal Care, 2 (2), 84-92. Ekstrom, A., Matthiesen, A. S., Widstrom A. M., & Nissen, E. (2005). Breastfeeding attitudes among counselling health professionals. Scand J Public Health, 33 (5), 353-359. Ekstrom, A., Widstrom, A. M., & Nissen, E. (2005). Process-or iented training in breastfeeding alters attitudes to br eastfeeding in health professionals. Scand J Public Health, 33 (6), 424-431. Espy, K. A., & Senn, T. E. (2003). Incidence a nd correlates of breast milk feeding in hospitalized preterm infants. Soc Sci Med, 57 (8), 1421-1428. Fergusson, D. M., & Woodward, L. J. (1999) Breast feeding and later psychosocial adjustment. Paediatr Perinat Epidemiol, 13 (2), 144-157. Gartner, L. M., Morton, J., Lawrence, R. A., Na ylor, A. J., O'Hare, D ., Schanler, R. J., et al. (2005). Breastfeeding and the use of human milk. Pediatrics, 115 (2), 496-506. Goldrick, B., Gruendemann, B., & Larson, E. (1993). Learning styles and teaching/learning strategy preferences: imp lications for educating nurses in critical care, the operating room, and infection control. Heart Lung, 22 (2), 176-182. Gomez-Sanchiz, M., Canete, R., Rodero, I., Ba eza, J. E., & Avila, O. (2003). Influence of breast-feeding on mental and psychomotor development. Clin Pediatr (Phila), 42 (1), 35-42. Gray, L., Miller, L. W., Philipp, B. L., & Bla ss, E. M. (2002). Breas tfeeding is analgesic in healthy newborns. Pediatrics, 109 (4), 590-593. Gross, S. J., David, R. J., Bauman, L., & Tomarelli, R. M. (1980). Nutritional composition of milk produced by mothers delivering preterm. J Pediatr, 96 (4), 641-644. Hanson, L. A. (1998). Breastfeeding provide s passive and likely long-lasting active immunity. Ann Allergy Asthma Immunol, 81 (6), 523-533; quiz 533-524, 537. Hanson, L. A., Korotkova, M., Haversen, L ., Mattsby-Baltzer, I., Hahn-Zoric, M., Silfverdal, S. A., et al. (2002). Breastfeeding, a complex support system for the offspring. Pediatr Int, 44 (4), 347-352.

PAGE 92

81 Harrington, S. S., & Walker, B. L. (2004). Th e effects of computer-based training on immediate and residual learning of nursing facility staff. J Contin Educ Nurs, 35 (4), 154-163; quiz 186-157. Harrold, J., & Schmidt, B. (2002). Eviden ce-based neonatology: making a difference beyond discharge from the neonatal nursery. Curr Opin Pediatr, 14 (2), 165-169. Hart, S., Boylan, L. M., Carroll, S., Musick, Y. A., & Lampe, R. M. (2003). Brief report: breast-fed one-week-olds demonstrate s uperior neurobehavi oral organization. J Pediatr Psychol, 28 (8), 529-534. Hill, P. D., Andersen, J. L., & Ledbetter, R. J. (1995). Delayed initiation of breast-feeding the preterm infant. J Perinat Neonatal Nurs, 9 (2), 10-20. Hill, P. D., Hanson, K. S., & Mefford, A. L. (1994). Mothers of low birthweight infants: breastfeeding pattern s and problems. J Hum Lact, 10 (3), 169-176. Holditch-Davis, D., & Miles, M. S. (2000). Moth ers' stories about thei r experiences in the neonatal intensive care unit. Neonatal Netw, 19 (3), 13-21. How breast-feeding postpones ovulation. (1985). Network, 7 (1), 3. Hwang, W. J., Chung, W. J., Kang, D. R., & Suh, M. H. (2006). [Factors affecting breastfeeding rate and duration]. J Prev Med Pub Health, 39 (1), 74-80. Hylander, M. A., Strobino, D. M., & Dhanir eddy, R. (1998). Human milk feedings and infection among very low birth weight infants. Pediatrics, 102 (3), E38. Hylander, M. A., Strobino, D. M., Pezzullo, J. C., & Dhanireddy, R. (2001). Association of human milk feedings with a reduction in retinopat hy of prematurity among very low birthweight infants. J Perinatol, 21 (6), 356-362. Isaacson, L. J. (2006). Steps to successfu lly breastfeed the premature infant. Neonatal Netw, 25 (2), 77-86. Jaeger, M. C., Lawson, M., & Filteau, S. (1997) The impact of prematurity and neonatal illness on the decision to breast-feed. J Adv Nurs, 25 (4), 729-737. Jang, Y. S. (2005). [Effects of a workbook program on the perceived stress level, maternal role confidence and breast f eeding practice of mothers of premature infants]. Taehan Kanho Hakhoe Chi, 35 (2), 419-427. Karl, D. J. (2004). Using principles of newbor n behavioral state orga nization to facilitate breastfeeding. MCN Am J Matern Child Nurs, 29 (5), 292-298. Kavanaugh, K., Mead, L., Meier, P., & Mangurten, H. H. (1995). Getting enough: mothers' concerns about breastfeeding a preterm infant after discharge. J Obstet Gynecol Neonatal Nurs, 24 (1), 23-32.

PAGE 93

82 Kemp, A., & Kakakios, A. (2004). Asth ma prevention: breast is best? J Paediatr Child Health, 40 (7), 337-339. Kirsten, G. F., Bergman, N. J., & Hann, F. M. (2001). Kangaroo mother care in the nursery. Pediatr Clin North Am, 48 (2), 443-452. Kronborg, H., & Vaeth, M. (2004). The influenc e of psychosocial factors on the duration of breastfeeding. Scand J Public Health, 32 (3), 210-216. Lanari, M., Papa, I., Venturi, V., Sermasi, S ., Corvaglia, L., Faldella, G., et al. (2001). [Neonatal sepsis]. Recenti Prog Med, 92 (11), 690-695. Lang, S. (1996). Breastfeeding special care babies. Mod Midwife, 6 (11), 34-35. Laubereau, B., Brockow, I., Zi rngibl, A., Koletzko, S., Gruebl, A., von Berg, A., et al. (2004). Effect of breast-feeding on the de velopment of atopic dermatitis during the first 3 years of life--results fr om the GINI-birth cohort study. J Pediatr, 144 (5), 602-607. Li, R., Darling, N., Maurice, E., Barker, L., & Grummer-Strawn, L. M. (2005). Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 National Immunization Survey. Pediatrics, 115 (1), e31-37. Lucas, A., Morley, R., Cole, T. J., & Gore S. M. (1994). A randomised multicentre study of human milk versus formula and la ter development in preterm infants. Arch Dis Child Fetal Neonatal Ed, 70 (2), F141-146. Lucas, A., Morley, R., Cole, T. J., Lister, G., & Leeson-Payne, C. (1992). Breast milk and subsequent intelligence quotie nt in children born preterm. Lancet, 339 (8788), 261-264. Lugo-Vicente, H. (2003). Necrotizing enterocolitis. Bol Asoc Med P R, 95 (2), 17-22. Lupton, D., & Fenwick, J. (2001). 'They've forg otten that I'm the mum': constructing and practising motherhood in sp ecial care nurseries. Soc Sci Med, 53 (8), 1011-1021. Marild, S., Hansson, S., Jodal, U., Oden, A., & Svedberg, K. (2004). Protective effect of breastfeeding against ur inary tract infection. Acta Paediatr, 93 (2), 164-168. Matthews, K., Webber, K., McKim, E., Banoub-Baddour, S., & Laryea, M. (1998). Maternal infant-feeding decisi ons: reasons and influences. Can J Nurs Res, 30 (2), 177-198. McGrath, J. M., & Braescu, A. V. (2004). State of the science: feeding readiness in the preterm infant. J Perinat Neonatal Nurs, 18 (4), 353-368; quiz 369-370. McVea, K. L., Turner, P. D., & Peppler, D. K. (2000). The role of breastfeeding in sudden infant death syndrome. J Hum Lact, 16 (1), 13-20.

PAGE 94

83 Meier, P. P. (1998). Strategies for assi sting breatfeeding in preterm infants. Meier, P. P. (2001). Breastfeeding in the sp ecial care nursery. Prematures and infants with medical problems. Pediatr Clin North Am, 48 (2), 425-442. Meier, P. P., & Brown, L. P. (1996). State of the science. Breastfeeding for mothers and low birth weight infants. Nurs Clin North Am, 31 (2), 351-365. Meier, P. P., Engstrom, J. L., Mingolelli, S. S., Miracle, D. J., & Kiesling, S. (2004). The Rush Mothers' Milk Club: breastfeeding in terventions for mothers with very-lowbirth-weight infants. J Obstet Gynecol Neonatal Nurs, 33 (2), 164-174. Mikiel-Kostyra, K. (2000). [Breast feeding as a component of reproductive health]. Ginekol Pol, 71 (7), 641-647. Miles, M. S., Funk, S. G., & Kasper, M. A. (1992). The stress response of mothers and fathers of preterm infants. Res Nurs Health, 15 (4), 261-269. Mitra, A. K., Khoury, A. J., Hinton, A. W ., & Carothers, C. (2004). Predictors of breastfeeding intention among low-income women. Matern Child Health J, 8 (2), 65-70. Morley, R., Cole, T. J., Powell, R., & Lucas, A. (1988). Mother's choice to provide breast milk and developmental outcome. Arch Dis Child, 63 (11), 1382-1385. Neiva, F. C., Cattoni, D. M., Ramos, J. L., & Issler, H. (2003). [Early weaning: implications to oral motor development]. J Pediatr (Rio J), 79 (1), 7-12. Nikolajski, P. Y. (1992). Invest igating the effectiveness of se lf-learning packages in staff development. J Nurs Staff Dev, 8 (4), 179-183. Nyqvist, K. H., Ewald, U., & Sjoden, P. O. (1996). Supporting a preterm infant's behaviour during breastf eeding: a case report. J Hum Lact, 12 (3), 221-228. Nyqvist, K. H., Sjoden, P. O., & Ewald, U. (1994). Mothers' advice about facilitating breastfeeding in a neonatal intensive care unit. J Hum Lact, 10 (4), 237-243. Nyqvist, K. H., Sjoden, P. O., & Ewald, U. ( 1999). The development of preterm infants' breastfeeding behavior. Early Hum Dev, 55 (3), 247-264. Oddy, W. H., Sherriff, J. L., de Kl erk, N. H., Kendall, G. E., Sly, P. D., Beilin, L. J., et al. (2004). The relation of breastfeeding and body mass index to asthma and atopy in children: a prospective c ohort study to age 6 years. Am J Public Health, 94 (9), 1531-1537. The optimal duration of exclusive breastfeed ing: results of a WHO systematic review. (2001). Indian Pediatr, 38 (5), 565-567.

PAGE 95

84 Owen, C. G., Whincup, P. H., Odoki, K., G ilg, J. A., & Cook, D. G. (2002). Infant feeding and blood cholestero l: a study in adolescents and a systematic review. Pediatrics, 110 (3), 597-608. Page, D. C. (2001). Breastfeeding is early functional jaw orthopedics (an introduction). Funct Orthod, 18 (3), 24-27. Pantazi, M., Jaeger, M. C., & Lawson, M. ( 1998). Staff support for mothers to provide breast milk in pediatric ho spitals and neonatal units. J Hum Lact, 14 (4), 291-296. Philipp, B. L., Malone, K. L., Cimo, S., & Merewood, A. (2003). Sustained breastfeeding rates at a US baby-friendly hospital. Pediatrics, 112 (3 Pt 1), e234-236. Pinelli, J., Atkinson, S. A., & Saigal, S. (2001). Randomized trial of breastfeeding support in very low-birth-weight infants. Arch Pediatr Adolesc Med, 155 (5), 548553. Piper, S., & Parks, P. L. (1996). Predicting the duration of lactation: evidence from a national survey. Birth, 23 (1), 7-12. Powers, N. G., Bloom, B., Peabody, J., & Clar k, R. (2003). Site of care influences breastmilk feedings at NICU discharge. J Perinatol, 23 (1), 10-13. Premji, S. S., Paes, B., Jacobson, K., & Ch essell, L. (2002). Evidence-based feeding guidelines for very low-birth-weight infants. Adv Neonatal Care, 2 (1), 5-18. Prochaska, J. M., Prochaska, J. O., & Le vesque, D. A. (2001). A transtheoretical approach to changing organizations. Adm Policy Ment Health, 28 (4), 247-261. Prochaska, J. O., & DiClemente, C. C. (1983) Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol, 51 (3), 390-395. Rea, M. F. (2004). [Benefits of br eastfeeding and women's health]. J Pediatr (Rio J), 80 (5 Suppl), S142-146. Register, N., Eren, M., Lowdermilk, D., Hammond, R., & Tully, M. R. (2000). Knowledge and attitudes of pediatric o ffice nursing staff about breastfeeding. J Hum Lact, 16 (3), 210-215. Riskin, A., & Bader, D. (2003). [Breast is best--human milk for premature infants]. Harefuah, 142 (3), 217-222, 237, 236. Rooney, B. L., & Schauberger, C. W. (2002) Excess pregnancy weight gain and longterm obesity: one decade later. Obstet Gynecol, 100 (2), 245-252.

PAGE 96

85 Ryan, A. S., Wysong, J. L., Martinez, G. A., & Simon, S. D. (1990). Duration of breastfeeding patterns established in the hospita l. Influencing factors. Results from a national survey. Clin Pediatr (Phila), 29 (2), 99-107. Schack-Nielsen, L., & Michaelsen, K. F. (2006). Breast feeding and future health. Curr Opin Clin Nutr Metab Care, 9 (3), 289-296. Schanler, R. J., Hurst, N. M., & Lau, C. ( 1999). The use of human milk and breastfeeding in premature infants. Clin Perinatol, 26 (2), 379-398, vii. Scott, J. A., Binns, C. W., Graham, K. I., & Oddy, W. H. (2006). Temporal changes in the determinants of breastfeeding initiation. Birth, 33 (1), 37-45. Shadish, W. R., Cook, T. D., & Campbell, D. T. (2001). Experimental and quasiexperimental designs for gene ralized causal inference Boston: Houghton Mifflin. Siddell, E., Marinelli, K., Froman, R. D ., & Burke, G. (2003). Evaluation of an educational intervention on br eastfeeding for NICU nurses. J Hum Lact, 19 (3), 293-302. Singhal, A., Cole, T. J., Fewtrell, M., & Lucas, A. (2004). Breastmilk feeding and lipoprotein profile in adol escents born preterm: fo llow-up of a prospective randomised study. Lancet, 363 (9421), 1571-1578. Sisk, P. M., Lovelady, C. A., Dillard, R. G., & Gruber, K. J. (2006). Lactation counseling for mothers of very low birth weight infant s: effect on maternal anxiety and infant intake of human milk. Pediatrics, 117 (1), e67-75. Slusher, T., Hampton, R., Bode-Thomas, F., Pam, S., Akor, F., & Meier, P. (2003). Promoting the exclusive feeding of own mo ther's milk through the use of hindmilk and increased maternal milk volume for hos pitalized, low birth weight infants (< 1800 grams) in Nigeria: a feasibility study. J Hum Lact, 19 (2), 191-198. Smith, M. M., Durkin, M., Hinton, V. J., Be llinger, D., & Kuhn, L. (2003). Influence of breastfeeding on cognitive outcomes at age 68 years: follow-up of very low birth weight infants. Am J Epidemiol, 158 (11), 1075-1082. Smithers, L. G., McPhee, A. J., Gibson, R. A., & Makrides, M. (2003). Characterisation of feeding patterns in infants born < 33 weeks gestational age. Asia Pac J Clin Nutr, 12 Suppl S43. Spicer, K. (2001). What every nurse needs to know about breast pumping: instructing and supporting mothers of premature infants in the NICU. Neonatal Netw, 20 (4), 35-41. Stewart-Knox, B., Gardiner, K., & Wright, M. (2003). What is the problem with breastfeeding? A qualitative analysis of infant feeding perceptions. J Hum Nutr Diet, 16 (4), 265-273.

PAGE 97

86 Swanson, V., & Power, K. G. (2005). Initiati on and continuation of breastfeeding: theory of planned behaviour. J Adv Nurs, 50 (3), 272-282. Torgus, J., Gotsch, G., & La Lech e League International. (1997). The womanly art of breastfeeding (6th rev ed.). Schaumburg, Ill.: La Leche League International. Vannuchi, M. T., Monteiro, C. A., Rea, M. F., Andrade, S. M., & Matsuo, T. (2004). [The Baby-Friendly Hospital Initiative a nd breastfeeding in a neonatal unit]. Rev Saude Publica, 38 (3), 422-428. Viggiano, D., Fasano, D., Monaco, G., & Str ohmenger, L. (2004). Breast feeding, bottle feeding, and non-nutritive sucking; eff ects on occlusion in deciduous dentition. Arch Dis Child, 89 (12), 1121-1123. What is best birth control to use after having a baby? (1989). Contracept Technol Update, 10 (10), 1S-2S. Wheeler, J., Chapman, C., Johnson, M., & Langdon, R. (2000). Feeding outcomes and influences within the neonatal unit. Int J Nurs Pract, 6 (4), 196-206. Wheeler, J. L., Johnson, M., Collie, L., Sutherland, D., & Chapman, C. (1999). Promoting breastfeeding in the neonatal intensive care unit. Breastfeed Rev, 7 (2), 15-18. Wold, A. E., & Adlerberth, I. (2000). Breast f eeding and the intestinal microflora of the infant--implications for protecti on against infect ious diseases. Adv Exp Med Biol, 478 77-93. Wolf, J. H. (2003). Low breastf eeding rates and pub lic health in the United States. Am J Public Health, 93 (12), 2000-2010. Yip, E., Lee, J., & Sheehy, Y. (1996). Breas t-feeding in neonata l intensive care. J Paediatr Child Health, 32 (4), 296-298. Ziemer, M. M., & George, C. (1990). Br eastfeeding the low-birthweight infant. Neonatal Netw, 9 (4), 33-38. Zimmerman, D. R., & Guttman, N. (2001). "Breast is best": knowledge among lowincome mothers is not enough. J Hum Lact, 17 (1), 14-19.

PAGE 98

87 BIOGRAPHICAL SKETCH Dr. Roberta Gittens Pineda received her doctor of philosophy degree at the University of Florida. She received her B achelor of Science in occupational therapy at the Florida Agricultural and Mechanical Univ ersity in 1992 and ach ieved her Master of Health Science degree at the University of Florida in 1994. She has worked as an occupational therapist, primarily in the inpati ent pediatric setting, a nd has been a lecturer at University of Florida as well as Washington University. Dr. Pineda’s primary clinical setting is the neonatal intensive care unit, where she most recently has specialized in treatment of feeding and swallowing problems in these complex, medically fragile infants. In addi tion, she suffered premature labor with her 3 pregnancies and learned, first hand, the difficulties associated with being a mother of an infant hospitalized in the neonatal intensive care unit. Dr. Pineda decided on her di ssertation topic following an invitation by the chief of neonatology at Shands Hospital to be part of a March of Dimes Advisory Committee. The University of Florida at Shands Hospita l had decided to participate in a program sponsored by the March of Dimes aimed at making the unit more developmentally supportive and family centered. Through this project, she joined efforts with a pediatrician to design a plan aimed at making the neonatal intensive care unit (NICU) more breastfeeding friendly. As she had fre quently assisted mothers with breastfeeding in the unit as part of occupa tional therapy intervention and had struggled with the issues of nursing in the NICU when her own s on was born at 29 weeks gestation, she found

PAGE 99

88 herself very passionate about fo stering changes and quickly d ecided to focus her research around the changes that were set to be made. Dr. Pineda’s disserta tion topic is entitled “Breastfeeding Practices in the Neonatal Intensive Care Unit before and after an Intervention Plan”. Dr. Pi neda has thoroughly enjoyed the research process and looks forward to a career in re search and teaching.


