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HX; #Avoidable admissions to the NNU (3) FBarriers to breastfeeding: early feeding and close contact with motherGGdOnly 29% (30/102) had documented skin to skin contact* 77% babies had first feed on the labour ward*7-e0Barriers to breastfeeding: breastfeeding supportOn labour ward:26% (29/112) mothers had documented support, less likely if admitted to NNU33% mothers had no documented support despite breastfeeding being their intended method of feedingIn neonatal unit:33% (13/42) mothers had documented supportL++: Barriers to breastfeeding: type of milk at first feed (1);;63% (67/106) received infant formula as first feed 63% More likely if admitted to NNU (p=0.001)All babies admitted received infant formulaNo admitted baby received exclusive breastmilk feeds28% (27/96) babies were fed at variance to mother s feeding intention. More likely to occur for admitted babies (50%, p<0.001) 8)aH*8)aH@ #9Barriers to breastfeeding: type of milk at first feed (2)9 [Main reason for infant formula when remaining with mothers was maternal choice 46% (32/70)\[[ %0Panel assessment of feeding in the neonatal unitr38% (16/42) type of feeding inappropriate In 36% (15/42) management of baby was likely to have affected feeding (+Gs Blood glucose management (1)>Timing of first blood glucose testing too earlyFirst 2 hrs after birth in most instancesMedian time of first blood glucose measurement 1.2h (range 0-7.6 h) in babies admitted to NNULater for babies staying with mothers (p=0.08)Inappropriate methods used75% (53/70) reagent strip in 75% 26% had post-feed testing T0ZZZ=Z0=$Blood glucose management (2) Poor documentation in 69% (77/112)More so in babies remaining with mothers (p<0.001)Main panels comments:Poor recording of method usedNo written management plan Also main overall documentation concern of the enquiry (67% of babies notes)V#J;N#J;N   $Recommendations: Admissions to NNU %%"All units delivering women with diabetes should have a written policy for management of baby. Policy should assume that babies will remain with their mothers in the absence of complications.4_0Z0Za0ZRecommendations: BreastfeedingMothers with diabetes should be informed antenatally of beneficial effects of breastfeeding on metabolic control for both themselves and their babies.All mothers should be offered opportunity for skin-skin contact with their babies as soon as possible after delivery. Breastfeeding within 1 h of birth should be encouraged.Midwives should recognise importance of supporting early breastfeeding for women with diabetes, and need to document this aspect of care.Z+Recommendations: Blood Glucose Monitoring Blood glucose testing healthy babies without signs of hypoglycaemia should be deferred until after the physiological early postnatal fall. Testing should be performed before a feed using a reliable method (ward-based glucose electrode or laboratory analysis).For all blood glucose tests: time, method, result and action taken should be clearly documented in the notes. Further research is needed to establish the most optimal timing of first blood glucose test in babies of diabetic mothers. P  Conclusion 1Many healthy babies of women with diabetes separated from their mothers without obvious medical reason Basic neonatal care must be delivered closer to the mother in maternity units in England, Wales and Northern Ireland. Rhvh#v$! Conclusion 28Poor quality care including lack of breastfeeding support, inappropriate blood glucose management and overall poor documentation Little evidence of senior staff involvementGuidelines clarification: NICE diabetes in pregnancy specific guidelines are pendingFurther research needed in some aspects of management,ZZ"(Diabetes neonatal enquiry project group  )' 'Dr Jane Hawdon, Chair Dr Alison Leaf Dr Dominique Acolet Ms Joan Oliver Dr Laura de Rooy Ms Justine Pepperell Ms Caron Gooch Dr Martin Ward Platt Ms Alison Johns Dr Anthony Williams Ms Alree Hunt VPP'PP#P/0&'()*+,-. / 0 1 2345678   0` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@|?" dd@   " @ ` n?" dd@   @@``PV    @ ` `p>>  Y(    nAL Y?