Breastfeeding and Vitamin D
Supplementation
Broadway Clinic QI Project
Rakhee Bowker, Michael Goldman, Stuart Holzer, Lisa Kurz, Lacy-Ann
Landell, Robbie Majzner, Lindsay McGann, Lisa McReynolds, Lisa Nowell,
Anne Pierog, Gabe Rama, Corinna Rea, Daniel Stephens, Emily Whitesel,
Kristal Woldu
Heidi Beutler, Renie Eis, Mariellen Lane, Pran Saha, Nan Salamon, John
Rausch, Laura Robbins-Milne
Breastfeeding
 It is well demonstrated that breastfeeding provides benefits
for both mothers and infants, including:
 Infants Stimulate GI motility and growth, decrease risk of NEC
 Increased immune response due to transmission in breastmilk of
maternal antibodies
 Decrease risk of diseases such as asthma, obesity, and diabetes
 Mothers Stimulate oxytocin release and acceleration of recovery from
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childbirth
Increased weight loss
Increased bonding with infant
Prolonged annovulation postpartum
Economic savings on formula
Reduced risk of breast and ovarian cancer
Decreased risk of cardiovascular disease
Vitamin D
 Important in calcium homeostasis
 Transferred across the placenta
from mother to fetus
 Often low in infants if maternal
levels low or infant premature
 Amount of vitamin D in breastmilk
is low, especially if mom is vitamin
D deficient
AAP Recommendations
 The AAP recommends exclusively breastfeeding
infants until 6 months and then supplementing with
breastmilk up to and beyond the first year of life
 The AAP now recommends starting vitamin D
supplementation within the first few days of life to any
infant breastfeeding or taking less than 27oz of formula
per day
Baseline Data For Broadway
 Breastfeeding (exclusive and partial)
 2 months- 32%
 4 months- 16%
 Vitamin D supplementation
 2 months- 57%
 4 months- 57%
AIM Statement
 We aim to improve collective breastfeeding rates in the
Washington Heights community, specifically to 30% at
the 4 month well child visit in the Broadway Ambulatory
Clinic pediatric population.
 Within this patient population, we aim to increase
vitamin D supplementation per current AAP guidelines
to 90% in all nursing infants (including both fully and
partially breastfed infants).
Interventions
 Breastfeeding Resource Sheet in English & Spanish
created and distributed to mothers at the newborn visit
Interventions
 Breastfeeding Resource Sheet in English & Spanish created
and distributed to mothers at the newborn visit
 Didactic educating clinic providers regarding
breastfeeding and vitamin D supplementation
guidelines
Interventions
 Breastfeeding Resource Sheet in English & Spanish created
and distributed to mothers at the newborn visit
 Didactic educating clinic providers regarding breastfeeding
and vitamin D supplementation guidelines
 Breastfeeding checklist placed in all exam rooms with
guidelines for providers regarding vitamin D
supplementation
Interventions
 Breastfeeding Resource Sheet in English & Spanish created
and distributed to mothers at the newborn visit
 Didactic educating clinic providers regarding breastfeeding
and vitamin D supplementation guidelines
 Breastfeeding checklist placed in all exam rooms with
guidelines for providers regarding vitamin D
supplementation
 Schedule breastfeeding newborns for a weight
check/breastfeeding check at one month of age to
troubleshoot and encourage continued breastfeeding
Other Interventions Also
Happening At Broadway
Centering Group
 Prenatal counseling at Broadway for teenage expecting
mothers
 Residents developed a breastfeeding and Vitamin D
supplementation presentation. Each month the
outpatient resident gives the presentation to the
expectant mothers in the group
Cross Cradle Position
Breastfeeding Your Baby:
Healthy and Natural
Sitting comfortably with the baby at
breast height using a pillow for
support (excellent options are My
Breast Friend or Boppy pillows), tuck
the baby's tush in the crook of the
opposite arm of the breast being fed.
The mother's forearm should be
positioned up the length of the baby's
back. The baby's head is supported
by her thumb and forefinger, right
behind the ears. The baby is held
tummy-to-tummy with the mother
Breastfeeding Support Group
 Meets every 1st and 3rd
Wednesday morning
 Mothers can walk-in
 For expecting and new mothers
of Broadway Clinic
 Organized by Dr. Salamon and
Alyssa Wynn
Percent of Infants Receiving Any Breastmilk
100.0%
90.0%
80.0%
Baseline
Data
70.0%
Cycle 1
60.0%
Cycle 2
50.0%
Cycle 3
40.0%
Final Data
30.0%
20.0%
10.0%
0.0%
Newborns
2 Months
4 Months
Percent of Breastfed Infants Receiving
Vitamin D Supplementation
100.0%
90.0%
80.0%
70.0%
Baseline Data
60.0%
Cycle 1
50.0%
Cycle 2
40.0%
Cycle 3
30.0%
Final Data
20.0%
10.0%
0.0%
Newborns
2 Months
4 Months
Lessons We Learned
 We were unable to improve our 4 month breastfeeding
rates. This reinforced that to positively Influence
breastfeeding rates interventions need to reach
mothers prior to the first outpatient office visit.
 As shown in other studies, effective prenatal counseling
and Baby Friendly Hospitals are important factors in
educating mothers and families and improving
breastfeeding rates.
 Educational interventions and reminders in clinic aimed
at providers were able to increase vitamin D
prescription rates.
References

Carol L. Wagner, MD, Frank R. Greer, MD and the Section on Breastfeeding and Committee on Nutrition.
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Pediatrics Vol. 122 No. 5
November 2008, pp. 1142-1152.

Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS. Influence of breastfeeding and nipple stimulation on
postpartum uterine activity. Br J Obstet Gynaecol. 1994 Sep;101(9):804-5.

Dellifraine J, Langabeer J 2nd, Williams JF, Gong AK, Delgado RI, Gill SL. Cost comparison of baby friendly
and non-baby friendly hospitals in the United States. Pediatrics. 2011 Apr;127(4):e989-94. Epub 2011 Mar 21.

Dewey KG, Heining MJ, Nommsen LA. Maternal weight-loss patterns during prolonged lactation. Am J Clin
Nutr. 1993 Aug;58(2):162-6.

Gartner LM, Morton J, Lawrence RA, Naylor AJ, O’Hare D, Schanler RJ, Eidelman AI: American Academy of
Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005 ,
Feb;115(2):496-506.

Office of the Surgeon General. Call to Action to Support Breastfeeding.
http://www.surgeongeneral.gov/topics/breastfeeding/index.html. 2011.

Walter F. The Parathyroid and Vitamin D. Medical Physiology: A Cellular And Molecular Approach, 1300,
Elsevier/Saunders, Boron. 2003, 1094.

Wang IV, Fraser IS. Reproductive function and contraception in the postpartum period. Obstet Gynecol Surv.
1994 Jan;49(1):56-63.