Permanent Link: http://ufdc.ufl.edu/UFE0015659/00001

Material Information

Title: Breastfeeding Practices in the Neonatal Intensive Care Unit before and after an Intervention
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0015659:00001

Permanent Link: http://ufdc.ufl.edu/UFE0015659/00001

Material Information

Title: Breastfeeding Practices in the Neonatal Intensive Care Unit before and after an Intervention
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0015659:00001


This item has the following downloads:


Full Text












BREASTFEEDING PRACTICES IN THE NEONATAL INTENSIVE CARE UNIT
BEFORE AND AFTER AN INTERVENTION PLAN















By

ROBERTA GITTENS PINEDA


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2006

































Copyright 2006

by

Roberta Gittens Pineda




























This dissertation is dedicated to all the mothers who have premature and medically
fragile infants in the neonatal intensive care unit (NICU). It is hoped that this and other
works with infants and mothers in the NICU will give you the hope, courage, and
information needed to "mother" in the complex environment of the NICU, during your
infant's first precious days. This dissertation is also dedicated to my husband, Jose, for
his endless source of love and inspiration. It is also dedicated to my children, Alan and
Marissa, whose early birth made me realize the importance of education and support for
mothers, as well as to my daughter Abigail, whose premature birth in the middle of this
research gave me the extra steam to see it through. This dissertation is especially
dedicated to my mom, Barbara Gittens Valentine, whose expertise with mothers and
babies was critical during my own son's hospitalization.















ACKNOWLEDGMENTS

This research would not have been possible without the support and guidance of

Dr. Lorie Richards, who has been my advisor, mentor, and friend. I want to thank Lorie

for having faith in me and inspiring me to do my best. I would like to thank the nurses

and health care professionals at Shands Hospital who participated in this research

endeavor. In particular, I give special thanks to Annmarie Brennan, who enabled this

research project to occur in the neonatal intensive care unit (NICU) at Shands and

supported the project every step of the way. I also would like to thank Cammy Pane, the

co-author of the Educational Module; Stephanie Meeks for your hours of work on "A

Mother's Gift", and other members of the Lactation Committee at Shands who helped

with my research: Elayne McNamara, Sandra Sullivan, Brenda Owens, Sheila Walker

and Jeannette Sexton. I want to give special thanks to Susan Frazier from Medela for

your support at the inservices. I also want to thank all those who provided donations as

incentives for participation: Sonny's Barbeque, Atlanta Bread Company, Scholotsky's

Deli, and TGIF. I want to thank Dr. David Burchfield, the medical director of the NICU

at Shands, for assisting with this project. I thank Sarah Boslaugh for guiding me through

the statistics and for all your patience from the many questions that came up along the

way. I would also like to thank my committee for sticking with me through the years,

and the move to St. Louis and the addition of the new baby. I appreciate your endless

patience, high expectations and sincere enthusiasm for my interests and work. I want to

thank Drs. Richards, Foss, Krueger, Seung, and Rosenbek!









I would finally like to thank my parents who always showed unconditional love and

always motivated me to strive to do better. I extend special thanks to my husband, Jose,

for always being there when I needed you most and giving me patience and love every

step of the way. You enabled me to go back to school and were there when it came to

crunch time. You have made this all possible and I am eternally grateful for your love

and support.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iv

LIST OF TABLES ........ ..... ... .... .......... ........... .......... ..... viii

LIST OF FIGURES ......... ........................................... ............ ix

A B STR A C T ................................................. ..................................... .. x

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

The Importance of Breast Milk and Breastfeeding....................................................2
Health Benefits of Breastfeeding for the Full Term Infant ................................
Health Benefits of Breastfeeding for Premature Infants ....................................
Long Term Benefits of Breastfeeding .....................................................5
Developmental Benefits of Breastfeeding............... .......... .................5
Benefits of Breastfeeding for the M other............... ...................... .............6
Current Breastfeeding Recom m endations ........................ ......... .................... ... 7
Why More Women Are Not Giving Their Infants the Benefits of Breast Milk...........8
G general B reastfeeding B barriers ........................................ ......... ............... 9
Barriers to Breastfeeding Prem ature Infants .......................................................9
Health Care Professionals Can Hinder the Breastfeeding Process in the
Neonatal Intensive Care Unit........... ........... ... .................. .. 14
Treatments to Foster Improved Breastfeeding Rates.............................................16
Need for an Educational Package for Health Care Professionals and Mothers of
Infants in the Neonatal Intensive Care Unit................................. ..... ............. ...19
Synactive Theory and Breastfeeding Interventions in the Neonatal Intensive Care
U nit................................... ........... ....... ....... ............ 20
Theory Governing the Behavior of Health Care Professionals ............................. 25
Transtheoretical Model of Behavior Change and Methods of Education ..................31
Sum m ary and R research Questions ........................................ ........................ 33

2 M E T H O D O L O G Y ............................................................................ ................... 35

P a rtic ip a n ts ........................................................................................................... 3 5
R research Interventions................ .. .. .................. .......... ............ ........ 36
Intervention 1: Breast Pump Loaner Closet ....................................... .......... 36









Intervention 2: Health Professional Education Initiative .................................37
Intervention 3: Breastfeeding Guideline ........................ .....................38
Intervention 4: Educational Pamphlet for New Mothers of Neonatal
Intensive Care Unit Infants .......................... ........................ 38
Intervention Plan Modification..................................................... 39
Design .............. ........ .................................39
P ro c e d u re s ..................................................................................................... 4 0
Program Evaluation ....... ... .. ...... .... ... ........... .. .... .... .......41
D ata C o lle ctio n ..................................................................................................... 4 2
D ata A nalysis................................................... 42
H y p oth eses ..............................................................4 3
Adjusting the Alpha Level ............. ... ......... ............. 44

3 R E S U L T S .............................................................................4 6

Intervention Im plem entation .............................................. ............... 46
The Sample ......................... .............................48
Inter-Rater Agreement ............. ......... .......... ........ 50
Demographics ...... .................. ........................ 50
Investigation for Selection Differences ..................................................... 52
Results Per Research Question................... ......................52

4 D IS C U S S IO N ......... ....................................................... .......................................59

The Effect of the Interventions on Breastfeeding Practices in the Neonatal
Inten siv e C are U nit ..................................................................... .....................59
Lim stations ................. ............. ... ......... ..................... .................64
Recommendations for Further Research ............................................... ......69
C conclusions ....................................... ........ .... .. ........ .......... 71

APPENDIX

A OUTLINE OF THE EDUCATION MODULE.......................................................73

B OUTLINE OF ITEMS ADDED TO THE INDIVIDUALIZED CARE PLAN.........75

C OUTLINE OF THE EDUCATIONAL BOOKLET FOR MOTHERS...................76

L IST O F R E F E R E N C E S ......... .. ............... ................. ................................................78

B IO G R A PH IC A L SK E TCH ..................................................................... ..................87
















LIST OF TABLES

Table pge

1-1 Stages of change in which particular processes of change are emphasized.............28

2-1 Hypothesis testing according to dependent variable............................. .............43

3-1 Demographics of the pre-intervention and post-intervention groups with test
statistics for selection differences ........................................ ......... ............... 51

3-2 B reast m ilk feeding initiation rates ........................................ ....................... 53

3-3 Comparison of rates of breastfeeding after 30 weeks gestation.............................55

3-4 Rates of ever breastfed in the neonatal intensive care unit ......................................56

3-5 Rates of breast milk feedings at discharge........................... ...............57
















LIST OF FIGURES


Figure pge

3-1 Number of times breastfed per day after 30 weeks gestation .............................54

3-2 Proportion of the stay that breast milk was provided.............................................58















Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

BREASTFEEDING PRACTICES IN THE NEONATAL INTENSIVE CARE UNIT
BEFORE AND AFTER AN INTERVENTION PLAN

By

Roberta Gittens Pineda

August 2006

Chair: Lorie Richards
Major Department: Rehabilitation Science

The benefits of breastfeeding for both mother and infant are cited extensively in the

literature. Premature infants hospitalized in the neonatal intensive care unit (NICU) have

a great need for the benefits that breast milk offers, due to their fragile health states.

However, mothers of very low birth weight infants hospitalized in the NICU have

magnified barriers to the breastfeeding process due to the complexity of medical

conditions that warrant admission to the NICU and the separation of the infant from the

mother to enable medical care. Studies have cited lack of education about lactation

among health care professionals and discrepancies in education dissemination to mothers

as a major barrier to the breastfeeding process. A three-part intervention within the

NICU was implemented that consisted of an educational initiative for health care

professionals who instruct and support mothers, modifications to the individualized care

plan that included a new breastfeeding pathway, and an educational booklet for mothers

with infants hospitalized in the NICU. Change in breast milk feeding initiation rates,









breastfeeding rates, breast milk at discharge rates, and proportion of the hospital stay that

breast milk was provided was investigated between pre-intervention and post intervention

groups. Results indicated general positive trends in all variables, but only one variable

achieved statistical significance. The percentage of infants who were ever breastfed

while in the hospital increased from 25.9% before the intervention to 44.4% after the

intervention, and this reached statistical significance with ap value of .025. Full

implementation of strategies learned in the interventions was questionable. This study

provides partial support of the three-part intervention in facilitating breastfeeding in the

NICU. Possible reasons for lack of change across all variables, as well as other possible

interventions that could affect change, are explored.














CHAPTER 1
INTRODUCTION

Breastfeeding is an important part of the occupation of mothering. However,

mothers of infants admitted into the neonatal intensive care unit (NICU) are not able to

function in the traditional role of mother. They are usually separated from their infants,

and the role of caregiver shifts to health care professionals. In addition, many infants

may be attached to life-saving or monitoring equipment, which can be intimidating for

new parents. Even more intimidating is that many of these infants are fragile or lack

neurological maturity, which affects how the mother will interact with and care for her

infant. This environment presents significant barriers to the provision of breast milk,

including the fragility of the infant, the separation of the infant from the mother, and the

behavior of the health care professionals who are focused on the medical interventions

necessary for these infants. This is unfortunate, because the established benefits of breast

milk may be even greater in these medically fragile and maturationally immature infants.

The rate of breastfeeding in the United States, despite repeated advertisement of

its benefits, is only 71.4% (Li, Darling, Maurice, Barker, & Grummer-Strawn, 2005).

Unfortunately, due to the many barriers to breastfeeding in the NICU environment, this

percentage is significantly lower for infants discharged from the NICU, with breast milk

feedings in premature infants reaching only approximately 50% (Espy & Senn, 2003).

However, despite the medical complexities of the NICU and the shift of care to health

care professionals, with adequate circumvention of barriers, mothers can be supported in

the occupation of mothering through support of breastfeeding.









Studies have identified that health care professional support is predictive of success

with breastfeeding (Swanson & Power, 2005). However, health care professionals must

be given the tools to foster breastfeeding in the complex NICU environment. Therefore,

the aim of this study was to test the efficacy of an intervention to support breastfeeding

practices in the NICU. The intervention centered on health care professional behavior

change through an educational initiative for health care professionals, modifications to

the individualized care plan (ICP) with a breastfeeding protocol, and educational

materials for mothers with infants in the NICU. It was hypothesized that the intervention

plan would foster change in health care professionals, which would then enable positive

changes in breastfeeding practices in the NICU.

The Importance of Breast Milk and Breastfeeding

Breast milk can be provided to the infant either directly through infant suckling at

the breast (breastfeeding) or by having the mother express the breast milk with a pump

and providing the milk via enteral feedings or bottle (breast milk feedings). The health

benefits of breastfeeding for the infant are cited in the literature extensively (Wolf, 2003).

Breast milk has a protective effect against many childhood health problems. Breast milk

differs from formula in that it has unique ingredients that are difficult, if not impossible,

to duplicate. Important components of breast milk are IgA antibodies, which aid in

preventing infection by creating a non-inflammatory response in body cells. This enables

a more active immune system, which demonstrates better defense against infection.

Other factors in breast milk, such as lactoferrin and oligosaccharides have also been

isolated and are believed to prevent mucous attachment, the origin of most infections

(Hanson, 1998; Hanson et al., 2002).









Infant formulas continue to strive to be similar to breast milk and have become

nutritionally advanced in the last decade, however, research continues to illustrate that

breast milk is far superior to formula (Agostoni & Haschke, 2003; Baker, 2003; Wold &

Adlerberth, 2000). Thus far, formula companies have been unable to replicate the exact

ingredients of breast milk. Perhaps predominantly due to the IgA antibodies found in

human milk, breastfed infants have superior protection from many ailments that

compromise health and prevent optimal functioning.

Health Benefits of Breastfeeding for the Full Term Infant

When comparing babies who are fed breast milk to those who are formula fed,

there is a significant reduction in respiratory infections, diarrhea, necrotizing

enterocolitis, meningitis, sepsis, urinary tract infections, atopic dermatitis, celiac disease,

and inflammatory bowel disease in the breastfed babies (Dai & Walker, 1998; Hanson,

1998; Hylander, Strobino, & Dhanireddy, 1998; Laubereau et al., 2004; Marild, Hansson,

Jodal, Oden, & Svedberg, 2004; Wold & Adlerberth, 2000). Although preliminary

studies have not been conclusive, it is also suggested that allergies and asthma are also

diminished among breastfed babies (Kemp & Kakakios, 2004; Oddy et al., 2004).

Breastfed babies have a diminished risk of sudden infant death syndrome (Alm et al.,

2002; McVea, Turner, & Peppler, 2000), as well as a significantly lower risk of mortality

after the neonatal period (Chen & Rogan, 2004).

Because it is associated with less infant illness, breast feeding may cut medical

expenses for the infant. Ball and Wright (1999) addressed excess medical costs for 3

common childhood illnesses: gastrointestinal infection, respiratory tract infection and

otitis media among breast fed versus formula fed infants in the first year of life. There

was evidence that children who were never breast fed incurred significantly more office









visits, hospitalizations, prescriptions and subsequently had higher health care costs (Ball

& Wright, 1999). Thus, the health advantages associated with breastfeeding create less

financial burden as health care costs diminish (Ball & Wright, 1999) and, more

importantly, they improve the quality of life and health status among mother-infant

dyads.

There have been a multitude of studies that have also investigated health and

developmental benefits of breast milk for premature and high risk neonates (Callen &

Pinelli, 2005). The fragile health states of these infants make them more susceptible to

infection, gastrointestinal problems, and life threatening illnesses than full term infants

(Lanari et al., 2001; Lugo-Vicente, 2003). Therefore, breast milk is perhaps more

important in this fragile population, because it diminishes the risk of multiple medical

problems, which can complicate the medical course and put them at a higher risk of

developmental sequelae.

Health Benefits of Breastfeeding for Premature Infants

Breast milk fed infants from the NICU differ significantly from formula fed infants

in incidence of infection and diagnosis of sepsis/meningitis (Hylander et al., 1998),

necrotizing enterocolitis, and retinopathy of prematurity (Hylander et al., 1998; Hylander,

Strobino, Pezzullo, & Dhanireddy, 2001; Schanler, Hurst, & Lau, 1999). Breast fed

premature babies have been noted to experience less stress than bottle fed infants as

evidenced by fewer episodes of oxygen desaturation and temperature instability (C. H.

Chen, Wang, Chang, & Chi, 2000). Breastfeeding has been cited as an intervention that

has lasting, long term benefit beyond discharge from the hospital (Harrold & Schmidt,

2002), and studies have detected significant reductions in length of stay among breastfed

premature infants (Gomez, Acosta, Sevillano, Curbelo, & Alvarez, 1997).









Long Term Benefits of Breastfeeding

More recent studies are suggesting that the effects of breast milk extend beyond the

period of infancy and early childhood, and promote long term immunity and protection

from chronic diseases. Lower risk of developing childhood cancers, obesity, type I

diabetes, and cardiovascular disease have been cited as long term benefits of

breastfeeding (Davis, 2001; Hanson, 1998; Schack-Nielsen & Michaelsen, 2006; Singhal,

Cole, Fewtrell, & Lucas, 2004). Studies of long term effects of breast milk on premature

infants have also found benefits with lower blood pressure readings in adolescence

(Owen, Whincup, Odoki, Gilg, & Cook, 2002). Despite concerns that breastfeeding

results in suboptimal growth in infancy, studies have demonstrated an increased growth

velocity in late childhood in breastfed groups (Schack-Nielsen & Michaelsen, 2006).

Additionally, improved parental attachment in the teenage years has been linked to

breastfeeding (Fergusson & Woodward, 1999).

Developmental Benefits of Breastfeeding

Research also points to the importance of breastfeeding on infant development.

Breastfeeding results in improved oral motor development and orthodontics (Page, 2001),

with early weaning increasing the risk of malocclusion, mouth breathing, dysfunctional

oral motor development and subsequent suboptimal speech development (Neiva, Cattoni,

Ramos, & Issler, 2003; Viggiano, Fasano, Monaco, & Strohmenger, 2004). Breastfed

infants have improved visual motor skills (Birch et al., 1993), have better responses to

pain (Gray, Miller, Philipp, & Blass, 2002) with improved neurobehavioral organization

(Hart, Boylan, Carroll, Musick, & Lampe, 2003) and have demonstrated improved scores

on mental functioning (Gomez-Sanchiz, Canete, Rodero, Baeza, & Avila, 2003).









Premature infants have a greater risk of poor neurological outcome, which suggests

that breast milk may be critical to enable optimal developmental functioning. Research

has demonstrated improved cognitive and motor functioning scores among premature

infants who had breast milk feedings (Lanari et al., 2001; Schanler et al., 1999). Studies

demonstrate improved cognitive scores and intelligence quotients that continued to be

evident through middle childhood among breastfed infants (Lucas, Morley, Cole, &

Gore, 1994; Lucas, Morley, Cole, Lister, & Leeson-Payne, 1992; Morley, Cole, Powell,

& Lucas, 1988; Smith, Durkin, Hinton, Bellinger, & Kuhn, 2003).

Benefits of Breastfeeding for the Mother

In addition to the benefits given to the baby through breastfeeding, there are also

benefits for the mother. Women who succeed with breastfeeding comment on the special

bonding experience (Torgus, Gotsch, & La Leche League International., 1997). Women

who breastfeed have less postpartum bleeding (Chua, Arulkumaran, Lim, Selamat, &

Ratnam, 1994) and have a faster rate of pregnancy related weight loss (Dewey, Heinig, &

Nommsen, 1993). Women who breastfeed also postpone ovulation (Rea, 2004), and

breastfeeding has been demonstrated to serve as a natural and effective birth control

method in the postpartum period ("How breast-feeding postpones ovulation," 1985;

"What is best birth control to use after having a baby?," 1989). In addition, women who

succeed with breastfeeding lower their risk of osteoporosis (Chantry, Auinger, & Byrd,

2004), obesity (Rooney & Schauberger, 2002), ovarian cancer, breast cancer (Mikiel-

Kostyra, 2000), diabetes and rheumatoid arthritis (Rea, 2004).

