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Release Notes:
Data Element
Version 2010B

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.

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:

Y (Yes) There is documentation by physician/APN/PA/CNM of a reason for not exclusively feeding breast milk during the entire hospitalization due to a maternal medical condition where breast milk feeding should be avoided.

N (No) There is no documentation by physician/APN/PA/CNM of a reason for not exclusively feeding breast milk during the entire hospitalization due to a maternal medical condition for which breast milk feeding should be avoided OR unable to determine from medical record documentation.

Notes for Abstraction:The mother's refusal to feed the newborn breast milk does not constitute a reason for not exclusively feeding breast milk.

When determining whether there is a reason documented by a physician/APN/PA or CNM for not exclusely feeding breast milk, reasons must be explicitly documented (e.g., "mother is HIV positive - infant will not be breast fed") or clearly implied (e.g., "mother is currently abusing alcohol - infant will be fed formula"). If reasons are not mentioned in the context of infant feeding, do not make references (e.g., Do not assume that the infant is not receiving breast milk because of the medications the mother is currently taking).

Suggested Data Sources:

PHYSICIAN/APN/CNM DOCUMENATION ONLY

  • 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
None

Reason for Not Exclusively Feeding Breast Milk
Specifications Manual for Joint Commission National Quality Core Measures (2010B)
Discharges 10-01-10 (4Q10) through 03-31-11 (1Q11)