$dv418111ucPreview_imgMain#" `S  6 ,  T Click to edit Master title style! !  0; 'g  RClick to edit Master text stylesSecond levelThird levelFourth levelFifth level!   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S  t T(cbfbf #  n*  <<<ZZxx  t TTabfbf D [# p*  <<<ZZxxH t 0Pe ̕ ? 3380___PPT10.k9 @((    N!bfbf 5  !\* <<<ZZxx  N!bfbf D [5 !^* <<<ZZxx  T!bfbf #  !\* <<<ZZxx  T !bfbf D [# !^* <<<ZZxxH  0Pe ̕ ? 3380___PPT10.>P{'  0  p(  x  c $HM'   H  0޽h ? 33___PPT10i.P@v+D=' =@B + 0 P0(  x  c $@*  x  c $'g  H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B + 0 ` x(  x  c $*    <t@)24Random sampling from diabetes cohort study (n=3808)554 RB  s *D2     0e0e #" 0e)6   RB @ s *D6  RB  s *D6  &   <l(  mRemained with mothers (n=70)   < , gAdmitted to NNU (n=42) H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B + 0 p0(  x  c $L*  x  c $,x'gv  H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B +  0 j8g(  8x 8 c $tIt  x 8 c $H/vm   80  fA ,?AA ?"`^;  ,   j j8 #"& j  !8 BDz?[jQ14(& 33   8 B?[p"Other medical condition (cardiac) 2# "& 33  8 B8?j[Q54(& 33  8 B?[gRespiratory difficulties 2 & 33  8 B@?jQ34(& 33  8 B|?n Macrosomia (otherwise well baby)2!  & 33  8 B?q jQ34(& 33  8 Bȝ?q o!Poor feeding (with hypoglycaemia)2" !& 33  8 Bx? jq Q64(& 33  8 Bئ? q n Hypothermia (with hypoglycaemia)2!  & 33 `B "8 0331 ? j `B #8 0331 ?j`B $8 0331 ? `B %8 0331 ?j j`B *8 0331 ? `B .8 0331 ?q jq `B 68 0331 ?j`B >8 0331 ?j`B F8 0331 ?[j[XB g8@ 0DԔ wF H 8 0޽h ? 33___PPT10i.8+D=' =@B + 0  h(  hr h S (1Y   h s H20e0e #" 0edt  H h 0޽h ? 33___PPT10i.h9 5+D=' =@B + 0 !l7(  lr l S wIG   '"- l #"*y"'-  (l B?  -O42(&33 'l B,?] -O12(&33 &l B{?' ] -y-Blood glucose tested too soon after delivery 0. -&33 %l B?   O42(&33 $l B?]  O12(&33 #l BG?' ] @Poor maternal blood glucose management during labour/at delivery0A @&33 "l BtL?   O82(&33 !l BP?]  O22(&33  l BXU?' ] gDelay in initiating feeding0 &33 l Bx?   P212(&33 l B/?]   O52(&33 l BL4?' ] jPoor management of temperature0 &33 l B8? ) R634(& l B<=?] )  R154(& l BA?')]  kNo medical need for admission2 & l B ? ")r"% of avoidable admissions (N=24) 4#("&33 l B?] " )oNo. of comments (Total = 24) 4 (&33 l Bt?'"] )M0 & 33 `B )l 0331 ?'""`B *l 0331 ?'--`B +l 0331 ?'"'-`B ,l 0331 ?"-`B /l 0331 ?'))`B 1l 0331 ?] "] -`B 4l 0331 ? " -`B 8l 0331 ?'  `B El 0331 ?'  `B Rl 0331 ?'  `B _l 0331 ?'   ~l 0]'*]%Panel comments on avoidable admission& 2&H l 0޽h ? 33___PPT10i.j9XvS+D=' =@B +  0   -@X (  @x @ c $|t9t  x @ c $'   @ 0 v@`*within 30 minutes of delivery, or as soon as the mother was able to respond following c-section*a 2` C  -@ #"`   @ B??  g50%2(&33 @` @ B?  g95%2(&33 @` @ B <? C *Admitted to NNU (n=42) 2+(*&33 @` @ B?C Remaining with mother(n=70)2(&33 @``B @ 0331 ?CC`B @ 0331 ?  `B @ 0331 ?C `B @ 0331 ?C `B @ 0331 ?  `B @ 0331 ? C  )@ 0\  < 2   *@ 0^ ( TvOAt least half of the babies admitted to the NNU were well enough to breastfeed PN +@ 0  ;P<0.001 2H @ 0޽h ? 33___PPT10i.8 +D=' =@B +$  0 $(  r  S 0 t  r  S Č  H  0޽h ? 3380___PPT10.s9,H$  0  $(  r  S    r  S _M'g  H  0޽h ? 3380___PPT10.s9 0 0(  x  c $*  x  c $P'g   H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B +  0 0(  x  c $*  x  c $@g   H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B +} 0 D$(  Dr D S t)  r D S dqqg  H D 0޽h ? 33___PPT10i.8Ԭ+D=' =@B + 0 0(  x  c $$tV  x  c $'g   H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B +} 0 p\$(  \r \ S ]  r \ S 'g  H \ 0޽h ? 33___PPT10i.8x+D=' =@B +:  0 `X:(  Xr X S ,    X S ] "p`PpH X 0޽h ? 3380___PPT10.8 ` 0 PT:(  Tr T S ,    T S q "p`PpH T 0޽h ? 