ALERT! Warning: your browser isn't supported. Please install a modern one, like Firefox, Opera, Safari, Chrome or the latest Internet Explorer. Thank you!
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Reason for Not Exclusively Feeding Breast Milk

Release Notes:
Data Element
Version 2015A

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 mother’s initial feeding plan which included formula feeding upon admission of the newborn.

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) /international board certified lactation consultant (IBCLC)/ certified lactation counselor (CLC) 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 by physician/APN/PA/CNM/IBCLC/CLC/RN that the newborn’s mother's initial feeding plan for the hospitalization included formula upon admission of the newborn.

3.) None of the above or unable to determine from medical record documentation.
Notes for Abstraction:Admission is defined as the birth of the newborn. The mother'’s initial feeding plan or diet plan must be documented in the newborn'’s medical record and may only be used if it is documented prior to the first feeding. If the discussion of the mother'’s initial feeding plan occurred prior to birth of the newborn, this may be used provided the date and time of the discussion appears in the newborn'’s medical record. The date and time the discussion took place must also be prior to the date and time of the first feeding.
  • Example: The discussion of the initial feeding plan with the mother was documented in the mother's medical record on 6-1-20xx at 10:00. The baby was born (admitted) on 6-1-20xx at 13:00. The first feeding was documented on 6-1-20xx at 13:30 in the newborn’s medical record. The newborn's medical record should have documentation of the discussion of the initial feeding plan that took place with the mother, the content of the discussion and the mother’s decision for the initial feeding plan along with the date and time of the discussion (6-1-20xx at 10:00). If the date and time documented in the newborn’s medical record does not match that of the original discussion documented in the mother's record and it turns out to be a another discussion and feeding plan taking place after the first feeding, this documentation cannot be used, e.g., discussion occurring at 6-1-20xx at 14:00.

When determining whether there is a reason due to a medical maternal condition documented by a physician/APN/PA/CNM/IBCLC or CLC 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). RN or certified lactation educator (CLE) documentation is not acceptable for maternal medical conditions.

If newborn medical conditions, i.e., hypoglycemia, weight loss, hyperbilirubinemia, etc. are documented as a reason for not exclusively feeding breast milk, select allowable value “"3"”.

A mother'’s initial feeding plan existing at the time of admission of the newborn that includes formula feeding during the hospitalization must be clearly documented in the newborn'’s medical record in the context of the newborn substance fed in order to select allowable value "“2"”. Do not assume that the newborn was not exclusively fed breast milk due to the mother'’s initial feeding plan in the absence of such documentation.

There is no evidence to support feeding both breast milk and formula, so the discussion of the mother'’s initial feeding plan should focus on the benefits of exclusive breast milk feeding and the risks of adding formula when breast feeding. If there is documentation in the newborn'’s medical record of the discussion and the mother's initial feeding plan for the hospitalization, and the mother still elected to feed both formula and breast milk upon admission select allowable value "2".

If the mother’s initial feeding plan was to exclusively feed breast milk upon admission, and the mother’s feeding plan changed later in the hospitalization to include formula feeding select allowable value "3". Standing orders and check boxes listing the method of feeding to include formula based on the mother’s initial feeding plan cannot be used alone to select allowable value "2". There must be additional supporting documentation from the physician/APN/PA/CNM/IBCLC/CLC that the initial feeding plan was discussed with the mother. RN documentation of the discussion and the mother’s initial feeding plan to include formula discussed upon admission is acceptable ONLY if there is supporting documentation by the physician/APN/PA/CNM/IBCLC/CLC at some point during the hospitalization to corroborate the RN’s initial discussion with the mother. If the mother decides to feed formula prior to the supporting documentation, only the initial feeding plan findings can be used.

The mother'’s medical record cannot be used to determine the mother'’s initial feeding plan. This documentation must appear in the newborn'’s medical record without using the mother’s medical record to perform the abstraction even if there is a link between the mother and newborn medical records in the EHR.

Bottle is a method of feeding and is not the same as formula. Bottle cannot be used interchangeably for formula, since breast milk can also be fed via a bottle.
Suggested Data Sources:

  • Clinician progress notes
  • History and physical
  • Nursing assessment
  • 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
  • Newborn and mother will be separated after discharge from the hospital, and the mother will not be providing care for the newborn after the hospitalization. Some examples include, but are not limited to: adoption, foster home placement, surrogate delivery, incarceration of the mother
  • Previous breast surgery, i.e., bilateral mastectomy, bilateral breast reduction or augmentation where the mother is unable to produce breast milk
  • Breast abnormality, i.e., hypoplasia, tumor, etc. 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 (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
^