Mothers of preterm infants have additionally reported an improved sense of well

being, as they feel that they are actively contributing to the health of their babies

(Schanler et al., 1999). Having an infant in the NICU is a difficult challenge. Mothers









may feel shut off from their infant as the nurses take on the role of primary caregiver.

Being able to provide the best source of nutrition can be one task that embraces the

mother in her role and fosters parental involvement, as it is something only she can do for

her baby.

Current Breastfeeding Recommendations

The health benefits of breastfeeding for mother, baby and health care systems are

evident and extensive. Therefore, the American Academy of Pediatrics (AAP), as well as

the American Dietetic Association, have responded to the benefits of breastfeeding for

mother and baby by recommending exclusive breastfeeding for the first 6 months with

breastfeeding and supplemental solids until the infant is 1 year old ("Breastfeeding and

the use of human milk. American Academy of Pediatrics. Work Group on

Breastfeeding," 1997). The World Health Organization recommends breastfeeding for at

least 2 years ("The optimal duration of exclusive breastfeeding: results of a WHO

systematic review," 2001). However, breastfeeding statistics continue to demonstrate a

gap between these recommendations and how the general population of mothers in the

United States chooses to feed their infants (Li et al., 2005).

Some women never breastfeed, some breastfeed exclusively, some supplement

breastfeeding with bottle feeds of human milk, some supplement breastfeeding with

bottle feeds of formula, some bottle feed formula only, some bottle feed breast milk only,

and some women start out breastfeeding and completely wean once formula is

introduced. Statistics from the year 2003 indicated that 71.4. % of women in the general

population initiated breastfeeding while in the hospital, and 35.1% of mothers were still

breastfeeding when their babies turned 6 months of age. At one year of age, 16.1%

continued to provide some breast milk for their infants (Li et al., 2005). Variable rates of









breastfeeding have been reported for infants in the NICU. The rates for infants receiving

some breast milk at some point range from 50% to 83% (Byrne & Hull, 1996; Espy &

Senn, 2003; Meier, Engstrom, Mingolelli, Miracle, & Kiesling, 2004; Smithers, McPhee,

Gibson, & Makrides, 2003; Yip, Lee, & Sheehy, 1996). However, studies have found that

the rates of breast milk feeds at discharge are 64%, with the rate of breastfeeding being

38% (Yip et al., 1996). One study found that at 4 months of age, only 24% of infants born

at less than 33 weeks gestation continue to receive some breast milk feedings (Smithers et

al., 2003). Subsequently, breastfeeding rates at hospital discharge for infants born

prematurely are significantly lower than those of full term, healthy infants (Yip et al.,

1996).

To understand the suboptimal breastfeeding rates for premature and high risk

neonates, it is beneficial to investigate the barriers to breastfeeding. By understanding

the barriers to breastfeeding, appropriate interventions can be developed and

implemented to facilitate improved breastfeeding practices.

Why More Women Are Not Giving Their Infants the Benefits of Breast Milk

Maternal demographics are strong predictors of breastfeeding. Women with higher

socioeconomic status, more education, previous children but smaller family size,

Caucasian race, and women who are married are more likely to succeed with

breastfeeding (Bueno et al., 2003; Kronborg & Vaeth, 2004; Mitra, Khoury, Hinton, &

Carothers, 2004). However, perinatal medical condition is also an important predictor of

successful breastfeeding (Espy & Senn, 2003; Powers, Bloom, Peabody, & Clark, 2003).

Scott (2006) discovered that the infant being admitted to the intensive care unit was the

strongest predictor of not being exclusively breastfed at discharge (Scott, Binns, Graham,

& Oddy, 2006). Other studies have concluded that having a cesarean section, as well as









having a low birth weight infant, makes a woman less likely to breastfeed (Hwang,

Chung, Kang, & Suh, 2006). Demographic factors as well as medical condition and type

of delivery have been shown to be strong influences on the decision to breastfeed and the

success of breastfeeding.

General Breastfeeding Barriers

The barriers to breastfeeding full term, healthy infants include lack of family and

spouse support and perceptions of lack of support; (Arora, McJunkin, Wehrer, & Kuhn,

2000; Matthews, Webber, McKim, Banoub-Baddour, & Laryea, 1998; Scott et al., 2006),

social withdrawal and isolation (Stewart-Knox, Gardiner, & Wright, 2003), perceived

inconvenience (Zimmerman & Guttman, 2001), perceived inadequacy to provide

adequate nutrition (Arora et al., 2000; Matthews et al., 1998), early supplementation or

first feeding of formula (Wheeler, Chapman, Johnson, & Langdon, 2000), lack of

appropriate education (Arora et al., 2000), functional problems with the process of

breastfeeding; (Bick, MacArthur, & Lancashire, 1998), intent to return to work (Arora et

al., 2000; Matthews et al., 1998; Piper & Parks, 1996; Ryan, Wysong, Martinez, &

Simon, 1990), and maternal illness (Black & Hylander, 2000; Riskin & Bader, 2003).

Barriers to Breastfeeding Premature Infants

Breastfeeding challenges are stronger and even more numerous for the high risk

neonate, despite these babies having an even greater need for human milk. Mothers of

infants who are born prematurely have unique challenges to successful breastfeeding.

One barrier to breastfeeding the premature infant is that when an infant is born

prematurely and warrants admission into the NICU, the mother is separated from her

baby (Black & Hylander, 2000). The time after birth is very different for these mothers

compared to those with full term infants. There is usually not a period of being able to put









the baby to breast immediately after birth, and breastfeeding may not be possible for

several weeks or months, depending on the infant's level of prematurity and medical

instability.

When visitation is possible, mothers may visit their baby in the intensive care unit.

Here, they may have difficulty with the transition to motherhood as the doctors and

nurses make decisions related to the care of the baby, including whether or not the mother

may hold her new baby (Holditch-Davis & Miles, 2000; Lupton & Fenwick, 2001). The

machines and equipment present and being utilized by the baby in the NICU can be

overwhelming for many parents (Wheeler et al., 2000), and this environment is very

different from the quiet, home-like environment one would typically envision during the

first days of the baby's life. An additional barrier is that the ability to achieve let down, in

which breast milk begins to flow during infant feeding and pumping, is hindered by the

inability to relax in this stressful environment (Beresford, 1984; Nyqvist, Ewald, &

Sjoden, 1996; Wheeler, Johnson, Collie, Sutherland, & Chapman, 1999).

Many low birth weight infants are unable to breast feed for several weeks or

months following birth (Hill, Andersen, & Ledbetter, 1995). Their gastrointestinal

systems are immature and feedings can be dangerous or life threatening. During the first

days, a baby may be fed intravenously or through an orogastric or nasogastric tube, in

which feeds may be slowly introduced and advanced. When the gastrointestinal system is

ready for bolus feeds directly into the stomach, the baby's immature central nervous

system may not enable consistent presentation of sucking and swallowing responses to

enable safe oral feeding (Nyqvist, Sjoden, & Ewald, 1999; Ziemer & George, 1990).

Although breastfeeding may not be possible initially, breast milk can be expressed by the









mother with a breast pump, and the infant can be advanced on gastric feeds with breast

milk.

Just as the first feeding by breast is a good predictor of sustained breastfeeding in

full term infants, timely pumping for those mothers who are unable to put the baby to

breast is an important predictor of sustained breastfeeding in the premature baby (Jaeger,

Lawson, & Filteau, 1997). Women of premature babies may express their breast milk and

supply it to hospital staff so that the baby may be tube fed with human milk instead of

infant formula (Meier & Brown, 1996). Additionally, this process establishes and

maintains a milk supply so that the mother will not have diminished or absent milk

supply, when the baby is stable enough to engage in the breastfeeding process. Barriers to

breastfeeding related to this early process include increased amounts of stress (Docherty,

Miles, & Holditch-Davis, 2002; Miles, Funk, & Kasper, 1992) and time constraints

placed on these new mothers, difficulty in acquiring hospital grade breast pumps for milk

expression, lack of special bonding and emotional feedback received from using a pump,

delayed initiation of milk expression, separation from the infant, reliance on medical

technology to feed the baby, and psychological adjustment to the idea of not being able to

breastfeed for weeks or even months (Byrne & Hull, 1996). With the mother

experiencing stress associated with coping with her sick baby (Miles et al., 1992) and a

shift of care from the mother to the baby after the birth, there may be delayed initiation of

pumping and lack of accessibility of hospital grade pumps to promote milk supply in an

efficient manner.

New studies are highlighting the importance of investigating barriers at different

time periods during an infant's hospitalization (Callen & Pinelli, 2005). If a mother









successfully overcomes the challenge of maintaining her milk supply, there are additional

challenges as an infant approaches discharge from the hospital. Poor central nervous

system maturity may initially prevent complete success with breastfeeding, and

dysphagia is common in this population (Hill, Hanson, & Mefford, 1994). The literature

cites problems with the mechanics of breastfeeding a premature baby as a barrier to

breastfeeding (Kavanaugh, Mead, Meier, & Mangurten, 1995). Once discharge is

approaching, there frequently is little time to enable a mom and baby to achieve

successful breastfeeding (Meier & Brown, 1996). Bottle feeding is often preferred as it

allows nurses to orally feed the baby when the mother is not present and the exact amount

ingested can be accurately measured (McGrath & Braescu, 2004). Additionally, infants

can be fed more passively with bottle feeding compared to the active process of

breastfeeding. Although this can have negative side effects of desaturations and

bradycardic events as well as increased risk of gastroesophageal reflux, it is frequently

preferred because of the efficiency of oral feeding. However, breastfeeding can be

achieved in this population despite the preferences of health care staff and the challenges

that must be overcome.

Infants in the NICU are fed according to a schedule, typically every 3 to 4 hours,

and may be fed via bottle, tube or breast to optimize the nutritional status. The inability

of a preterm baby to breastfeed on demand in an environment with scheduled feedings

via different modes is a significant barrier to breastfeeding (Black & Hylander, 2000). It

undermines the typical procedures associated with breastfeeding a full term infant which

involves feeding a baby when he/she shows hunger signs and not supplementing until

breastfeeding is well established. This allows for the infant to ingest a smaller feeding









and thus become hungrier and to have a more rigorous, larger feeding for the next one.

However, scheduled feedings of specific amounts can affect the transition to active

breastfeeding in the NICU. If the infant typically receives a prescribed amount of breast

milk by bottle or nasogastric tube and the mother attempts to breastfeed, not knowing the

exact amount of breast milk ingested by breastfeeding may result in the health care

professional doubting if there was adequate intake. Thus supplementation frequently

occurs, which inhibits the next breastfeeding session, decreases the demand for breast

milk produced by the mother and diminishes milk supply, and thus becomes a cyclic

problem.

Diminished milk supply is cited extensively in the literature as one of the

significant barriers to breastfeeding in the NICU (Callen & Pinelli, 2005). Among the

earliest of premature infants, the average duration of providing breast milk is 4-5 weeks

(Byrne & Hull, 1996). Lack of ability to engage in active breastfeeding due to the health

status of the infant, lack of presentation of sucking and swallowing capabilities of the

infant and the need for the mother to demonstrate consistent milk expression via a breast

pump to establish and maintain a milk supply all contribute to diminished milk supply in

mothers of infants hospitalized in the NICU.

Infants who are born prematurely have different nutritional needs than full term

infants. Thus, there are premature infant formulas that are utilized in the neonatal period

and many are used until one year of life. When gastric feeds are being established,

physicians are concerned with establishing a good weight gain trend. If an infant is not

gaining weight as desired, the physician may increase caloric density or add lipids to

infant formula or expressed breast milk to foster weight gain. Frequently nutrients and









calories are added to human milk by the way of human milk fortifiers (Chan, 2001),

which promote establishment of a good weight gain curve. However, this is a barrier to

breastfeeding as the mother perceives that the composition of her breast milk is not

adequate to promote the health of her child. She may perceive that formula or fortified

breast milk by bottle is essential to enable the appropriate milk composition (Kavanaugh

et al., 1995). However, studies suggest that mother's milk of premature babies differs

from that of full term infants with the most notable differences evident between 4-6

weeks after delivery (Gross, David, Bauman, & Tomarelli, 1980). Additionally, the use

of hind milk, the milk at the end of a breastfeeding session that is very high in fat content,

has been shown to facilitate weight gain in premature babies (Slusher et al., 2003).

Research is identifying that there are factors in the hospital setting that influence

breastfeeding decisions. The site of care is a strong predictor of choice and success with

breastfeeding (Powers et al., 2003). In addition, literature is highlighting the important

role of health care professionals on the decision to initiate and continue breastfeeding

(Nyqvist, Sjoden, & Ewald, 1994; Swanson & Power, 2005).

Health Care Professionals Can Hinder the Breastfeeding Process in the Neonatal
Intensive Care Unit

There are many inconsistencies in what parents are educated about and many

disparities in what parents are instructed to do by health care professionals, and this can

be confusing and frustrating for new mothers (Byrne & Hull, 1996; Nyqvist et al., 1994).

One study identified that 48% of mothers reported receiving conflicting advice about

breastfeeding in the NICU (Jaeger et al., 1997).

Mothers rely on health care professionals in the NICU to provide accurate,

complete, and consistent information about breastfeeding their high risk infant. Many of









the mothers of preterm infants have not had an opportunity to fully prepare for

motherhood before the birth of their baby. Some may have planned on taking a

breastfeeding or parenting class, but the early arrival dampened these plans. In addition,

the NICU is a medically complex environment, and parents need guidance on how to

function in their role as mother with the environmental constraints. The literature

suggests that there is a lack of health care professionals who are trained in lactation and

breastfeeding with premature babies, and that many health care professionals have

incorrect knowledge and negative beliefs about lactation (Berens, 2001; Pantazi, Jaeger,

& Lawson, 1998; Register, Eren, Lowdermilk, Hammond, & Tully, 2000; Spicer, 2001).

Yet, it is the health care professionals in the NICU, despite lack of education, who are

teaching and instructing these new mothers on breast milk feedings and breastfeeding.

Health care professionals can influence breastfeeding behaviors, and their own

values and beliefs concerning breastfeeding can have supporting or damaging results on

the breastfeeding process (Ekstrom, Matthiesen, Widstrom, & Nissen, 2005). Studies

have identified that education and training can affect attitudes and knowledge about

breastfeeding (Bernaix, 2000; Siddell, Marinelli, Froman, & Burke, 2003; Swanson &

Power, 2005). However, to date, there are no studies that have investigated the indirect

impact of health care professionals' behavior change with acquisition of knowledge and

attitude change on breastfeeding outcomes in mothers and infants in the NICU.

The American Academy of Pediatrics issued a statement in February 2005 that

stated that breastfeeding or human milk feedings are recommended for all healthy,

premature and high-risk infants for whom breastfeeding is not specifically

contraindicated. It further states that health care professionals should provide complete,









current and accurate information to parents on the benefits and techniques involved with

breastfeeding (Gartner et al., 2005). However, to date there has been no specific,

standard set of tools developed and utilized to achieve education of health care

professionals to enable consistent information dissemination to parents.

Treatments to Foster Improved Breastfeeding Rates

The United States Surgeon General, David Satcher, identified breastfeeding as a

national health priority and released the "Health and Human Services, Blueprint for

Action on Breastfeeding" in October 2000. In response to this, The World Health

Organization in conjunction with UNICEF is promoting breastfeeding through the baby

friendly hospital initiative. To be designated as "baby friendly," the hospital must follow

the ten steps to successful breastfeeding:

Every facility providing maternity services and care for newborn infants should:

* Have a written breastfeeding policy that is routinely communicated to all health
care staff.

* Train all health care staff in skills necessary to implement this policy.

* Inform all pregnant women about the benefits and management of breastfeeding.

* Help mothers initiate breastfeeding within half an hour of birth.

* Show mothers how to breastfeed, and how to maintain lactation even if they should
be separated from their infants.

* Give newborn infants no food or drink other than breast milk, unless medically
indicated.

* Practice rooming-in (i.e., allowing mothers and infants to remain together) 24 hours
a day.

* Encourage breastfeeding on demand.

* Give no artificial teats or pacifiers (also called dummies or soothers) to
breastfeeding infants.









* Foster the establishment of breastfeeding support groups and refer mothers to them
on discharge from the hospital or clinic.

Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of
Maternity Services, a joint WHO/UNICEF statement published by the World Health
Organization.

These ten steps specifically involve how health care professionals and the hospital

system will deal with mother-infant dyads on regular maternity floors within a hospital.

Once these ten steps are put into practice, the hospital may apply for designation as a

baby friendly hospital. Hospitals that have been through the process of baby friendly

designation have demonstrated improvement with breastfeeding rates (Philipp, Malone,

Cimo, & Merewood, 2003). For example, Boston Medical Center was designated as

baby friendly in 1999, with increased breastfeeding rates of 58% in 1995 to 86.5% in

1999. Breastfeeding rates were maintained at this high rate from 1999 to 2001.

Although the baby friendly designation is specifically for the maternity floors of a

hospital system and not designed for the unique needs of the high risk population, there

have been positive effects on breastfeeding practices in the NICU following designation

(Vannuchi, Monteiro, Rea, Andrade, & Matsuo, 2004). However, a program specifically

designed for the high risk population with its significant barriers to breastfeeding, could

have the potential for greater enhancement in breastfeeding rates in the NICU Premature

infants are a unique population and warrant individualized breastfeeding strategies and

interventions (Kavanaugh et al., 1995; Meier, 2001)

Many hospitals have implemented practices that will educate and promote

breastfeeding practices for infants within the NICU. However, only a few have evaluated

their programs for effectiveness. The Rush Mother's Milk Club has proven to be

effective in increasing breastfeeding rates (Meier et al., 2004) by enabling free access to









hospital grade breast pumps, by offering lactation support 24 hours a day, by use of cue

based feeding when an infant consumes at least 50% of feeds orally, and by providing of

breastfeeding peer support. Other studies have found positive increases in breastfeeding

initiation with the introduction of counseling as well as contact with lactation consultants

among mothers with low birth weight infants (Pinelli, Atkinson, & Saigal, 2001; Sisk,

Lovelady, Dillard, & Gruber, 2006). A workbook program introduced at 2 different time

periods during the hospital stay was also shown to have positive effects on breastfeeding

with premature infants in one hospital setting (Jang, 2005).

Many papers have documented specific protocols to instruct mothers and promote

breastfeeding (Isaacson, 2006; Premji, Paes, Jacobson, & Chessell, 2002; Spicer, 2001),

but no research has been conducted to determine the effectiveness of such

recommendations. Although studies have shown increased knowledge acquisition by

health care professionals in the NICU following an education plan (Siddell et al., 2003),

there are no studies that have investigated the effect of education of health care

professionals coupled with protocols and standard written information for parents on

changes in breastfeeding practices in the NICU.

Of all interventions for breastfeeding with the high risk neonate, the Rush Mother's

Milk Club is probably the most well known. The health care providers in the NICU at

Rush University have an increased level of knowledge regarding breastfeeding in the

NICU. With this knowledge, they are able to implement advanced strategies, such as

putting breast milk in a centrifuge to modify the fat content to promote weight gain

(Meier, 1998). Many studies have been conducted to evaluate the effectiveness of the

Rush Mother's Milk Club with positive results (Meier et al., 2004). However, the high









level of education about breastfeeding among health care professionals at Rush

University likely underlies the capability to implement the more advanced interventions.

