Specifications Manual for Joint Commission National Quality Measures (v2020B1)
Posted: 3/30/2020
Home » Exclusive Breast Milk Feeding

Release Notes:
Data Element
Version 2020B1

Name:Exclusive Breast Milk Feeding
Collected For: PC-05
Definition:Documentation that the newborn was exclusively fed breast milk during the entire hospitalization.

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.
Question:Is there documentation that the newborn was exclusively fed breast milk during the entire hospitalization?
Allowable Values:

Y (Yes) There is documentation that the newborn was exclusively fed breast milk during the entire hospitalization.

N (No) There is no documentation that the newborn was exclusively fed breast milk during the entire hospitalization OR unable to determine from medical record documentation.
Notes for Abstraction:
  • If the newborn receives any other liquids including water during the entire hospitalization, select allowable value "No".

  • Exclusive breast milk feeding includes the newborn receiving breast milk via a bottle or other means beside the breast.

  • Sweet-Ease® or a similar 24% sucrose and water solution given to the newborn for the purpose of reducing discomfort during a painful procedure is classified as a medication and is not considered a supplemental feeding.

  • If the newborn receives donor breast milk, select allowable value "Yes".

  • If breast milk fortifier is added to the breast milk, select allowable value "Yes".

  • In cases where there is conflicting documentation and both exclusive breast milk feeding and formula supplementation is documented, select allowable value "No".

  • If the newborn received “drops” of water or formula dribbled onto the mother”s breast to stimulate latching and not an actual feeding, select “yes”.

  • If the newborn received IV fluids this is the same as a medication and not a feeding.

  • If dextrose or glucose 40% gel is given it is considered a medication not a feeding. This should be reflected as such in the documentation.

  • Actual feedings must be abstracted from the only acceptable data sources regardless of any documentation about feeding plans and changes to feeding plans which mention inclusion of formula.
Suggested Data Sources: ONLY ACCEPTABLE SOURCES:
  • Diet flow sheets
  • Feeding flow sheets
  • Intake and output sheets

Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Exclusive Breast Milk Feeding
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Specifications Manual for Joint Commission National Quality Measures (v2020B1)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)


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