33___PPT10i.8PE+D=' =@B +$ 0 0L$(  Lr L S !w G ! r L S Ե!M' ! H L 0޽h ? 3380___PPT10.8; 0 0(  x  c $8!* ! x  c $!'g ! H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B + 0 0(  x  c $4!* ! x  c $!'g ! H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B +&  0 x6(  x^ x S t&7   ! x c $X$!tx U  !,Breastfeeding initiatives are of benefit to mothers with diabetes and their babies, who may be more vulnerable to the negative psychological impact of a high-risk medical condition in pregnancy. There is evidence that babies whose mothers keep them in closer skin contact, are ward, calm and reassured. Systematic reviews of early skin contact between mothers and babies also show benefits in relation to breastfeeding and infant crying. National guidance for women with diabetes recommends breastfeeding as early as possible after delivery, as these babies may be at risk of hypoglycaemia. Additionally, infant feed supplementation may suppress the process of normal metabolic adaptation. Breast milk is though to promote ketogenesis and should therefore be the first choice for babies of women with diabetes, as they are at risk of hypoketonaemic hypoglycaemia. However, the previous CEMACH descriptive study found that the intention to breast feed rate in women with diabetes was lower than the initial  H x 0Pe ̕ ? 3380___PPT10.k90 0  (  X  C t&7     S tx U  " H  0Pe ̕ ? 3380___PPT10.}@+ 0  (  X  C t&7   !  S *!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@+ 0  (  X  C t&7   !  S T,!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@+ 0  (  X  C t&7   !  S p!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@k. 0  (  X  C t&7   !  S F!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@k. 0   (  X  C t&7   !  S LL!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@k. 0 0 (  X  C t&7   !  S Q!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@k. 0 @ (  X  C t&7   !  S W!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@0 0 P (  X  C t&7   !  S  ]!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@0 0 ` (  X  C t&7   !  S b!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@&3 0 p (  X  C t&7   !  S Xh!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@&3 0  (  X  C t&7   !  S m!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@&3  0  (  X  C t&7   !  S s!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@&3 0  (  X  C t&7   !  S ,y!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@5  0  (  X  C t&7   !  S ~!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@5 0  (  X  C t&7   !  S d!tx U  !" H  0Pe ̕ ? 3380___PPT10.}@5 0  (  X  C t&7   !  S !tx U  !" H  0Pe ̕ ? 3380___PPT10.}@5 0  (  X  C t&7   !  S  !tx U  !" H  0Pe ̕ ? 3380___PPT10.}@5 0  (  X  C t&7   !  S !tx U  !" 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HX; #Avoidable admissions to the NNU (3) FBarriers to breastfeeding: early feeding and close contact with motherGGdOnly 29% (30/102) had documented skin to skin contact* 77% babies had first feed on the labour ward*7-e0Barriers to breastfeeding: breastfeeding supportOn labour ward:26% (29/112) mothers had documented support, less likely if admitted to NNU33% mothers had no documented support despite breastfeeding being their intended method of feedingIn neonatal unit:33% (13/42) mothers had documented supportL++: Barriers to breastfeeding: type of milk at first feed (1);;63% (67/106) received infant formula as first feed 63% More likely if admitted to NNU (p=0.001)All babies admitted received infant formulaNo admitted baby received exclusive breastmilk feeds28% (27/96) babies were fed at variance to mother s feeding intention. More likely to occur for admitted babies (50%, p<0.001) 8)aH*8)aH@ #9Barriers to breastfeeding: type of milk at first feed (2)9 [Main reason for infant formula when remaining with mothers was maternal choice 