For many hospitals, basic education on lactation with high risk infants is lacking. In

addition, many interventions that have proven to be effective, including the use of free

access to pumps and accessibility to lactation counseling, have associated costs, which

many hospitals do not have budgets to support.

Need for an Educational Package for Health Care Professionals and Mothers of
Infants in the Neonatal Intensive Care Unit

Breastfeeding and human milk feedings are possible and beneficial in the NICU,

however, there is significant support and education that must occur to enable success

among mothers in the NICU (do Nascimento & Issler, 2004). Education and treatments

should be based on research with premature and high risk infants, as they have unique

needs in the breastfeeding process (Meier, 2001). The use of developmental care

practices can drive the understanding of appropriate breastfeeding interventions based on

infant readiness cues (Karl, 2004).

Although there have been many articles and books written on the subject of

breastfeeding with the high risk neonate, there was no up to date, comprehensive,

evidence based education packet with complementary information for both parents and

health care professionals available on the market. By understanding each of the

challenges to breastfeeding the medically fragile infant and the specific developmental

and nutritional needs of the high risk infant, an education initiative can be developed and

then evaluated for efficacy.









Synactive Theory and Breastfeeding Interventions in the Neonatal Intensive Care
Unit

While investigating, developing and implementing appropriate interventions

targeted to improve breastfeeding rates, it is important to consider the vulnerability of the

special population in the NICU and the impact of environmental stressors on this

population. One theory that can be used to guide appropriate interventions in the NICU

is the synactive theory, which identifies the process of neurobehavioral maturation of the

infant. Breastfeeding interventions should be individualized, based on infant readiness

cues and tailored to the responses of the infant (Blackburn, 1998). Review of the

synactive theory and its application to breastfeeding should be part of any education

initiative for health care professionals who serve the vulnerable infants in the NICU.

The synactive theory was developed by Heidelese Als in the early 1980's (Als,

1982). The process of developmental care, related to the synactive theory, is intended to

facilitate a well organized, stable infant who may optimally grow and develop.

Developmental care has been instituted in many neonatal intensive care units around the

country as a developmental care initiative. It provides a framework for interacting with

these fragile infants without jeopardizing health. The synactive theory of development

describes the process of neurobehavioral maturation related to an infant's internal and

external environment. As the infant attempts to interact with the external environment, a

dynamic process occurs internally among 5 different subsystems. The dynamic process

among the 5 subsystems can explain the behaviors and responses exhibited by the

premature infant and can guide appropriate interventions.

The 5 distinct, yet interdependent subsystems are physiological or autonomic,

motor, state organization, attention and interaction, and the state regulation subsystems.









These subsystems are believed to impact the functional organization of the infant's

system in an ordered fashion. The subsystems are not hierarchical, but they are believed

to be ordered and interdependent (Als, 1982; Als, 1994).

The physiological subsystem is considered the core of the system. It is the

foundation for which all of the other systems gain stability. This physiological subsystem

allows the infant to have control over autonomic functions such as voiding, breathing,

maintaining steady vital signs, and processing nutrition. The motor system provides

control over movement, muscle tone, and posture. The state subsystem gives the infant

control over his/her level of consciousness. It enables the infant to move through

identifiable states and move smoothly from one state to another. The

attentional/interactive subsystem enables control over functional responses to stimulation

in the environment and governs the ability to interact. The state regulation subsystem

gives the infant the ability to balance environmental stressors and recover by modulating

all the other systems (Als, et al, 1982). While the autonomic subsystem serves as the

foundation of the system, the state regulation subsystem serves as the gate keeper and is

achieved with increasing maturity.

A cone shaped diagram is used to represent the complex development of the infant

as it relates to the five subsystems (Als, 1982). The cone has its tip at the bottom with the

funnel going upward. The five subsystems can be viewed at the top of the open cone. At

the smallest center is the physiological subsystem with the remaining (motor, state,

attentional/interaction) forming layers outside the center, much like an onion. The

youngest fetus is represented at the bottom of the cone and has with it only components

(not yet a fully developed system) from the autonomic subsystem. This indicates that









infants who are born early are unable to integrate the higher order systems. Stressors

within the system interfere with the physiologic capabilities of the infant. Subsequently,

early premature infants are incapable of any interaction and need all their energy to

maintain homeostasis of the system to sustain life. There is also instability in the

physiologic system, which is why premature infants frequently have medical or

physiological problems when born early and have to contend with the stressful

environment.

With the earliest fetus at the bottom of the cone, increasing gestational age is

associated with increasing maturity spreading out to the other layers of the system. With

increasing gestational age and thus maturity, the infant may extend its control out to the

next level, the motor subsystem. The infant may demonstrate improved muscle tone and

postural control. This concept parallels the literature, which demonstrates improvement

in muscle tone and reflex development with increasing gestational age (Allen & Capute,

1990). Further maturity may extend the infant's control out to the state subsystem

enabling the infant to demonstrate some awake periods and to smoothly transition from

one state to another. As maturity continues, the infant may be able to achieve some

attention and interaction with caregivers and the environment. Lastly, as the infant

approaches term and achieves more maturity, he/she will be able to tolerate stressors,

cope with them, reorganize and continue interaction without being knocked down to

functioning at the lower subsystems.

The term synaction refers to the relationship between all the subsystems and how

instability in one system has the potential to affect all the other subsystems and thus the

integrity of the child's health and well-being (Als, 1982). On the right side of the cone









are gestational ages that reflect the increasing maturity of the system (dependent on the

subsystems) with increasing gestational age. On the left side of the cone are influences of

the environment on the maturation of the system, with a break in the intrauterine and

extrauterine environment before term to indicate the premature birth, thus representing

the role of environmental stresses before full maturity occurs. With earlier birth and

more stressors from the environment, there will be a resultant decrease in

neurobehavioral maturity.

When an infant is stressed from the environment, he/she may initially demonstrate

stress reactions based on the predominant level of neurobehavioral maturation. If he/she

is primarily functioning in the physiological state, he/she may demonstrate bradycardic

events, oxygen desaturations, hiccups, stooling, or spitting up. If he/she is primarily in

the motor state, he/she may demonstrate grimacing, arching, saluting, finger splaying, or

sitting on air. If he/she is in the state subsystem he may shut down or move to a light

sleep state. If he/she is in the attentional/interactive subsystem, he/she may avoid

interaction by turning away. The infant has the capability to re-achieve organization with

time outs or specific strategies designed to help him cope. Interventions designed to help

infants cope with stressors include providing boundaries, swaddling, positioning in

flexion, bringing hands to mouth, minimizing environmental stimulation, non nutritive

sucking, and enabling grasping. Infants additionally will demonstrate approach signals

such as smiling, mouthing, ooh face, cooing, quiet and alert state, and soft and relaxed

facial expressions when they are ready for interaction (Hussey-Gardner, 1996). Once

reorganized and demonstrating approach signals, the stressor may be reintroduced slowly.









The synactive theory defines the subsystem along with stress and coping signs

consistent with each of the subsystems to enable caregivers to identify and respond to

behaviors appropriately. When stress signs are recognized, the caregiver can then

withdraw the stressor that contributed or help facilitate the infant to cope. Once a time

out is given and the infant reorganizes, the treatment or interaction can continue. This

"give and take" enables the infant to function optimally within the environment and

allows him/her to continue to benefit from interaction and stimulation, including

breastfeeding, as he/she tolerates. The synactive theory proposes an approach for each

individual child that is adapted to fit the needs of that infant. It promotes infant

development to occur as normally as possible, despite medical complications and

immaturity brought on by an early birth.

Infants born at earlier gestational ages and with decreased neurobehavioral

maturation are not capable of handling environmental stressors typically experienced by

newborns. When interventions for these neurobehaviorally immature infants are done

without respect for readiness cues, the infant is at risk for regressing to one of the more

primitive states, putting them at risk of developmental and medical sequelae.

Breastfeeding is an environmental stressor. Without observing infant readiness cues and

introducing breastfeeding at the appropriate time individualized for each infant, optimal

responses to the environment as well as optimal neurological maturation are delayed.

Therefore, breastfeeding cannot be introduced at a prescribed time or introduced in the

same way that it would be for a full term infant, but it must be based on the

neurobehavioral maturation of the infant and advanced according to stress and readiness

cues. These concepts need to be in any educational program for both health care









professionals and for mothers of infants in the NICU to help them implement the best

breast milk feeding program for these infants.

While the synactive theory defines the appropriate time and way to introduce

interventions, it also assists with understanding that many extremely low birth weight

infants and low birth weight infants are too neurologically immature and fragile to

engage in any breastfeeding. Subsequently, mothers of infants in the NICU need

equipment that will enable them to achieve and maintain a milk supply, in the absence of

infant suckling at the breast, until the infant is appropriate for nutritional breastfeeding.

Hospital grade breast pumps that will enable long term milk expression are necessary for

mothers with infants in the NICU to maintain adequate milk supplies while they are

waiting for their babies to become medically and developmentally stable enough to

engage in feeding at the breast.

Understanding the synactive theory and implementing developmentally supportive

care can instruct and guide interventions and NICU practices as they relate to

breastfeeding the premature infant. One case study in the literature highlighted the

significant benefits of a developmentally supportive plan on the breastfeeding process in

a premature infant (Nyqvist et al., 1996). The synactive theory should guide the

development of any educational module and inservice for health care professionals who

serve infants in the NICU.

Theory Governing the Behavior of Health Care Professionals

Studies have identified that there is a lack of education about lactation and lack of

consistent support and instruction about breastfeeding among health care professionals in

the NICU (Ekstrom, Widstrom, & Nissen, 2005; Pantazi et al., 1998). Having educated

health care professionals will not necessarily impact breastfeeding practices. It is how









those health care professionals respond and utilize that education to execute new

interventions that will foster change and subsequent improvement in human milk

feedings. The behavior of health care professionals in the NICU needs to change to

support the breastfeeding process. Studies have shown that behavior change is much

more successful when interventions are matched to the stage of readiness to change

(Prochaska, Prochaska, & Levesque, 2001). The transtheoretical model (TTM) provides

a description of how the individual's state of readiness to change translates into

behavioral change.

The premise of the TTM is that there are several stages associated with behavior

change. Individuals go through these stages on their way to making a change. They may

start anywhere along the continuum of the 5 stages and they may move forward or

backward or skip stages, but there is some progression through the stages on their way to

behavior change. The TTM has been used to describe many health behavior changes,

such as use of sunscreen, use of condoms, self examination breast checks, smoking

cessation and initiating an exercise plan. Appropriate interventions can be tailored to the

stage of readiness to change.

The five stages of the TTM are precontemplation, contemplation, preparation,

action and maintenance. Each stage identifies if the individual has an intention of

changing behavior and identifies how significant the intention to change behavior is

(Prochaska & DiClemente, 1983). Someone in the precontemplation stage does not

intend to take action within 6 months. A person in the contemplation stage intends to

take action within the next 6 months. Someone in the preparation phase intends to take

action in the next 30 days. The action stage refers to persons who have made obvious









changes less than 6 months ago. The maintenance stage refers to individuals who have

made significant changes more than 6 months ago.

Interventions that are implemented to enable behavior change should be conducted

in such a way that the intervention matches the stage an individual is in, or should be

tailored to how ready the person is for change. Ten fundamental processes that can affect

change have been identified along with interventions that can be matched to the stage of

readiness to change (Table 1-1) (Prochaska et al., 2001). Certain interventions will only

be effective if they are appropriate for the stage of readiness for behavioral change of the

individual. For example if someone is in the precontemplation stage, interventions should

be focused on educational initiatives and strategies to promote reflection about how the

change may impact the person's situation and how it will benefit others, while

interventions for the person in the contemplative stage should be about supporting and

motivating the person to actually initiate the intended behavioral change. These latter

interventions provided to the precomtemplater would not be effective because the person

has not yet formed the conviction that change is needed or desired and could actually

create significant resistance and prevent behavioral change from succeeding (Prochaska

et al., 2001). By enabling stage matched interventions, education and strategies can be

implemented to foster movement across stages to enable successful change.

The TTM has been used to address behavior change within organizations by

targeting employees. By providing stage matched interventions, all employees can be

given opportunities to participate in the change process. Although stage matched

interventions have been shown to facilitate movement toward action, not all employees

may achieve action. Change at the organizational level should include interventions that









are stage matched to each stage of change to give all employees the opportunity for

participation in the change initiative (Prochaska et al., 2001).

Table 1-1. Stages of change in which particular processes of change are emphasized
Stages
Precontemplation Contemplation Preparation Action
Maintenance
Process Conscious
Raising,
Dramatic Relief,
Environmental -
Reevaluation
Self
Reevaluation
Self -
Liberation
Contingency-
Management,
Helping
Relationship,
Counter
Conditioning,
Stimulus Control

To foster behavior change regarding support and information dissemination about

breastfeeding within the NICU, the TTM can be utilized to structure an intervention

program. By matching breastfeeding interventions to stages of readiness to change, all

health care professionals can have the opportunity to participate in the change process.

By introducing interventions that can target health care professionals in each stage of

readiness to change, a meaningful intervention plan can be implemented to foster change

at the organizational level. A breastfeeding intervention for the NICU with 4 parts could

theoretically target individuals in all of the stages of readiness to change.

For those health care professionals in the pre-contemplation stage, there is no

intention of making a behavior change. Health care professionals in the contemplation

stage intend to make a change within the next 6 months. Both of these stages describe









individuals who are not yet ready for action, and interventions for those in either of these

stages would be the same. Interventions for those in these stages should be two-fold.

One intervention, education, would be aimed directly at the health care professional.

With education, conscious raising can be fostered. With it, it is hoped that health care

professionals will have the resources needed to become aware of the need for

breastfeeding support in premature infants and will start to see solutions to the problem.

However, because those in the pre-contemplation stage have no intention of making a

behavior change, there would be no motivation to participate in an educational initiative.

Likewise, those in the contemplation stage also may need incentives to push them to

participate. Therefore, incentives on annual review, food, prizes and continuing

education units could serve as motivation for participation among those who lack

motivation to attend without some perceived personal benefit. With the participation in

the educational initiative, they would be exposed to content of the education that

highlights the great benefits of breast milk and the need for support and education among

mothers. With this increased awareness of the problem and possible solutions, behavior

change could be fostered.

The other intervention should be aimed at achieving some level of support and

education for the mothers. Materials that provide consistent and thorough information

could be issued to all new parents in the NICU to ensure that all mothers receive

information about initiating and sustaining breast milk feedings in the NICU. Although

this intervention would serve to enable education of mothers, it also may serve as a

conscious raising effort for the health care professional, who may be asked for guidance

and support by the mother on information contained in the educational materials. The









health care professional may then better understand the problem and the need for

behavior change to facilitate success with the breastfeeding process.

Individuals in the preparation phase intend to make a change in the next 30 days.

These individuals are ready for action oriented interventions. Therefore, clinical

pathways or protocols could foster change in how they deal with breastfeeding mothers.

Protocols or pathways, which become a part of required paperwork, could theoretically

facilitate professionals to make a commitment to change by giving protocols that

necessitate action.

Those in the action and maintenance stages have already made changes. The

mother's positive experiences could serve as motivation from the environment, and there

could be other motivators for continued compliance from within the organizational

structure, such as acknowledgement on the annual review and identification as one who

has expertise in breastfeeding with high risk infants. Those in the action and preparation

phase also may take an active part in motivating others and facilitating more positive

change related to breastfeeding interventions in the NICU.

Thus based on the TTM, an educational initiative that includes educational

materials to parents, opportunities for education with incentives for health care

professionals, and protocols or pathways of care could be effective in facilitating change

in breastfeeding practices in the NICU, and each is theoretically matched to all of the

stages of readiness to change.

Although the primary focus of the intervention for this research is health care

professional behavior change, interventions structured to enable change in breastfeeding

practices also must target behavior change in the mothers. Theoretically, developed









interventions for the health care professionals can also be matched to mothers in each

stage of readiness to change. An educational booklet for new mothers could enable

conscious raising for mothers in the precontemplation and contemplation stages. A

breast pump loaner closet as well as milk expression guidelines and a breast milk log

(that could be included in the educational booklet) could be appropriate interventions for

those in the preparation and action stages. Appropriate interventions for those mothers in

the action and maintenance stages would include concepts such as the first feeding being

at the breast and enabling breastfeeding while in the hospital to support continued breast

milk feedings in the presence of the decision to initiate breast milk feedings.

Interventions targeted at health care professional change can be structured to

move mothers to decide to breastfeed and help them maintain that behavior once they

start. Theoretically, interventions including a breast pump loaner closet, an educational

booklet for new mothers, a breastfeeding pathway, and an educational initiative for health

care professionals can support behavior change in two different groups, the health care

professionals as well as the mothers. The health care professional group functions as a

primary support for the mothers to initiate and sustain breastfeeding.

Transtheoretical Model of Behavior Change and Methods of Education

Equally important with providing stage matched interventions for health care

professionals is consideration of what mode of learning to utilize for the conscious

raising strategy. Self learning modules can be considered easy to implement and enables

staff to participate in the learning initiatives at their own pace, enables them to take

modules home if work responsibilities prevent participation during working hours, and is

rather inexpensive when compared to other modes. The literature reflects good success

with self-directed learning modules, with good performance on post tests and learning









retention (Coleman, Dracup, & Moser, 1991). When compared with lecture-discussion

formats, self learning methods were comparable in achieving the educational objectives

being targeted within the nursing field (Nikolaj ski, 1992).

Computer based training is another method of education gaining increased

acceptance and use in the last several years with the increasing capabilities of technology.

Harrington and Walker (2004) discovered that, although both groups significantly

improved their post test scores, a group of individuals who engaged in computer based

training did significantly better than individuals in an instructor led course on fire safety

(Harrington & Walker, 2004). Research and experience are beginning to define computer

based learning as a viable option for educational purposes. However, the access to

technology and to the people who format and design the computer systems is a significant

barrier to widespread use of such learning practices today.

Not all individuals have the same learning style. While some may prefer self paced

methods, others may be more motivated and embraced in a face to face lecture and

discussion with peers. Goldrick, Gruendemann, and Larson (1993) found that 64% of

nurses in a pediatric intensive care unit had an abstract learning style and preferred self

learning modules. However, there remained 36% who preferred more traditional methods

(Goldrick, Gruendemann, & Larson, 1993).

Self directed learning, through an educational module, is an effective form of

educating health care professionals. However, not all individuals possess the learning

style necessary for successful completion of self learning modules and prefer lecture-

discussion formats. By providing both forms of educational opportunities, more health









care professionals could be encouraged to participate in an educational initiative.

Computer based training could also be effective if access to technology can be achieved.

