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Release Notes:
Data Element
Version 2013A1

Data Element Name: Reason for Not Exclusively Feeding Breast Milk
Collected For: PC-05,
Definition:Reasons for not exclusively feeding breast milk during the entire hospitalization are clearly documented in the medical record. These reasons are due to a maternal medical condition for which feeding breast milk should be avoided or due to motherís choice to not breast feed.

Exclusive breast milk feeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.

Suggested Data Collection Question:Was there documentation of a reason for not exclusively feeding breast milk during the entire hospitalization?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1.) There is documentation by physician/advanced practice nurse(APN)/physician assistant (PA)/certified nurse midwife (CNM) /lactation consultant of a reason for not exclusively feeding breast milk during the entire hospitalization due to a maternal medical condition with which breast milk feeding should be avoided.

2.) There is documentation that the newbornís mother chose not to breast feed.

3.) There is no documentation by physician/APN/PA/CNM/lactation consultant of a reason for not exclusively feeding breast milk during the entire hospitalization due to a maternal medical condition with which breast milk feeding should be avoided OR newborn's mother's choice to not breast feed OR unable to determine from medical record documentation.

Notes for Abstraction:When determining whether there is a reason due to a medical maternal condition documented by a physician/APN/PA/CNM or lactation consultant for not exclusively feeding breast milk, reasons must be explicitly documented (e.g., "mother is HIV positive - newborn will not be breast fed") or clearly implied (e.g., "mother is currently abusing alcohol - newborn will be fed formula"). If reasons are not mentioned in the context of newborn feeding, do not make inferences (e.g., do not assume that the newborn is not receiving breast milk because of the medications the mother is currently taking).

A motherís choice to not breast feed must be clearly documented in the newbornís medical record in the context of the newborn feeding method in order to select allowable value ď2Ē. Do not assume that the newborn was not exclusively fed breast milk due to maternal choice in the absence of such documentation.

Suggested Data Sources:

PHYSICIAN/APN/CNM/LACTATION CONSULTANT DOCUMENTATION ONLY

  • Clinician progress notes
  • History and physical
  • Physician progress notes
  • Physician's orders
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
These are the only acceptable maternal medical conditions for which breast milk feeding should be avoided which includes one or more of the following medical conditions:
  • HIV infection
  • Human t-lymphotrophic virus type I or II
  • Substance abuse and/or alcohol abuse
  • Active, untreated tuberculosis
  • Taking certain medications, i.e., prescribed cancer chemotherapy, radioactive isotopes, antimetabolites, antiretroviral medications and other medications where the risk of morbidity outweighs the benefits of breast milk feeding
  • Undergoing radiation therapy
  • Active, untreated varicella
  • Active herpes simplex virus with breast lesions
  • Admission to Intensive Care Unit (ICU) post-partum
  • Adoption or foster home placement of newborn
  • Previous breast surgery, i.e., bilateral mastectomy, bilateral breast reduction or augmentation where the mother is unable to produce breast milk
None

Reason for Not Exclusively Feeding Breast Milk
Specifications Manual for Joint Commission National Quality Measures (v2013A1)
Discharges 01-01-13 (1Q13) through 06-30-13 (2Q13)