46% (32/70)\[[ %0Panel assessment of feeding in the neonatal unitr38% (16/42) type of feeding inappropriate In 36% (15/42) management of baby was likely to have affected feeding (+Gs Blood glucose management (1)>Timing of first blood glucose testing too earlyFirst 2 hrs after birth in most instancesMedian time of first blood glucose measurement 1.2h (range 0-7.6 h) in babies admitted to NNULater for babies staying with mothers (p=0.08)Inappropriate methods used75% (53/70) reagent strip in 75% 26% had post-feed testing T0ZZZ=Z0=$Blood glucose management (2) Poor documentation in 69% (77/112)More so in babies remaining with mothers (p<0.001)Main panels comments:Poor recording of method usedNo written management plan Also main overall documentation concern of the enquiry (67% of babies notes)V#J;N#J;N   $Recommendations: Admissions to NNU %%"All units delivering women with diabetes should have a written policy for management of baby. Policy should assume that babies will remain with their mothers in the absence of complications.4_0Z0Za0ZRecommendations: BreastfeedingMothers with diabetes should be informed antenatally of beneficial effects of breastfeeding on metabolic control for both themselves and their babies.All mothers should be offered opportunity for skin-skin contact with their babies as soon as possible after delivery. Breastfeeding within 1 h of birth should be encouraged.Midwives should recognise importance of supporting early breastfeeding for women with diabetes, and need to document this aspect of care.Z+Recommendations: Blood Glucose Monitoring Blood glucose testing healthy babies without signs of hypoglycaemia should be deferred until after the physiological early postnatal fall. Testing should be performed before a feed using a reliable method (ward-based glucose electrode or laboratory analysis).For all blood glucose tests: time, method, result and action taken should be clearly documented in the notes. Further research is needed to establish the most optimal timing of first blood glucose test in babies of diabetic mothers. P  Conclusion 1Many healthy babies of women with diabetes separated from their mothers without obvious medical reason Basic neonatal care must be delivered closer to the mother in maternity units in England, Wales and Northern Ireland. Rhvh#v$! Conclusion 28Poor quality care including lack of breastfeeding support, inappropriate blood glucose management and overall poor documentation Little evidence of senior staff involvementGuidelines clarification: NICE diabetes in pregnancy specific guidelines are pendingFurther research needed in some aspects of management,ZZ"(Diabetes neonatal enquiry project group  )' 'Dr Jane Hawdon, Chair Dr Alison Leaf Dr Dominique Acolet Ms Joan Oliver Dr Laura de Rooy Ms Justine Pepperell Ms Caron Gooch Dr Martin Ward Platt Ms Alison Johns Dr Anthony Williams Ms Alree Hunt VPP'PP#P/0&'()*+,-. / 0 1 2345678r91 ՜.+,0,   On-screen ShowCEMACH ArialDefault DesignMicrosoft Excel ChartuCARING FOR BABIES AFTER BIRTH Neonatal care of babies of mothers with type 1 and type 2 diabetes Dr Jane Hawdon BackgroundMethodsMethods$Avoidable admissions to the NNU (1)$Avoidable admissions to the NNU (2)$Avoidable admissions to the NNU (3)GBarriers to breastfeeding: early feeding and close contact with mother1Barriers to breastfeeding: breastfeeding support; Barriers to breastfeeding: type of milk at first feed (1):Barriers to breastfeeding: type of milk at first feed (2)1Panel assessment of feeding in the neonatal unitBlood glucose management (1)Blood glucose management (2)%Recommendations: Admissions to NNU Recommendations: Breastfeeding,Recommendations: Blood Glucose Monitoring Conclusion 1Conclusion 2)Diabetes neonatal enquiry project group  Fonts UsedDesign TemplateEmbedded OLE ServersSlide Titles%_0rosie.houstonrosie.houston