Summary and Research Questions

The provision of breast milk has important benefits to infants, especially those in

the NICU who are less healthy and less mature at birth than full term infants. Yet

significant, but not insurmountable, barriers to breast milk feedings and breastfeeding

exist in the NICU. Health care professionals are a powerful influence (Swanson &

Power, 2005). It is proposed that change from the health care professionals can enable

mothers and infants to overcome many of the barriers to breastfeeding, and subsequently,

positive changes in breastfeeding practices can occur in the NICU. Therefore, in this

study, the effect of a 4-pronged education and support intervention to promote

breastfeeding in the NICU, based on the synactive theory and transtheoretical model of

behavior change, will be explored. The four parts of the proposed intervention are a

breast pump loaner closet, a breastfeeding pathway on the individualized care plan, an

educational booklet for mothers, and an educational initiative for health care

professionals who work with infants and mothers in the NICU. The research questions

are

Is there a significant difference in breast milk feeding initiation in very low birth
weight (VLBW) infants admitted to the NICU before and after implementation of
the intervention plan?

Is there a significant difference in the rate of breastfeeding in the hospital among
women with VLBW infants hospitalized in the NICU before and after the
implementation of the intervention plan?

Is there a significant difference in breast milk feedings at discharge in VLBW
infants admitted to the NICU before and after the implementation of the
intervention plan?






34


* Is there a significant difference in the proportion of the hospital stay that breast
milk is provided in VLBW infants admitted to the NICU before and after the
implementation of the intervention plan?














CHAPTER 2
METHODOLOGY

The purpose of this study was to test the efficacy of a 4-part intervention on

improving breastfeeding practices in the neonatal intensive care unit (NICU). The

overall goal was to attempt to develop an effective intervention to assist mother-infant

dyads in the complex NICU environment.

Participants

Very low birth weight (VLBW) infants (<1500 grams) were included in the study if

they were 1) admitted to the Level II or III nursery at Shands Hospital during the study

periods and 2) had a length of stay greater than or equal to 7 days, 3) were admitted to the

NICU within the first 3 days of life, 4) were hospitalized less than 4 months, 5) achieved

full gastric feeds during their stay, and 6) had a hospital stay that did not cross over from

the pre-intervention group time period into the education initiative time period. Very low

birth weight infants were excluded from the study if they 1) had a length of stay less than

7 days, 2) were transferred to Shands Hospital after the third day of life, 3) were

hospitalized greater than 4 months, 4) did not achieve full gastric feeds during the

hospital stay, 5) had a hospital stay that crossed over from the pre-intervention group

time period to the education plan time frame, or 6) had conditions that would make

breastfeeding contraindicated as established by the physician.

Power indicates the probability of rejecting the null hypothesis, if a condition

exists. With a power of 80%, which is frequently used in the literature, there is a 20%

chance of failing to reject the null hypothesis when it should be rejected.









Prior to conducting the study, a power analysis was conducted to determine the

appropriate sample size. The mean and standard deviations of breast milk feeding

initiation were unavailable from other studies to compute an effect size and subsequently

a sample size. Therefore Cohen's Criteria was utilized to make sample size estimations

(Cohen, 1988). According to Cohen, a .2 standard deviation change is a small effect, a .5

is a medium effect, and a .8 is a large effect. For the purposes of this study, a medium

size effect was selected. By using Cohen's criteria and determining the sample size

necessary with a power of 80%, alpha of .05, and looking for a medium size effect of .5,

Cohen's Criteria indicated a needed sample size of 82 per group. Therefore the research

plan consisted of intent to conduct quota sampling with participants enrolled from the

beginning study dates for both the pre-intervention and post-intervention groups until 82

were achieved in each group.

The planned pre-intervention group consisted of all very VLBW infants admitted to

Shands Hospital NICU from April 15, 2004 forward until 82 participants were enrolled in

the study. The intervention started on March 1, 2005 with conclusion of the educational

initiative on April 15, 2005. The planned post-intervention group consisted of all very

low birth weight infants admitted to Shands Hospital NICU after implementation of the

intervention plan, from April 15, 2005 until 82 were admitted into the study. Data from

participants were collected from the same time of year to account for seasonal confounds.

Research Interventions

Intervention 1: Breast Pump Loaner Closet

Intervention 1 consisted of the development of a breast pump loaner closet for use

by mothers with infants hospitalized in the NICU. Hospital grade breast pumps could be

checked out by mothers who had infants in the NICU to enable them to express their milk









the recommended 8 to 12 times per 24 hour period. This would enable a supply of

expressed breast milk for initiation of breast milk feedings in the infant and would enable

the mothers to establish and maintain a milk supply until the infant was able to go

directly to breast.

Intervention 2: Health Professional Education Initiative

Although there are many different recommendations and published articles about

breast milk feedings and breastfeeding in the NICU, there was no up to date, available

educational plan that could be utilized for staff education. Therefore, an education

initiative encompassing key areas of education on breastfeeding special care babies was

developed to educate as many of existing staff in the NICU as possible. The initiative

consisted of education to staff on breastfeeding to enable health care providers to have

the education and tools to support mothers in the breastfeeding process. The education

was offered through completion of a self study educational module on breastfeeding in

the NICU or through attendance at an inservice on breastfeeding in the NICU.

Education topics contained in the self study module and discussed in the inservice

included the benefits of breastfeeding, the barriers to breastfeeding, the physiology of

lactation, use of breast pumps, pre feeding interventions based on the synactive theory

and breastfeeding interventions that acknowledge the readiness of the infant. All the

information contained in the module was based on an extensive literature review to

represent evidence based practice and was designed to foster success with breastfeeding

in the high risk neonate population while acknowledging their unique needs. The

educational module was reviewed by two individuals considered to be experts in the area

of breastfeeding for establishing validity of information provided. Minor adjustments

were made to the education plan based on the expert feedback. Refer to the outline of the









educational module, appendix A, or contact the author for further details. The successful

completion of the health professional education was defined as completion of the module

or attendance at one of the inservices and a passing score of at least 80% on a post test

that was identical for either form of the education.

Intervention 3: Breastfeeding Guideline

Each medical chart contains an individualized care plan (ICP) for documentation

by nurses. This ICP was modified to also have a pathway of care for providing

breastfeeding support to new mothers (appendix B). This ICP necessitated

documentation of education and support by nurses at critical times in the breastfeeding

process. The guideline called attention to and necessitated documentation on specific key

points that were identified in the literature to be predictive of success: achieving and

maintaining a milk supply, timely pumping, skin to skin contact, and first feeding being

at the breast. It also included areas to check off, date, and sign at the following critical

times in the breastfeeding process: within 6 hours of delivery, issue and instruct in proper

pumping and breast milk storage techniques; within 24 hours, ensure proper pumping and

storage technique; on day 3 to 5, ensure that the milk has come in and trouble shoot any

problems; weekly, foster continued pumping and skin to skin care; first oral feeding,

ensure that it is a breastfeeding session; 10 days, monitor milk supply and make referrals

as appropriate.

Intervention 4: Educational Pamphlet for New Mothers of Neonatal Intensive Care
Unit Infants

An educational pamphlet, "A Mother's Gift", for mothers who had an infant

admitted to the NICU was developed. The outline of the educational booklet (see

appendix C) addressed the following key points: benefits of breastfeeding, how to









express and store human milk, pre-breastfeeding strategies, and cue based breastfeeding

interventions. The back of this pamphlet also included a place for mothers to document

breast milk production to facilitate communication with nurses about their milk supply.

This educational pamphlet was developed to ensure that all mothers received a standard

set of educational points during their infant's hospitalization, and that the information

contained in it was consistent with the education that the health care professionals

received.

Intervention Plan Modification

The original intervention plan consisted of 4 parts: a breast pump loaner closet, an

education module and inservicing, changes to the individualized care plan and an

educational booklet. Prior to the initiation date of March 1, 2005, it was learned that

external funding for the breast pump loaner closet could not be obtained. Therefore, this

prong of the intervention had to be deleted from the intervention program. The study was

then conducted with the following being the intervention/education plan: the education

initiative, the mother's educational booklet, and the breastfeeding pathway addition to the

individualized care plan.

Design

This study was a quasi experimental, matched through cohort controls, design

(Shadish, Cook, & Campbell, 2001), investigating indirect changes in breastfeeding

practices following a 3-part breastfeeding intervention in the NICU. Through this design

the pre-intervention group consisted of a group of VLBW infants hospitalized in the

NICU before the implementation of the intervention plan. This group was then compared

to the post-intervention group, which consisted of a group of VLBW infants who were

hospitalized in the NICU after the implementation of the intervention plan.









The independent variable was the implementation of the intervention as described

above. Dependent variables included 1) breast milk feeding initiation rate (was breast

milk ever consumed/breast milk feeds initiated? (yes/no)), 2) breastfeeding rate (number

of times the infant was put to the mother's breast after 30 weeks gestation divided by the

number of days hospitalized after 30 weeks gestation), 3) breast milk feeding at discharge

rate (did the infant continue to have breast milk feedings at discharge? (yes/no)), and 4)

the proportion of the hospital stay that breast milk was provided (total number of days

into the hospitalization that breast milk was provided divided by the length of stay).

Procedures

The educational intervention was implemented March 1, 2005 to April 15, 2005

with opportunities for health care professionals to complete the self study educational

module or participate in an inservice. "A Mother's Gift", the educational booklet for

mothers was issued to all new mothers with infants admitted to the NICU on or after

March 1, 2005. Last, the modified individualized care plan was used in the medical chart

on all new admissions after March 1, 2005.

To promote completion of the educational initiative, incentives were given to those

who participated in the breastfeeding education initiative by way of food, prizes,

continuing education credits and documentation on the annual review of their

performance. Following the six week educational initiative, completion of the self study

educational module on breastfeeding in the NICU became part of the orientation process

to enable the same education for those staff who were not employed at Shands Hospital

during the six week educational initiative.

The educational opportunities during the initiative dates included a self study

module and/or inservices. A breastfeeding module was available for health professionals









to check out and complete at home or work. Food and prize incentives as well as 2

continuing education credits were awarded for those who completed the educational

module. For those who preferred lecture-discussion formats for learning, 1 hour

inservices were offered at least one time per week throughout the education initiative

period. Those who attended the inservices were educated on the same information

contained in the education module, however in a condensed amount of time. Therefore

one continuing education credit, in addition to food and prizes, were awarded to those

who attended an inservice during the initiative dates.

The booklet entitled "A Mother's Gift" was issued to mothers with infants admitted

into the NICU after March 1, 2005. There was a central location at the reception desk

where nurses who had new admissions could access and issue them to mothers. Nurses

were instructed to issue these booklets during staff meetings, through the monthly

bulletin and in the breastfeeding inservice that occurred over the six week period.

The modified individualized care plan with the breastfeeding pathway replaced the

old ICPs and were placed in the chart as routine paperwork as of March 1, 2005. Nursing

staff were instructed to use it by way of a monthly written bulletin. It was also discussed

in staff meetings and further reminders were given to document on it during the

breastfeeding inservices that occurred over the six week period.

Program Evaluation

The desired impact of this program was increased breastfeeding in the NICU.

However, the intervention strategies used in the current study can only be effective if

they are implemented. The full implementation of the 3-pronged intervention was

evaluated in four ways. All the educational tools (the educational module, the inservice,

the educational booklet for he mothers and the modified ICP) stressed that the first oral









feeding should be at the breast. Therefore the primary outcome measure to determine

implementation of the intervention was whether the first oral feeding was at the breast.

Second, attempts were made to track the percentage of mothers of infants newly admitted

to the NICU to whom educational booklets were issued to determine if, in fact, most

mothers were being issued this educational booklet. Last, weekly communications with

the nursing administrator indicated the degree of compliance with educational key points

based on her monthly experiences as a bedside nurse, in which she worked directly with

mothers and their babies in the NICU.

Data Collection

Participants were recruited by way of a data base containing all admissions and

discharges from the NICU during the two different time periods. For each infant

admitted to the hospital during the applicable time periods, an extensive retrospective

chart review was conducted. Each identified chart was first investigated to ensure that the

infant did not have any exclusion criteria. Given that inclusion criteria were met, the

dependent variables as well as demographics were collected and recorded on a laptop

computer.

Inter-rater reliability was determined in 3 different participants to ensure that

accurate variables were collected from the charts. This occurred by having another

researcher collect data on the same participants following data collection by the principal

investigator and comparing if the variables collected by the two different researchers

were in agreement.

Data Analysis

Retrospectively, charts were reviewed and data was analyzed for significant

differences in the proportion of mothers who initiated breast milk feedings, the number of









times per day the mother breastfed after 30 weeks gestation, the proportion of mothers

who provided breast milk at discharge, and the proportion of the hospital stay that breast

milk feedings occurred. Table 2-1 summarizes the dependent variables and null

hypotheses.

Table 2-1. Hypothesis testing according to dependent variable
Group Breast milk The Number Breast milk Proportion of the hospital
feedings of Time provided at stay that breast milk was
initiated s the Mother discharge provided
(yes, no) Breastfed Per (yes, no)
Day After 30
EGA

Pre- Al B1 Cl Dl
Intervention
Group

Post A2 B2 C2 D2
Intervention
Group

Hypotheses

The following hypotheses and data analysis plan guided this study.

The rate of breast milk feeding initiation will be higher in the post

intervention group (A2>A1).

Data Analysis Plan: A Pearson's Chi Square was used to test two proportions for

significant differences between the two groups.

The number of times per day that an infant is breastfed after 30 weeks

gestation will be higher in the post-intervention group (B2>B 1).

Data Analysis Plan: A one-way analysis of variance (ANOVA) was not possible

secondary to a violation of the assumption of normality. Therefore, the nonparametric

Mann Whitney was used to test for differences between the 2 groups.









The rate of breast milk feedings at discharge will be higher in the post

intervention group (C2>C1).

Data Analysis Plan: A Pearson's Chi Square was used to test two proportions for

significant differences between the two groups.

The proportion of the hospital stay that breast milk was provided will be

higher in the post intervention group (D2>D1).

Data Analysis Plan: A one-way analysis of variance (ANOVA) was not possible

secondary to a violation of the assumption of normality. Therefore, the nonparametric

Mann Whitney was used to test for differences between the 2 groups.

In this study, the pre-intervention group and post-intervention group were

compared for significant differences in four different variables. For the purposes of this

study, an alpha level of .05 was chosen, which is standard throughout the literature.

Adjusting the Alpha Level

There are no statistical procedures that can simultaneously test multiple outcomes,

some of which are continuous and some of which are dichotomous. Therefore, the

significance levels of the individual tests were adjusted by the ranked Bonferroni

adjustment. There has been criticism of the standard Bonferroni adjustment being too

conservative and that, in theory, if many tests were run, the level of significance would be

so low that no differences could be detected. The ranked Bonferroni adjustment was

preferred over a standard Bonferroni adjustment to enable maximum power in initial

comparisons, by adjusting the alpha level with each additional comparison to prevent

inflation of the type I error rate. This would help to prevent the researcher from rejecting

the null hypothesis inappropriately while minimizing inappropriate stringentp value









constraints (Benjamini & Hochberg, 1995). For this study, the questions were ranked in

order of importance. The first question, whether or not there was a difference in breast

milk feeding initiation, was tested at an alpha of .05. The second question, whether or

not there was a difference in number of times breastfed after 30 weeks gestation, was

tested at an alpha of .025 (.05/2). The third question was tested at an alpha of .017

(.05/3). The fourth question was tested at an alpha of .013.

Each statistical analysis was conducted as a one sided test as it was assumed that

trends would be toward increased rates of breastfeeding with the interventions that were

implemented.














CHAPTER 3
RESULTS

Intervention Implementation

One hour inservices were conducted 1 to 3 times per week for a total of 10

inservices during the intervention period of March 1, 2005 through April 15, 2005.

General attendance at each inservice was low with approximately 2 to 5 participants at

each one. Self-study modules were also available for check out during this time. Overall

response to complete the self-study modules was also low in the month of March.

Therefore, in April, the researcher started directly asking health care professionals to

complete the modules and offered food prizes for those who did. It appeared that

directly requesting participation was beneficial in promoting participation by the health

care professionals. There were 11 health care professionals who completed the self study

education modules from March 1 through March 31, 2006, and there were 45 health care

professionals who completed the educational module from April 1 through April 15,

2006.

The total number of health care professionals who participated in the educational

initiative was 88, which was 63% of health care professionals working in the neonatal

intensive care unit (NICU). The total number of nurses who participated in at least one

of the methods of education was 75, which was 77% of all nurses who care for infants in

the NICU. There were 3 rehabilitation therapists (100%), 1 nurse practitioner (9%), 2

neonatologists (20%), 2 social workers (100%), 1 respiratory therapist (10%), and 5 other









health professionals (83%). All those who participated in the education achieved a

passing score of 80% on a post test.

Nursing managers reported variable levels of compliance with the new strategies

presented in the educational initiative, contained in the educational booklet for mothers,

and on the modified individualized care plan (ICP). Starting on March 1, 2005 the nurses

initiated use of a new, revised individualized care plan (ICP) for documentation. The

revised ICP was supposed to replace the old one. However, in mid April, it was realized

that some old stores of the previous ICP, that did not include the breastfeeding pathway,

had been pulled from the shelf and were being utilized. According to the nursing

manager, this problem was resolved with full use of the new ICP by May 1, 2005.

Although all nurses were expected to follow the established guidelines on the

breastfeeding pathway, during data collection it was observed that the new ICP was not

utilized fully. One example of the lack of full implementation of the new pathway

concerned whether the first oral feeding was at the breast. On the breastfeeding pathway,

all mothers should have been encouraged to have the first feeding at the breast with

documentation accordingly or documentation stating why care deviated from the

pathway. However, the first feeding being at the breast occurred in only 25% of mothers

in the post intervention group, and with full implementation it should have approached

100%. Although it is possible that mothers were encouraged, but declined to participate

in the first feeding at breast, it is more likely that there was lack of full compliance with

the educational key points and the modified individualized care plan.

Starting on March 1, 2005 "A Mother's Gift", the educational booklet for mothers,

was available to be issued to new mothers with infants in the NICU. Initial "Mother's









Gift" educational booklets were tracked to be able to determine if the number of booklets

that were issued matched the number of admissions. Not all mothers were given the

pamphlet over the first few weeks of the intervention. There were reports of running out

of the booklets and not being able to find them. Multiple copies of these were distributed

during and after the educational initiative, but they became impossible to track as they

were frequently misplaced, redirected to the maternity floor rather than remaining in a

central location in the NICU, and others outside of the research initiative made copies of

the booklet for distribution.

Nursing managers reported variable levels of compliance with the new strategies

presented in the educational initiative, contained in the educational booklet for mothers

and on the modified ICP. One nursing administrator, who would function in the role of

bedside nurse approximately once a month and would work directly with mothers and

their babies during this time, reported certain personnel to be implementing strategies

while others, even those who participated in the educational initiative, to be consistently

ignoring the pathway of care contained in the medical chart. The nursing administrator's

occasional role of bedside nurse revealed that there were mothers who never received the

educational materials and that ICPs in the medical chart had inadequate documentation.

The Sample

The pre-intervention sample data was obtained before the education plan

implementation using quota sampling from the beginning study date of April 15, 2004.

The post-intervention group was obtained after the intervention period implementation

from April 15, 2005 onward. Eighty one participants were obtained for the pre-

intervention group from April 15, 2004 through discharges on December 7, 2004. Data

collection in the pre-intervention group was stopped at 81, because the subsequent 2









admissions crossed into the treatment period. Data from only fifty four participants in the

post-intervention group was collected from April 15, 2005 through discharges on

November 29, 2005. There were no discharges from the NICU of participants who met

inclusion criteria from November 29, 2005 to December 7, 2005.

This sample included all admissions of VLBW infants admitted during the pre-

intervention study dates except for 17 infants who did not meet inclusion criteria.

Among the 17 infants who were excluded, 13 of them were extremely low birth weight

and expired shortly after birth, thus never achieved full gastric feeds. Two of them did

not achieve full gastric feeds before being transferred to another hospital, and 2 of them

had a length of stay that extended into the treatment period. The pre-intervention group

consisted of 83% of all admissions of VLBW infants admitted to the NICU at Shands

during the study dates. The sample included all admissions of VLBW infants admitted

during the post-intervention study dates except for 11 infants. Among those 11 infants

who were excluded were 9 infants who never achieved full gastric feeds and expired

shortly after birth and 2 who had genetic disorders that made eventual oral feeding

contraindicated. The post-intervention group also consisted of 83% of all admissions of

VLBW infants admitted to the NICU at Shands during the study dates.

The data collection period was not extended in order to capture the remaining 17

participants for two reasons: the first is that a long period of time had passed since the

intervention plan, and new interventions were scheduled to be implemented in the NICU.

These would have introduced significant additional confounds into the study. Secondly, a

new power analysis based on actual effect sizes of this partial sample indicated a need for

data from an additional 124 participants in the post-intervention group and 95 in the pre-









intervention group to achieve 80% power because of the already high breast milk

initiation rate (74.1%). Continuing data collection to enroll 82 in each group based on

the original research plan would have increased power from 38.6% to 45.6%, an increase

that was considered to not be feasible given the potential confounders listed above, or

likely to change the statistical outcomes.

Inter-Rater Agreement

To ensure accurate documentation of the research variables, inter-rater agreement

was tested on the chart review procedures. Another researcher conducted data collection

on 3 charts that the principal investigator had already collected data from. There was

100% agreement in 2 out of 3 of the charts. However, one chart revealed agreement of

92%, for a total inter-rater agreement of 97% for this study. The principal investigator

reviewed the chart that did not have complete agreement to find 100% agreement with

her initial findings.

Demographics

Table 3-1 includes sample demographics andp values for statistical tests to rule out

selection differences. All demographics were collected as continuous or dichotomous

variables, with the exception of race. Race in the medical chart was classified as White,

Black, Asian, Hispanic or Other. Therefore, race is documented with the same

classifications. The pre-intervention group was 4% Hispanic, 42% Black, and 54%

White. The post-intervention group was 2% Asian, 3% Hispanic, 49% Black, 42% White

and 4% with undocumented race in the medical chart. Due to the majority of participants

being Black or White, with minimal representation of other racial backgrounds, and due

to Black being a known predictive factor in the literature, race was dichotomized into

Black and not Black for statistical purposes to rule out selection differences.










Table 3-1. Demographics of the pre-intervention and post-intervention groups with test
statistics for selection differences
Low Race Maternal Marital Transferred Length Birth EGA No.
SES (Black) Age Status Instead of of Weight of
(not DC Home Stay Sibs
married)
Pre- .775 .42 25.46 .56 .432 50 1074 28.57 1.01
Intervention
Group
Post- .70 .49 25.62 .57 .327 54 1114 28.7 .86
Intervention
Group
p Value to .339 .256 .899 .860 .225 .534 .368 .762 .297
Investigate
Selection
Differences


There was a large percentage of participants of low socioeconomic status (77.5% in

pre-intervention group and 70% in the post-intervention group), Black race (42% in the

pre-intervention group and 48% in the post-intervention group), and unmarried mothers

(56% in the pre-intervention group and 57% in the post-intervention group). Average

maternal age in the pre-intervention group was 25.46 and in the post-intervention group

was 25.62 years. The average birth weight in the pre-intervention group was 1074 grams,

and the average birth weight in the post-intervention group was 1114 grams. The average

gestational age (abbreviated EGA) at birth was 28.57 weeks gestation in the pre-

intervention group and 28.7 weeks in the post-intervention group. The average number of

siblings (abbreviated No. of Sibs) in the pre-intervention group was 1.01 and in the post-

intervention group was .86. Eighty four percent of the pre-intervention group consisted

of single births, and 83.3% of the post-intervention group consisted of single births. In

the pre-intervention group there were 43.2% of participants who were transferred to

another hospital instead of discharge home, and in the post-intervention group there were

32.7% who were transferred to another hospital. Average length of stay in the pre-

intervention group was 50 days and in the post-intervention group was 54 days.










Investigation for Selection Differences

Due to the matching through cohort controls research design, it was important to

first determine if there were selection differences in the two groups being compared.

Socioeconomic status was categorized into Women, Infants and Children (WIC) or

Medicaid eligibility or not WIC/Medicaid eligible. Difference in this variable between

the two groups was investigated by use of a z test for 2 proportions. Hypothesis testing

of two proportions with a z test was used to test for group differences in maternal race,

which was dichotomized as Black or not Black. Group dissimilarity based on maternal

age was investigated through an independent samples t test, while differences in marital

status (married, not married) and sex of the infant were investigated by use of a z test for

two proportions. Gestational age at birth, birth weight and number of siblings was

investigated by use of an independent samples t test. Discharge status was investigated

with a z test of 2 proportions and length of stay with an independent samples t test. By

testing each of the demographic variables at an alpha of .05, none of the demographic

variables were significantly different between the two groups (see table 3-1).

Subsequently, having no selection differences supports the ability to use the matching

through cohort controls design.

Results Per Research Question

The primary aim of this study was to implement a breastfeeding intervention that

would improve breastfeeding practices in the NICU. The results of this study are

provided per research question.

Is there a significant difference in breast milk feeding initiation in very low birth
weight (VLBW) infants admitted to the NICU before and after implementation of
the intervention plan?









Table 3-2 summarizes breast milk feeding initiation results. The breast milk

feeding initiation rate in the pre-intervention group was 74.1%. The breast milk feeding

initiation rate in the post-intervention group was 85.2%. This represents an increase of

11.1%. However, through a Pearson's Chi Square Test of 2 proportions, the p value is

.124, indicating no significant difference between groups when tested at an alpha of .05.

The odds ratio of breast milk feeding initiation is 2.013 with a confidence interval of .818

to 4.952.

Table 3-2. Breast milk feeding initiation rates
Was Brest Milk Ever Total Test
Provided? Statistic
No
Yes

Group Pre-Intervention Count 21 60 81
% within 25.9% 74.1% 100.0%
subject
Post- Count 8 46 54
Intervention % within 14.8% 85.2% 100.0%
subject
Total Count 29 106 135
% within 21.5% 78.5% 100.0%
subject
Pearson's Chi-Square .124
Significance
Odds Ratio 2.013
Odds Ratio Confidence .818 to
Interval 4.952

Is there a significant difference in the rate of breastfeeding in the hospital among
women with VLBW infants hospitalized in the NICU before and after the
implementation of the intervention plan?

For the continuous variable of number of times breastfed per day after 30 weeks

estimated gestational age (EGA), see figure 3-1. The graph is clearly skewed toward 0.

Due to the violation of normality, a Mann Whitney nonparametric test was used to test

significance of this variable. Interpretation of this graph and variable is difficult as the








54



rate of breastfeeding in the NICU is significantly low at .059 in the pre-intervention


group, which is once every 17 days, and .139 in the post-intervention group, which is


once every 7 days (see Table 3-3). This variable proved to be significantly different


between the two groups with ap value of .011.


70-

60-



40-

30-

20-

10-



70-

so-

so50-

40-

30-

20-

10-

0-- F=


7-
0

0
0-
a
a)
+-i




0
0
0


n
03




a-

a,



0a)


0.00000 0.20000 0.400O 0 0.60000 0.80000 1.00000 1.20000

Number of Times Breastfed Per Day After 30 Weeks Gestation

Figure 3-1. Number of times breastfed per day after 30 weeks gestation










Table 3-3. Comparison of rates of breastfeeding after 30 weeks gestation
Test Statistic
Number of Times
subject Breastfed Per Day
After 30 EGA

Pre-Intervention Men .
Mean .0593937
Group
N 81
Std. Deviation .18818812

Post-Intervention M
Mean .1389242
Group

N 54
Std. Deviation .24433376
Total Mean .0912059
N 135

.21513898
Std. Deviation .21513898
Mann Whitney .011
Significance

To enable easier interpretation of this variable, it was dichotomized into whether a

mother ever participated in breastfeeding while in the hospital. In the pre-intervention

group, there were 25.9% of mothers who ever breastfed their infant in the hospital. In the

post-intervention group, there were 44.4% of mothers who ever breastfed their infants in

the hospital (see Table 3-4). This represented an increase of 18.5%, which achieved ap

value of .025 through a chi-square test of 2 proportions. Therefore, there were significant

differences in proportion of women who ever breastfed in the two groups, using an alpha

of .025. The odds ratio of ever breastfed in the hospital was 2.286 with a confidence

interval of 1.1 to 4.750.









Table 3-4. Rates of ever breastfed in the neonatal intensive care unit
Frequency Was the Infant Ever Total Test
Breastfed While in the Statistic
Hospital?
No Yes
Group Pre- Count 60 21 81
Intervention % within 74.1% 25.9% 100.0%
subject
Post- Count 30 24 54
Intervention % within 55.6% 44.4% 100.0%
subject
Total Count 90 45 135
% within 66.7% 33.3% 100.0%
subject
Pearson's Chi
Square Significance .025

Odds Ratio 2.286
Odds Ratio
Confidence Interval 1.1 to
4.750


Is there a significant difference in breast milk feedings at discharge in VLBW
infants admitted to the NICU before and after the implementation of the
intervention plan?

There were 35.8% of infants who were provided with breast milk at the time of

discharge in the pre-intervention group. There were 40.7% of infants in the post-

intervention group who were provided with breast milk at discharge. This 4.9% increase

resulted in a p value of .562 through a chi-square test of 2 proportions, indicating no

statistically significant difference among groups. The odds ratio was 1.233 with a

confidence interval of .607 to 2.502.









Table 3-5. Rates of breast milk feedings at discharge
Was Breast Milk Total Test
Provided at Discharge Statistic
No Yes
Group Pre- Count 52 29 81
Intervention % within 64.2% 35.8% 100.0%
subject
Post- Count 32 22 54
Intervention % within 59.3% 40.7% 100.0%
subject
Total Count 84 51 135
% within 62.2% 37.8% 100.0%
subject
Pearson Chi-Square .344
Significance
Odds Ratio 1.233

Odds Ratio Confidence .607 to
Interval 2.502



Is there a significant difference in the proportion of the hospital stay that breast
milk is provided in VLBW infants admitted to the NICU before and after the
implementation of the intervention plan?

Looking at figure 3-2, both groups have peaks at 0 and 1. However, there is a

larger peak at 0 in the pre-intervention group. The variable, proportion of the hospital

stay that breast milk was provided, did not achieve the assumption of normality as the

graphs are u-shaped. Therefore, an ANOVA could not be run on this variable without

violating assumptions. The nonparametric Mann-Whitney test was used to test for

significant differences. This test indicated that thep value was .108, therefore there were

not significant differences between the two groups in proportion of the hospital stay that

breast milk was provided.







58





0
4-1
4a
--
a)
a


0
01


- 25-
hi- .I

C


10- .0
aI

1- 1-



O.0000 0.2000 0.40000 0.60000 0.8000 1.00000
Proportion of Hospital Stay That Breast Milk is Provided


Figure 3-2. Proportion of the stay that breast milk was provided

To look at effect size in a variable that does not have a normal distribution, the

proportion of the hospital stay was dichotomized into breast milk provided for most of

the hospitalization or not. This variable represented whether breast milk feeds were

supplied to the infant more than 50% of the length of stay not. There were 51% of the

pre-intervention group who provided breast milk for most of the hospital stay, and there

were 57% of the post-intervention group who provided breast milk for most of the

hospital stay. This gives an odds ratio 1.219 with a confidence interval of .608 to 2.444

for breast milk feeds being provided for most of the hospital stay.














CHAPTER 4
DISCUSSION

The Effect of the Interventions on Breastfeeding Practices in the Neonatal Intensive
Care Unit

This research investigated if a three-part intervention plan designed to promote

increased breastfeeding in premature infants would have an effect on breastfeeding

practices in the neonatal intensive care unit (NICU). The three-part intervention

consisted of opportunities for education of health care professionals over a 6 week

educational initiative, an educational booklet for new mothers in the NICU, and

modifications to the individualized care plan (ICP) with a pathway of care for

breastfeeding. This intervention did have an effect on breastfeeding practices in the

NICU, but it did not result in changes across all breastfeeding variables as hypothesized.

Evidence of improved breastfeeding practices was that rates of breastfeeding

(mothers putting their infants directly at the breast) in the NICU improved following

intervention. The number of times infants were breastfed per day after 30 weeks gestation

was significantly greater in the post-intervention group than in the pre-intervention group.

Mothers in the pre-intervention group breastfed their infants after 30 weeks gestation

.059 times per day, and in the post intervention group they breastfed .139 times per day.

This works out to an average of once every 17 days in the pre-intervention group and

once every 7 days in the post intervention group. Although a statistically significant

increase was observed following the intervention, the resultant rate of breastfeeding in

the NICU remained low. After dichotomizing this variable, it was noted that there were









25.9% of mothers who ever breastfed their infant in the hospital in the pre-intervention

group. In contrast, there were 44.4% of mothers who ever breast fed their infants in the

post intervention group. This represented a significant increase of 18.5%. This provides

some support that the program had a positive effect with increased participation in

breastfeeding among mothers in the NICU. However, the overall rate of breastfeeding

participation remains low in the NICU.

The variable of ever breastfed while in the hospital is an important one, as it

requires active participation by the mother and infant. Diminished milk supply is cited as

one of the most significant barriers to breastfeeding in the NICU population. Maternal

stress has been linked to inhibition of oxytocin, which is responsible for the let down

response during pumping and breastfeeding (Lang, 1996). However, physiologically,

oxytocin is facilitated with increased mother-infant contact and environments that foster

breastfeeding ("How breast-feeding postpones ovulation," 1985). Mothers with infants in

the NICU typically experience high levels of stress and anxiety and many are

overwhelmed by the NICU environment (Nyqvist et al., 1994). Many also comment on

the loss of control of their infant to others during stays in the NICU (Lupton & Fenwick,

2001). Close contact, as in skin to skin, as well as breastfeeding, are important in

maintaining bonding in a difficult environment, promoting the milk supply and providing

some control over care for mothers (Kirsten, Bergman, & Hann, 2001). This direct

interaction of the mother and infant can be assumed to be critical to the other

breastfeeding outcomes.

Although positive trends in favor of the post-intervention group were observed

across all variables, the intervention did not have a strong enough impact to result in









significant changes in breast milk feeding initiation rates, breast milk feeding at discharge

rates and proportion of the hospital stay that breast milk was provided. This could be

due to lack of a strong enough impact of the intervention with a need for a more

extensive list of interventions or adjustment of the interventions proposed in this study,

need for consistent compliance with the research interventions to promote change, or a

different time frame for the study to detect changes.

The breast milk feeding initiation rate (was breast milk ever provided) in the pre-

intervention and post-intervention groups appears to be fairly comparable to other

research findings, which have documented rates of breast milk feeding initiation in the

NICU at 64% (Byrne & Hull, 1996), 72.9% (Meier et al., 2004), and 83% (Yip et al.,

1996). Although breast milk feeding initiation failed to reach statistical significance,

there was an increase in breast milk feeding initiation of 11.1%, which was a positive

change in the right direction as more infants received some breast milk following the

intervention. Scientists are beginning to refer to breast milk as medicine and have

initiated discussing breast milk in terms of a dose (Meier et al., 2004). Thus following

the intervention, 11.1% more infants in the post-intervention group received breast milk

at the most critical stage of their recovery. However, this variable did not achieve

statistical significance, which could indicate that the impact of the interventions was not

strong enough or that there was not enough compliance with the interventions to promote

change. It is important to note that breast milk feeding initiation reflected whether breast

milk was ever provided and not if breastfeeding ever occurred or if breast milk continued

to be supplied after the 2nd day of life or at discharge.









Although the rate of breast milk feedings at discharge (was breast milk provided to

the infant at discharge) increased slightly by 4.9%, this difference failed to reach

statistical significance. Succeeding with breast milk feedings until discharge in the NICU

population is a significant challenge for mothers with infants in the NICU. Discharge for

many of these infants did not occur until they were 1 to 4 months old. This supports

other research findings that state that some of the strongest predictors of not

breastfeeding by discharge is being low birth weight, having decreased gestational age

and being admitted into the NICU (Hwang et al., 2006; Li et al., 2005; Powers et al.,

2003; Scott et al., 2006). The findings of this study in both the pre-intervention (35.8%)

and post-intervention (40.7%) groups are comparable to other research findings, which

document breast milk feedings at discharge to be 38% (Yip et al., 1996). The low rate of

breast milk feeding in the NICU at discharge gives some insight into the significant

challenges that women encounter with succeeding with breast milk feedings through a

NICU hospitalization. However, to enable mothers with this process, it is critical that

strategies to promote long term success are implemented. Although lack of full

implementation and compliance with intervention strategies may have factored into this

research study, these results suggest that this 3-pronged intervention was not sufficient to

enable mothers to overcome the barriers to maintaining breastfeeding until the time of

hospital discharge in this complex and challenging environment.

There was no difference between the groups in the proportion of the hospital stay

that breast milk was provided. These results again highlight the importance of

determining strategies for long term success to enable mothers to succeed with the









breastfeeding process for a larger proportion of the hospitalization. Such strategies could

enable breast milk feedings until discharge and beyond.

This study complements conclusions from other studies that attention to and

education about lactation affects health care professional knowledge and support of the

breastfeeding process (Siddell et al., 2003). Many studies cite lack of health care

professional education as a significant barrier to the breastfeeding process in the NICU

(Register et al., 2000). Although improvement in breastfeeding rates in the NICU was

observed in the post education group, there is no way to determine which part of the

intervention plan may have had an effect on this variable. Other studies have concluded

that health care professionals play a significant role in breastfeeding practices in the

NICU (Swanson & Power, 2005) as does increased knowledge about breastfeeding

among mothers in the NICU (Bernaix, 2000). However, because all the interventions

were implemented together as a 3-pronged approach, it is unclear if the educational

materials for mothers, the educational initiative, or the modifications to the

ICP/breastfeeding pathway resulted in the effect on breastfeeding in the NICU.

According to the transtheoretical model of behavior change, change is a process

and sometimes requires multiple approaches that are stage matched in addition to the

passage of time. The real impact of the education perhaps could not be fully observed in

assessing the indirect impact on breastfeeding practices among mothers and infants. By

assessing the indirect impact of the education intervention on breastfeeding strategies

without measuring the knowledge and behavior change of the health care professionals, it

cannot be determined if there was a change in the health care professionals and what the

magnitude of such a change was. This calls into question whether the educational









initiative did what it was intended, which was to change health care professional

behavior. With knowledge of a change in health care professional behavior, the true

impact of education and intervention strategies on breastfeeding outcomes in the NICU

could be assessed. In addition, there were 2 behavior changes that could have been

assessed, the health care professional as well as the mother. Further measuring the

mothers' behavior change, in the presence of education from the health care professional,

would have provided useful information on whether the intervention was strong enough

to elicit positive changes in the mothers.

Although positive changes are evident, the reported compliance with strategies and

follow through of education key points was called into question by the nursing

administration. Other studies have determined that education about breastfeeding has had

an effect on breastfeeding knowledge and supportive behaviors (Ekstrom, Widstrom et

al., 2005). This research study did not measure the behaviors of health care professionals

following education. Therefore, it could be that the 3 part intervention plan was not

strong enough to elicit changes in health care professional behavior, that not enough time

passed post intervention to enable successful change or that the health care professional

change elicited following the intervention was not enough to result in positive outcomes

across all proposed breastfeeding variables. Subsequently, this study provides only

partial support for positive changes in breastfeeding practices in the NICU following the

3 part intervention.

Limitations

This study is not without limitations. Limitations included inadequate

implementation of all the intervention strategies by the health care professionals, lack of

methods to determine behavior change and implementation by health care professionals,









lack of ability to give ample time for changes to be implemented without introducing

other confounds, lack of participation by key decision makers in the NICU, the inability

to control for other changes in the NICU environment, lack of a more comprehensive

breastfeeding intervention plan, and lack of a randomized sample.

An important limitation of this study was the questionable full implementation of

the strategies learned in the educational initiative as well as inconsistent use of the

modified ICP and inconsistent distribution of"A Mother's Gift". Although there was a

high health care professional participation rate in the education initiative of 63%, health

care professional behavior change and attitudes were not measured. Therefore, there is

no way to know the direct effect of the education and placement of the modified ICP in

the medical chart on health care behavior and attitudes. It can be assumed that although

there was good participation in the educational initiative by bedside nurses and the

breastfeeding pathway on the ICP was added to the medical record, there was a lack of

movement to action among many health care professionals based on the observations by

nursing administration as well as by the first feeding at the breast variable remaining low

in the post-intervention group.

Despite education about promoting breastfeeding in the NICU and how to

introduce such practices, there remained a large percentage of women (56%) who never

breastfed while in the hospital. This demonstrates that although the education may have

occurred, change was not fully embraced and implemented. Health care professionals

care for infants, including caring for nutritional feeds, in the NICU 24 hours a day, and

parents are visitors to the NICU when they come to see their infant. Breastfeeding is

typically something that health care professionals would enable, and thus its low rate









could be attributed to low health care professional support of the breastfeeding process.

This study investigated breastfeeding outcomes in the natural NICU environment in

which health care professionals may have had other priorities, may have had negative

beliefs about breastfeeding in the NICU, may have had control issues that interfered with

promoting a feeding method that they eventually cannot participate in, or may have been

suffering from bum out. However, without the intermediate measure of health care

behavior, it is difficult to determine if the intervention could be effective if health care

professionals demonstrated an appropriate behavior change and were called to action.

According to the trantheoretial model of behavior change (TTM), change is a

process with people moving through different stages of readiness to change (Prochaska et

al., 2001). The intervention plan was designed to provide interventions that are

appropriate for individuals in each stage of readiness to change. However, the

educational initiative and interventions were introduced with data collection occurring in

the post intervention group 6 short weeks later. This may not have been a long enough

period of time to enable individuals to respond to the intervention and move them to

action. According to the TTM, those in the pre-action stages are the precontemplators

(no intention of making a change), the contemplators (intention of making a change in the

next 6 months) and those in the preparation stage (intend on making a change in the next

30 days). Theoretically a six week period may not have been enough to enable

movement through the stages of change to promote action toward increasing

breastfeeding support and implementing strategies learned in the educational initiative.

In contrast, other confounds were being introduced in the NICU in the months following

the conclusion of this study, as more interventions were set to be implemented.









Therefore, this study could not account for the possible inadequate time frame due to the

potential introduction of confounds that could bias the results.

Another limitation was the weak participation in the education modules by

physicians and nurse practitioners, who are key decision makers in the NICU. Prior to

the educational initiative dates, they participated in a short, general inservice about

breastfeeding to facilitate discussion and direction. Due to this recent meeting, it was

difficult to get them to participate in the research educational initiative. Therefore,

participation was low with only 20% of neonatologists and 9% of nurse practitioners

attending an inservice or completing the self study educational module. Although the

researcher did meet with the physician medical director of the unit to discuss key points

of the educational initiative, the initiative may have been much more successful if the

neonatologists and nurse practitioners had higher levels of participation. Nursing staff

and parents look to physicians and neonatal nurse practitioners for direction, and their

lack of participation was a significant limitation to this study.

The NICU is a constantly changing environment that can not be fully controlled in

a study like this, where all infants during a specific time frame are being enrolled. This

study does not account for other changes that may have occurred, such as staff

changeover, other education that health care professionals may be receiving and

implementing, and changes made to the physical NICU environment. Cosmetic changes

were made to the NICU environment during the course of this study, and it was

impossible to determine if this may have had an effect on the results.

The lack of optimal resources that may facilitate breastfeeding may also pose a

limitation to this study. During the early stages of planning this research project, funds









were applied for to provide a breast pump loaner closet that would provide a needed

resource for long term maintenance of the milk supply (Meier et al., 2004). These funds

were not achieved, making it impossible to provide this resource to enable long term

success with maintaining the milk supply, and subsequently with addressing the idea of

providing breast milk all the way until the infant was discharged from the NICU.

Providing breast milk or breastfeeding at the time of discharge would be the goal, as this

would indicate that a mother succeeded with providing milk during the hospitalization

and would enable breastfeeding at discharge home. Without the funding, women were

left to find their own resources to access a hospital grade pump for milk expression.

Some may have accessed one for use at home while others may have used store bought

pumps or self expressed.

This study is a cohort study. Due to lack of randomization, there is the possibility

that there are unseen differences in the two groups that lead to differences or similarities

in breastfeeding practices that cannot be attributed to the intervention. Results from this

study can only give conclusions about the population of infants being studied at Shands

Hospital. In addition, the small sample size limited the ability to achieve adequate

power, which can affect being able to detect significant differences, if they exist. Based

on the utilized sample size, 38.6% power was achieved on the primary variable of breast

milk feeding initiation. This indicates that the probability of finding a difference in the

two groups was only 38.6%. The already high breast milk feeding initiation rate in the

pre-intervention group, 74.1%, gave less room for improvement in this variable.

Although comparable with other rates reported in the literature, the rate in this unit was

expected to be lower due to lack of lactation services in the unit and the large population









of Black mothers, mothers with low socioeconomic status and single mothers, which are

all predictive of decreased breastfeeding behaviors (Powers et al., 2003). The nature of

the population may have been a limitation, in that perhaps the effect of the intervention

would be different given a different demographic presence in the NICU. Given the effect

of the current intervention, a larger sample size would be needed to determine if there are

significant differences in the pre-intervention and post-intervention groups. Such sample

size was not feasible during the study period given the number of admissions and

discharges. Prolonging enrollment was not feasible given the risk of introducing

potential bias. To

Recommendations for Further Research

Women with infants in the NICU face unique challenges to the breastfeeding

process. These barriers result in decreased breastfeeding initiation rates and breast milk

feedings at discharge from the hospital. However, these fragile infants are at an increased

need for the benefits of breast milk. Therefore, further studies looking at trends in

breastfeeding and looking at interventions that can assist mothers in overcoming barriers

is necessary.

Future research could investigate the efficacy of educational interventions that

measure the intermediate effects of the intervention on health care professional behavior

as well as the effect on breastfeeding outcomes. With similar findings as this study, this

would make it easier to interpret if the educational interventions did not cause health care

professional behavior change and thus did not affect breastfeeding outcome or if the

educational interventions did affect health care professional behavior but that the

resultant effect of this was not strong enough to result in positive breastfeeding outcomes.









Future studies addressing an educational initiative for health care professionals

with more time to enable change would be appropriate to run in this population. If

change takes time to occur, a longer period between the intervention and the start of data

collection in the post intervention group would help identify change that occurred over a

longer period of time following the interventions. However, such a study would require

close control of the environment to prevent other confounds from being introduced as

time from the education initiative elapses.

Although an intervention with many parts that addresses milk expression and

breastfeeding over the course of hospitalization may be optimal in promoting

breastfeeding practices in the NICU, a look at intervention specific studies could help to

declare which interventions are successful and which are not. Such a study, although it

may require a much larger sample size and perhaps random assignment to groups and a

multi-center trial, could assist with understanding which, if any, and in what combination,

treatments) have an effect on breastfeeding practices in the NICU.

Further research could also investigate the specific results, amount of milk

expression and success with breastfeeding among women who had a nurse who was in an

action oriented stage of behavior change regarding support for lactation compared to

those receiving traditional NICU care. The effects of support and education for the

mother could further be investigated by including success and failure with breastfeeding

among mothers who demonstrated compliance with strategies in "A Mother's Gift"

compared to those who were not fully compliant.

With the paucity of breastfeeding (putting the infant to breast) in the NICU, it is of

great interest to determine the predictive effect of breastfeeding on breast milk feedings









at discharge, milk production, amount of breast milk feedings in the hospital, as well as

the effect on maternal and child health. Likewise, it would be of great interest to

determine if there are any negative effects of not enabling breastfeeding on the ability to

maintain the milk supply, success of breastfeeding at discharge and beyond and the

ability to transition from breast milk feeds to direct breastfeeding.

Conclusions

This study investigated change in breastfeeding practices following implementation

of an intervention plan with 3 parts; an educational booklet for new mothers, an

educational opportunity for health care professionals who serve mother-infant dyads in

the NICU, and changes to the individualized care plan that necessitate breastfeeding

practice documentation by nurses. There were general positive trends across all

variables, which make this type of intervention have some promise for affecting positive

changes in breastfeeding practices in the NICU, given the limitations of this study and the

difficulties that can be expected in the complex NICU environment. There were

statistically significant differences between groups in the rate of breastfeeding, with

infants in the post-intervention group being more than twice as likely to be breastfed in

the hospital.

While health care professionals may play a significant role in the breastfeeding

process, perhaps an educational plan and breastfeeding pathway as well as

complementary educational materials for mothers is not enough to promote full

participation and optimal breastfeeding practices in the NICU. This study demonstrated

limited, but encouraging, support for an intervention plan focused on education to

facilitate change in breastfeeding within the NICU, but perhaps a multifaceted

intervention plan, including hospital grade breast pump allocation may optimize positive






72


changes in breastfeeding practices. An important limitation of this study was lack of full

implementation of the intervention strategies. Future studies can be designed to better

measure compliance with educational interventions as well as the individual effect of

each intervention and the additive effect of multiple interventions implemented together.

Randomized multi-institutional studies will enable larger intervention trials as well as

generalization of findings.














APPENDIX A
OUTLINE OF THE EDUCATION MODULE

Breastfeeding in the Neonatal Intensive Care Unit
An Educational Module for Health Care Professionals


Introduction

Benefits of Breastfeeding for the Full Term Infant
Health Benefits
Developmental Benefits
Financial Benefits

Benefits for Preterm or High Risk Infants

Benefits for the Mother

Barriers to Breastfeeding
Full-term infants
High-risk infants
Contraindications

Breast Milk
Composition
Transition to Mature Milk

The Breast and Lactogenesis
Anatomy
Neuroendocrine control
Sucking pattern

General Interventions for Supporting Breastfeeding

Appropriate Timing of Interventions
Interventions in the NICU

Interventions Prior to Active Breastfeeding
Breast pumps
Maintaining a milk supply
Kangaroo Care
Non-nutritive suckling









Early initiation of direct breastfeeding

Monitoring Physiologic Responses
Transition to Direct Breastfeeding

Interventions for Supporting Breastfeeding
Privacy
Positioning
Timing
Special Techniques

Determining Adequacy of Intake

Conclusion

Post-test

References



For further information, contact the authors:
Roberta Gittens Pineda: jopineda@pol.net
Cammy Pane: cam92460@yahoo.com














APPENDIX B
OUTLINE OF ITEMS ADDED TO THE INDIVIDUALIZED CARE PLAN

Breastfeeding Guidelines:

Within 6 hours of delivery: Mom is given "A Mother's Gift"

Within 24 hours: Ensure proper pumping (with hospital grade pump) and storage

3 to 5 days of life: Assess Mom's milk production. Address problems

10 days of life: Mom's milk supply should be at least 350 ml per 24 hours

With each parent contact: Offer support and discuss any problems

Kangaroo care is encouraged as soon as possible

First oral feeing is at breast

Mom is encouraged to breastfeed at each visit with supplementation only when
medically indicated

At discharge: Encourage transition to full breastfeeding while monitoring weight
gain














APPENDIX C
OUTLINE OF THE EDUCATIONAL BOOKLET FOR MOTHERS

A Mother's Gift
Breastfeeding and Pumping for Your Baby in the NICU

Breast milk is the best food for your baby's start in life
Each mother's milk is prefect for her baby
Babies who drink breast milk are healthier and smarter
This makes breast milk even more important for premature babies
Breastfeeding is healthy for the mother too!

Providing breast milk for your baby is something very special you can do to help your
child
It is important to begin expressing your milk as soon after delivery as possible,
and to keep pumping
Pumping may seem complicated at first, but it is worth it for your baby
During pumping, relax and enjoy gentle thoughts about your baby
At first, you may not get any milk, or only a few drops
Here is how to store your milk
Every mother wants to know-"Am I making enough milk"
In order to maintain a good milk supply...

Most mothers really want to hold their babies
Kangaroo care is good for your baby
Kangaroo care is good for parents too

Privacy is more important to some than others...

Suckling at the breast is the best way to nourish your baby... and it takes practice
Positioning during breastfeeding will become easier with practice...
Is my baby really, really, really getting enough milk

Please take extra care of yourself too!
If you are taking medications
Making milk for twins or more...

Please ask if you have questions or need help

How to obtain a pump for home use...

Chart for tracking milk production






77



On-line resources

For more information, contact:
Roberta Gittens Pineda: jopineda@pol.net















LIST OF REFERENCES


Agostoni, C., & Haschke, F. (2003). Infant formulas. Recent developments and new
issues. Minerva Pediatr, 55(3), 181-194.

Allen, M. C., & Capute, A. J. (1990). Tone and reflex development before term.
Pediatrics, 85(3 Pt 2), 393-399.

Alm, J. S., Swartz, J., Bjorksten, B., Engstrand, L., Engstrom, J., Kuhn, I., et al. (2002).
An anthroposophic lifestyle and intestinal microflora in infancy. Pediatr Allergy
Immunol, 13(6), 402-411.

Arora, S., McJunkin, C., Wehrer, J., & Kuhn, P. (2000). Major factors influencing
breastfeeding rates: Mother's perception of father's attitude and milk supply.
Pediatrics, 106(5), E67.

Baker, R. (2003). Human milk substitutes. An American perspective. Minerva Pediatr,
55(3), 195-207.

Ball, T. M., & Wright, A. L. (1999). Health care costs of formula-feeding in the first year
of life. Pediatrics, 103(4 Pt 2), 870-876.

Berens, P. D. (2001). Prenatal, intrapartum, and postpartum support of the lactating
mother. Pediatr Cin North Am, 48(2), 365-375.

Beresford, H. J. (1984). The success of breast feeding. IPPFMedBull, 18(5), 3-4.

Bemaix, L. W. (2000). Nurses' attitudes, subjective norms, and behavioral intentions
toward support of breastfeeding mothers. JHum Lact, 16(3), 201-209.

Bick, D. E., MacArthur, C., & Lancashire, R. J. (1998). What influences the uptake and
early cessation of breast feeding? Midwifery, 14(4), 242-247.

Birch, E., Birch, D., Hoffman, D., Hale, L., Everett, M., & Uauy, R. (1993). Breast-
feeding and optimal visual development. JPediatr Ophthalmol Strabismus, 30(1),
33-38.

Black, K. A., & Hylander, M. A. (2000). Breastfeeding the high risk infant: implications
for midwifery management. JMidwifery Womens Health, 45(3), 238-245.

Blackburn, S. (1998). Environmental impact of the NICU on developmental outcomes. J
Pediatr Nurs, 13(5), 279-289.









Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group
on Breastfeeding. (1997). Pediatrics, 100(6), 1035-1039.

Bueno, M. B., de Souza, J. M., de Souza, S. B., da Paz, S. M., Gimeno, S. G., & de
Siqueira, A. A. (2003). [Risks associated with the weaning process in children born
in a university hospital: a prospective cohort in the first year of life, Sao Paulo,
1998-1999]. CadSaude Publica, 19(5), 1453-1460.

Byrne, B., & Hull, D. (1996). Breast milk for preterm infants. Prof Care Mother Child,
6(2), 39, 42-35.

Callen, J., & Pinelli, J. (2005). A review of the literature examining the benefits and
challenges, incidence and duration, and barriers to breastfeeding in preterm infants.
Adv Neonatal Care, 5(2), 72-88; quiz 89-92.

Chan, D. K. (2001). Enteral nutrition of the very low birth weight (VLBW) infant. Ann
AcadMed Singapore, 30(2), 174-182.

Chantry, C. J., Auinger, P., & Byrd, R. S. (2004). Lactation among adolescent mothers
and subsequent bone mineral density. Arch Pediatr Adolesc Med, 158(7), 650-656.

Chen, A., & Rogan, W. J. (2004). Breastfeeding and the risk of postneonatal death in the
United States. Pediatrics, 113(5), e435-439.

Chen, C. H., Wang, T. M., Chang, H. M., & Chi, C. S. (2000). The effect of breast- and
bottle-feeding on oxygen saturation and body temperature in preterm infants. J
Hum Lact, 16(1), 21-27.

Chua, S., Arulkumaran, S., Lim, I., Selamat, N., & Ratnam, S. S. (1994). Influence of
breastfeeding and nipple stimulation on postpartum uterine activity. Br J Obstet
Gynaecol, 101(9), 804-805.

Cohen, J. (1988). Statistical power analysisfor the behavioral sciences (2nd ed.).
Hillsdale, N.J.: L. Erlbaum Associates.

Coleman, S., Dracup, K., & Moser, D. K. (1991). Comparing methods of
cardiopulmonary resuscitation instruction on learning and retention. JNurs Staff
Dev, 7(2), 82-87.

Dai, D., & Walker, W. A. (1998). Role of bacterial colonization in neonatal necrotizing
enterocolitis and its prevention. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi,
39(6), 357-365.

Davis, M. K. (2001). Breastfeeding and chronic disease in childhood and adolescence.
Pediatr Clin North Am, 48(1), 125-141, ix.

Dewey, K. G., Heinig, M. J., & Nommsen, L. A. (1993). Maternal weight-loss patterns
during prolonged lactation. Am J Clin Nutr, 58(2), 162-166.









Diaz Gomez, M., Ramos Acosta, C. L., Rico Sevillano, J., Robayna Curbelo, M., &
Alvarez Alvarez, J. (1997). [Breast feeding and length of hospitalization]. Rev
Enferm, 20(231), 11-14.

do Nascimento, M. B., & Issler, H. (2004). [Breastfeeding in premature infants: in-
hospital clinical management]. JPediatr (Rio J), 80(5 Suppl), S163-172.

Docherty, S. L., Miles, M. S., & Holditch-Davis, D. (2002). Worry about child health in
mothers of hospitalized medically fragile infants. Adv Neonatal Care, 2(2), 84-92.

Ekstrom, A., Matthiesen, A. S., Widstrom, A. M., & Nissen, E. (2005). Breastfeeding
attitudes among counselling health professionals. ScandJPublic Health, 33(5),
353-359.

Ekstrom, A., Widstrom, A. M., & Nissen, E. (2005). Process-oriented training in
breastfeeding alters attitudes to breastfeeding in health professionals. ScandJ
Public Health, 33(6), 424-431.

Espy, K. A., & Senn, T. E. (2003). Incidence and correlates of breast milk feeding in
hospitalized preterm infants. Soc Sci Med, 57(8), 1421-1428.

Fergusson, D. M., & Woodward, L. J. (1999). Breast feeding and later psychosocial
adjustment. Paediatr Perinat Epidemiol, 13(2), 144-157.

Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O'Hare, D., Schanler, R. J., et
al. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506.

Goldrick, B., Gruendemann, B., & Larson, E. (1993). Learning styles and
teaching/learning strategy preferences: implications for educating nurses in critical
care, the operating room, and infection control. Heart Lung, 22(2), 176-182.

Gomez-Sanchiz, M., Canete, R., Rodero, I., Baeza, J. E., & Avila, 0. (2003). Influence of
breast-feeding on mental and psychomotor development. Clin Pediatr (Phila),
42(1), 35-42.

Gray, L., Miller, L. W., Philipp, B. L., & Blass, E. M. (2002). Breastfeeding is analgesic
in healthy newborns. Pediatrics, 109(4), 590-593.

Gross, S. J., David, R. J., Bauman, L., & Tomarelli, R. M. (1980). Nutritional
composition of milk produced by mothers delivering preterm. JPediatr, 96(4),
641-644.

Hanson, L. A. (1998). Breastfeeding provides passive and likely long-lasting active
immunity. Ann Allergy Asthma Immunol, 81(6), 523-533; quiz 533-524, 537.

Hanson, L. A., Korotkova, M., Haversen, L., Mattsby-Baltzer, I., Hahn-Zoric, M.,
Silfverdal, S. A., et al. (2002). Breast-feeding, a complex support system for the
offspring. Pediatr Int, 44(4), 347-352.









Harrington, S. S., & Walker, B. L. (2004). The effects of computer-based training on
immediate and residual learning of nursing facility staff. J Contin Educ Nurs,
35(4), 154-163; quiz 186-157.

Harrold, J., & Schmidt, B. (2002). Evidence-based neonatology: making a difference
beyond discharge from the neonatal nursery. Curr Opin Pediatr, 14(2), 165-169.

Hart, S., Boylan, L. M., Carroll, S., Musick, Y. A., & Lampe, R. M. (2003). Brief report:
breast-fed one-week-olds demonstrate superior neurobehavioral organization. J
Pediatr Psychol, 28(8), 529-534.

Hill, P. D., Andersen, J. L., & Ledbetter, R. J. (1995). Delayed initiation of breast-feeding
the preterm infant. JPerinat Neonatal Nurs, 9(2), 10-20.

Hill, P. D., Hanson, K. S., & Mefford, A. L. (1994). Mothers of low birthweight infants:
breastfeeding patterns and problems. JHum Lact, 10(3), 169-176.

Holditch-Davis, D., & Miles, M. S. (2000). Mothers' stories about their experiences in the
neonatal intensive care unit. Neonatal Netw, 19(3), 13-21.

How breast-feeding postpones ovulation. (1985). Network, 7(1), 3.

Hwang, W. J., Chung, W. J., Kang, D. R., & Suh, M. H. (2006). [Factors affecting
breastfeeding rate and duration]. JPrev MedPub Health, 39(1), 74-80.

Hylander, M. A., Strobino, D. M., & Dhanireddy, R. (1998). Human milk feedings and
infection among very low birth weight infants. Pediatrics, 102(3), E38.

Hylander, M. A., Strobino, D. M., Pezzullo, J. C., & Dhanireddy, R. (2001). Association
of human milk feedings with a reduction in retinopathy of prematurity among very
low birthweight infants. JPerinatol, 21(6), 356-362.

Isaacson, L. J. (2006). Steps to successfully breastfeed the premature infant. Neonatal
Netw, 25(2), 77-86.

Jaeger, M. C., Lawson, M., & Filteau, S. (1997). The impact of prematurity and neonatal
illness on the decision to breast-feed. JAdv Nurs, 25(4), 729-737.

Jang, Y. S. (2005). [Effects of a workbook program on the perceived stress level,
maternal role confidence and breast feeding practice of mothers of premature
infants]. Taehan Kanho Hakhoe Chi, 35(2), 419-427.

Karl, D. J. (2004). Using principles of newborn behavioral state organization to facilitate
breastfeeding. MCNAm JMatern ChildNurs, 29(5), 292-298.

Kavanaugh, K., Mead, L., Meier, P., & Mangurten, H. H. (1995). Getting enough:
mothers' concerns about breastfeeding a preterm infant after discharge. JObstet
Gynecol Neonatal Nurs, 24(1), 23-32.









Kemp, A., & Kakakios, A. (2004). Asthma prevention: breast is best? JPaediatr Child
Health, 40(7), 337-339.

Kirsten, G. F., Bergman, N. J., & Hann, F. M. (2001). Kangaroo mother care in the
nursery. Pediatr Clin North Am, 48(2), 443-452.

Kronborg, H., & Vaeth, M. (2004). The influence of psychosocial factors on the duration
of breastfeeding. ScandJPublic Health, 32(3), 210-216.

Lanari, M., Papa, I., Venturi, V., Sermasi, S., Corvaglia, L., Faldella, G., et al. (2001).
[Neonatal sepsis]. Recent ProgMed, 92(11), 690-695.

Lang, S. (1996). Breastfeeding special care babies. ModMidwife, 6(11), 34-35.

Laubereau, B., Brockow, I., Zirngibl, A., Koletzko, S., Gruebl, A., von Berg, A., et al.
(2004). Effect of breast-feeding on the development of atopic dermatitis during the
first 3 years of life--results from the GINI-birth cohort study. JPediatr, 144(5),
602-607.

Li, R., Darling, N., Maurice, E., Barker, L., & Grummer-Strawn, L. M. (2005).
Breastfeeding rates in the United States by characteristics of the child, mother, or
family: the 2002 National Immunization Survey. Pediatrics, 115(1), e31-37.

Lucas, A., Morley, R., Cole, T. J., & Gore, S. M. (1994). A randomised multicentre study
of human milk versus formula and later development in preterm infants. Arch Dis
Child Fetal Neonatal Ed, 70(2), F 141-146.

Lucas, A., Morley, R., Cole, T. J., Lister, G., & Leeson-Payne, C. (1992). Breast milk
and subsequent intelligence quotient in children born preterm. Lancet, 339(8788),
261-264.

Lugo-Vicente, H. (2003). Necrotizing enterocolitis. BolAsoc MedP R, 95(2), 17-22.

Lupton, D., & Fenwick, J. (2001). 'They've forgotten that I'm the mum': constructing and
practising motherhood in special care nurseries. Soc SciMed, 53(8), 1011-1021.

Marild, S., Hansson, S., Jodal, U., Oden, A., & Svedberg, K. (2004). Protective effect of
breastfeeding against urinary tract infection. Acta Paediatr, 93(2), 164-168.

Matthews, K., Webber, K., McKim, E., Banoub-Baddour, S., & Laryea, M. (1998).
Maternal infant-feeding decisions: reasons and influences. Can JNurs Res, 30(2),
177-198.

McGrath, J. M., & Braescu, A. V. (2004). State of the science: feeding readiness in the
preterm infant. JPerinat Neonatal Nurs, 18(4), 353-368; quiz 369-370.

McVea, K. L., Turner, P. D., & Peppler, D. K. (2000). The role of breastfeeding in
sudden infant death syndrome. JHum Lact, 16(1), 13-20.









Meier, P. P. (1998). Strategies for assisting breatfeeding in preterm infants.

Meier, P. P. (2001). Breastfeeding in the special care nursery. Prematures and infants
with medical problems. Pediatr Clin North Am, 48(2), 425-442.

Meier, P. P., & Brown, L. P. (1996). State of the science. Breastfeeding for mothers and
low birth weight infants. Nurs Clin North Am, 31(2), 351-365.

Meier, P. P., Engstrom, J. L., Mingolelli, S. S., Miracle, D. J., & Kiesling, S. (2004). The
Rush Mothers' Milk Club: breastfeeding interventions for mothers with very-low-
birth-weight infants. J Obstet Gynecol Neonatal Nurs, 33(2), 164-174.

Mikiel-Kostyra, K. (2000). [Breast feeding as a component of reproductive health].
GinekolPol, 71(7), 641-647.

Miles, M. S., Funk, S. G., & Kasper, M. A. (1992). The stress response of mothers and
fathers of preterm infants. Res Nurs Health, 15(4), 261-269.

Mitra, A. K., Khoury, A. J., Hinton, A. W., & Carothers, C. (2004). Predictors of
breastfeeding intention among low-income women. Matern Child Health J, 8(2),
65-70.

Morley, R., Cole, T. J., Powell, R., & Lucas, A. (1988). Mother's choice to provide breast
milk and developmental outcome. Arch Dis Child, 63(11), 1382-1385.

Neiva, F. C., Cattoni, D. M., Ramos, J. L., & Issler, H. (2003). [Early weaning:
implications to oral motor development]. JPediatr (Rio J), 79(1), 7-12.

Nikolaj ski, P. Y. (1992). Investigating the effectiveness of self-learning packages in staff
development. JNurs StaffDev, 8(4), 179-183.

Nyqvist, K. H., Ewald, U., & Sjoden, P. O. (1996). Supporting a preterm infant's
behaviour during breastfeeding: a case report. JHum Lact, 12(3), 221-228.

Nyqvist, K. H., Sjoden, P. O., & Ewald, U. (1994). Mothers' advice about facilitating
breastfeeding in a neonatal intensive care unit. JHum Lact, 10(4), 237-243.

Nyqvist, K. H., Sjoden, P. O., & Ewald, U. (1999). The development of preterm infants'
breastfeeding behavior. Early Hum Dev, 55(3), 247-264.

Oddy, W. H., Sherriff, J. L., de Klerk, N. H., Kendall, G. E., Sly, P. D., Beilin, L. J., et al.
(2004). The relation of breastfeeding and body mass index to asthma and atopy in
children: a prospective cohort study to age 6 years. Am JPublic Health, 94(9),
1531-1537.

The optimal duration of exclusive breastfeeding: results of a WHO systematic review.
(2001). Indian Pediatr, 38(5), 565-567.









Owen, C. G., Whincup, P. H., Odoki, K., Gilg, J. A., & Cook, D. G. (2002). Infant
feeding and blood cholesterol: a study in adolescents and a systematic review.
Pediatrics, 110(3), 597-608.

Page, D. C. (2001). Breastfeeding is early functional jaw orthopedics (an introduction).
Funct Orthod, 18(3), 24-27.

Pantazi, M., Jaeger, M. C., & Lawson, M. (1998). Staff support for mothers to provide
breast milk in pediatric hospitals and neonatal units. JHum Lact, 14(4), 291-296.

Philipp, B. L., Malone, K. L., Cimo, S., & Merewood, A. (2003). Sustained breastfeeding
rates at a US baby-friendly hospital. Pediatrics, 112(3 Pt 1), e234-236.

Pinelli, J., Atkinson, S. A., & Saigal, S. (2001). Randomized trial of breastfeeding
support in very low-birth-weight infants. Arch Pediatr Adolesc Med, 155(5), 548-
553.

Piper, S., & Parks, P. L. (1996). Predicting the duration of lactation: evidence from a
national survey. Birth, 23(1), 7-12.

Powers, N. G., Bloom, B., Peabody, J., & Clark, R. (2003). Site of care influences
breastmilk feedings at NICU discharge. JPerinatol, 23(1), 10-13.

Premji, S. S., Paes, B., Jacobson, K., & Chessell, L. (2002). Evidence-based feeding
guidelines for very low-birth-weight infants. Adv Neonatal Care, 2(1), 5-18.

Prochaska, J. M., Prochaska, J. O., & Levesque, D. A. (2001). A transtheoretical
approach to changing organizations. Adm Policy Ment Health, 28(4), 247-261.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of
smoking: toward an integrative model of change. J Consult Clin Psychol, 51(3),
390-395.

Rea, M. F. (2004). [Benefits ofbreastfeeding and women's health]. JPediatr (Rio J),
80(5 Suppl), S142-146.

Register, N., Eren, M., Lowdermilk, D., Hammond, R., & Tully, M. R. (2000).
Knowledge and attitudes of pediatric office nursing staff about breastfeeding. J
Hum Lact, 16(3), 210-215.

Riskin, A., & Bader, D. (2003). [Breast is best--human milk for premature infants].
Harefuah, 142(3), 217-222, 237, 236.

Rooney, B. L., & Schauberger, C. W. (2002). Excess pregnancy weight gain and long-
term obesity: one decade later. Obstet Gynecol, 100(2), 245-252.









Ryan, A. S., Wysong, J. L., Martinez, G. A., & Simon, S. D. (1990). Duration of breast-
feeding patterns established in the hospital. Influencing factors. Results from a
national survey. Clin Pediatr (Phila), 29(2), 99-107.

Schack-Nielsen, L., & Michaelsen, K. F. (2006). Breast feeding and future health. Curr
Opin Clin Nutr Metab Care, 9(3), 289-296.

Schanler, R. J., Hurst, N. M., & Lau, C. (1999). The use of human milk and breastfeeding
in premature infants. Clin Perinatol, 26(2), 379-398, vii.

Scott, J. A., Binns, C. W., Graham, K. I., & Oddy, W. H. (2006). Temporal changes in
the determinants of breastfeeding initiation. Birth, 33(1), 37-45.

Shadish, W. R., Cook, T. D., & Campbell, D. T. (2001). Experimental and quasi-
experimental designsfor generalized causal inference. Boston: Houghton Mifflin.

Siddell, E., Marinelli, K., Froman, R. D., & Burke, G. (2003). Evaluation of an
educational intervention on breastfeeding for NICU nurses. JHum Lact, 19(3),
293-302.

Singhal, A., Cole, T. J., Fewtrell, M., & Lucas, A. (2004). Breastmilk feeding and
lipoprotein profile in adolescents born preterm: follow-up of a prospective
randomised study. Lancet, 363(9421), 1571-1578.

Sisk, P. M., Lovelady, C. A., Dillard, R. G., & Gruber, K. J. (2006). Lactation counseling
for mothers of very low birth weight infants: effect on maternal anxiety and infant
intake of human milk. Pediatrics, 117(1), e67-75.

Slusher, T., Hampton, R., Bode-Thomas, F., Pam, S., Akor, F., & Meier, P. (2003).
Promoting the exclusive feeding of own mother's milk through the use of hindmilk
and increased maternal milk volume for hospitalized, low birth weight infants (<
1800 grams) in Nigeria: a feasibility study. JHum Lact, 19(2), 191-198.

Smith, M. M., Durkin, M., Hinton, V. J., Bellinger, D., & Kuhn, L. (2003). Influence of
breastfeeding on cognitive outcomes at age 6-8 years: follow-up of very low birth
weight infants. Am JEpidemiol, 158(11), 1075-1082.

Smithers, L. G., McPhee, A. J., Gibson, R. A., & Makrides, M. (2003). Characterisation
of feeding patterns in infants born < 33 weeks gestational age. Asia Pac J Clin
Nutr, 12 Suppl, S43.

Spicer, K. (2001). What every nurse needs to know about breast pumping: instructing and
supporting mothers of premature infants in the NICU. NeonatalNetw, 20(4), 35-41.

Stewart-Knox, B., Gardiner, K., & Wright, M. (2003). What is the problem with breast-
feeding? A qualitative analysis of infant feeding perceptions. JHum Nutr Diet,
16(4), 265-273.






86


Swanson, V., & Power, K. G. (2005). Initiation and continuation of breastfeeding: theory
of planned behaviour. JAdv Nurs, 50(3), 272-282.

Torgus, J., Gotsch, G., & La Leche League International. (1997). The womanly art of
breastfeeding (6th rev ed.). Schaumburg, Ill.: La Leche League International.

Vannuchi, M. T., Monteiro, C. A., Rea, M. F., Andrade, S. M., & Matsuo, T. (2004).
[The Baby-Friendly Hospital Initiative and breastfeeding in a neonatal unit]. Rev
Saude Publica, 38(3), 422-428.

Viggiano, D., Fasano, D., Monaco, G., & Strohmenger, L. (2004). Breast feeding, bottle
feeding, and non-nutritive sucking; effects on occlusion in deciduous dentition.
Arch Dis Child, 89(12), 1121-1123.

What is best birth control to use after having a baby? (1989). Contracept Technol Update,
10(10), 1S-2S.

Wheeler, J., Chapman, C., Johnson, M., & Langdon, R. (2000). Feeding outcomes and
influences within the neonatal unit. Int JNurs Pract, 6(4), 196-206.

Wheeler, J. L., Johnson, M., Collie, L., Sutherland, D., & Chapman, C. (1999).
Promoting breastfeeding in the neonatal intensive care unit. BreastfeedRev, 7(2),
15-18.

Wold, A. E., & Adlerberth, I. (2000). Breast feeding and the intestinal microflora of the
infant--implications for protection against infectious diseases. Adv Exp MedBiol,
478, 77-93.

Wolf, J. H. (2003). Low breastfeeding rates and public health in the United States. Am J
Public Health, 93(12), 2000-2010.

Yip, E., Lee, J., & Sheehy, Y. (1996). Breast-feeding in neonatal intensive care. J
Paediatr Child Health, 32(4), 296-298.

Ziemer, M. M., & George, C. (1990). Breastfeeding the low-birthweight infant. Neonatal
Netw, 9(4), 33-38.

Zimmerman, D. R., & Guttman, N. (2001). "Breast is best": knowledge among low-
income mothers is not enough. JHum Lact, 17(1), 14-19.















BIOGRAPHICAL SKETCH

Dr. Roberta Gittens Pineda received her doctor of philosophy degree at the

University of Florida. She received her Bachelor of Science in occupational therapy at

the Florida Agricultural and Mechanical University in 1992 and achieved her Master of

Health Science degree at the University of Florida in 1994. She has worked as an

occupational therapist, primarily in the inpatient pediatric setting, and has been a lecturer

at University of Florida as well as Washington University.

Dr. Pineda's primary clinical setting is the neonatal intensive care unit, where she

most recently has specialized in treatment of feeding and swallowing problems in these

complex, medically fragile infants. In addition, she suffered premature labor with her 3

pregnancies and learned, first hand, the difficulties associated with being a mother of an

infant hospitalized in the neonatal intensive care unit.

Dr. Pineda decided on her dissertation topic following an invitation by the chief of

neonatology at Shands Hospital to be part of a March of Dimes Advisory Committee.

The University of Florida at Shands Hospital had decided to participate in a program

sponsored by the March of Dimes aimed at making the unit more developmentally

supportive and family centered. Through this project, she joined efforts with a

pediatrician to design a plan aimed at making the neonatal intensive care unit (NICU)

more breastfeeding friendly. As she had frequently assisted mothers with breastfeeding

in the unit as part of occupational therapy intervention and had struggled with the issues

of nursing in the NICU when her own son was born at 29 weeks gestation, she found






88


herself very passionate about fostering changes and quickly decided to focus her research

around the changes that were set to be made. Dr. Pineda's dissertation topic is entitled

"Breastfeeding Practices in the Neonatal Intensive Care Unit before and after an

Intervention Plan". Dr. Pineda has thoroughly enjoyed the research process and looks

forward to a career in research and teaching.