Professor Paula Meier

Professor Paula P. Meier
Rush University Medical Center, Creator of PROVIDE – A Training Compendium on Providing Mothers’ Own Milk in NICU Settings

How has the translation of academic knowledge to digital training tools promoted practitioner training? Can you give us a few examples?

The original focus of PROVIDE was to be for low- and middle-income-countries (LMICs). And certainly it has had an impact, for example, in India. Brazil and Argentina aren’t LMICs, but it is certainly being used in the NICUs. I have been asked since I did these to hold a number of in-person meetings or webinars with the World Health Organization, institutions, agencies, individual countries, pediatric societies, all over the world. And I have focused my presentations to include PROVIDE because this is what people really want. 

I start by looking at what's so different about mother’s own milk for premature babies compared to donor milk and all the different health outcomes. Then I say, this is how you can explain it to families, and I show the education sheets. I do the same thing with some of the videos, like skin-to-skin care. Kay Kutschkau (Lead Knowledge Management & LactaHub) told me skin-to-skin care has a record number of viewings from LMICs. So in terms of its original purpose, yes, it’s certainly made an impact. 

PROVIDE is being incorporated into a project that PATH is doing on human milk for the small and sick newborn. That is probably going to be a huge dissemination effort, because I have worked with them as a consultant on those modules and we have made certain that there is a link to all of the different videos and education sheets, so that I think will have an even bigger impact. That's due out this month. 

I will give you one other example. The interest in high-income countries  has also been incredible. This is something I thought would probably happen, but I had no idea as to the extent, I was surprised. I did an entire four-hour series for Vermont Oxford last year because I served as expert faculty for lactation and human milk for their collaborative. Those were recorded, and the focus was how you use this curriculum in quality improvement efforts in the newborn intensive care unit (NICU). Those reach all over the world, to both LMICs and more developed countries as well.

A certain amount of the impact at this point has been word of mouth. But when you're speaking to the World Health Organization or to the Pediatric Society of Brazil or Argentina, and I spoke to Paraguay last year, that is a huge audience. Even though it's one webinar, it's for the entire country that has representatives there. 

What feedback are you receiving from NICU-based peers? From families? Is one topic or set of resources emerging as a stand-out training tool? 

One of the things that I'm hearing that the practitioners really like about it, is that it's a standardized communication tool. This I had envisioned early on. If you look at some of the research in this field, what makes families so frustrated is getting different information from different people in the NICU. So one of the focus points was to standardize the training tools so everybody uses the same information sheets, the same videos. What I have heard is that it's absolutely invaluable in terms of standardization of messaging. 

There have been a handful of institutions I'm aware of that have used the materials for specific quality improvement initiatives. For example, both the education sheets and the videos which enable nurses to help mothers initiate and maintain lactation in the NICU (pumping to achieve coming to volume), they've used the tools as a way to achieve that overall initiative.

The staff think it's an incredibly valuable resource, the quality of the videos especially. I just showed this yesterday to a group of peer counselors that are doing work with individual families. And they were stunned with the quality of the videos, because I think everybody's used to a video being something you do with your phone. The Foundation grant allowed us the opportunity to hire a superb professional videographer/sound team that filmed several “takes” for each individual video in the compendium. These individual segments allowed the producer (Ron Levinson) to incorporate the exact images, people, and flow of content that we wanted to showcase.  The quality of the videos is one of the things that's come up over and over again by practitioners and by families.

I received the Macy-Gyorgy Award from ISRHML (International Society for Research in Human Milk  and Lactation) last October in Panama. I spoke about my research career and said the culmination of any researcher’s work is to see it disseminated and impact policy and practice. This was the final thing that I've done, to provide this toolkit. The videographer created a two-minute overview of some education sheets and film footage to show specifically for my ISRHML presentation. That was huge in terms of the reception, the fact that the foundation had funded it, the fact that it was this culmination. It's what everybody hopes for, that your work will impact practice.

PROVIDE is being translated into German and French, as part of the Foundation’s commitment to healthcare practitioners and families at home. What makes it applicable across neonatal intensive care settings, regardless of geography?

It's already in Spanish, and I don't know if the Chinese decided to do it independently of the foundation, but I'm almost certain that the Chinese translated the education materials too. I think it's because the variability in NICU facilities and NICU practices is smaller than most people would think. There are many units in India, for example, that use these and they have almost the same equipment that we have. Newborn intensive care across many countries and cultures is much more similar than what we would call primary care practices, for example. So that's one. And then the other one is that we have such a diverse population at Rush where we filmed it, we have families of all ethnicities that were participating in this. 

My intent for the education sheets was to use words that I had kind of mastered over the 25 years or so I had worked with mothers in our NICU at Rush. I think I came with a unique background and the ability to explain really complicated things to families, in terms of making them understandable. That's what I built a career on, engaging the families in the science of milk. 

 So one of the things that makes them attractive is that it's really complex science that's new to many practitioners, but it's explained so that it's understood easily and it resonates. I don't want to make it sound like it's a grandiosity on my part, but that's one of the reasons I wanted to do the project, because I'd spent so many years having built this clinical program called Share the Science with Families. I didn't try to persuade families to provide their milk based on the World Health Organization Code of avoiding formula, I tried to persuade them based on what we know about how mothers’ own milk helps infants. For example, I had to get good at explaining such concepts as immunomodulation, the growth of the white matter in the brain so that families could understand them.

As I sat down to start to work on PROVIDE, those were all complicated concepts I wanted to bring to this. So it's new, it's cutting edge, yet it's understandable – I think that's what makes it generalizable across so many settings.

What is difficult about translating academic knowledge and clinical experience into accessible tools and training resources for practitioners and families? 

There are many brilliant researchers, even translational researchers, that produce cutting edge findings, but aren't that good at explaining them in terms of practice. There are also many practitioners that have very elegant ideas that aren't necessarily grounded in evidence. The fact that my position was 50% clinical and 50% research, and my whole career had been this way, and the philosophy from my very first research which involved putting all this equipment on little premature babies to measure suck, swallow, breathe, it involved having to engage families so they understood why we wanted them to participate, what knowledge it would provide to other families. If the trajectory of your research work has been so embedded in the clinical, it’s easier, and I think it is harder for people that don't have that expertise.

How did the partnership with the Foundation facilitate this goal, address this need? 

I had had this idea for some time. One of my first meetings with Katharina, I brought along a packet of materials that we used for our own families called Welcome to the Rush Mother's Milk Club. Within it was a booklet for families as well as different education sheets in English and Spanish that had been done professionally, but we didn't have videos. I also had a Rush Mother's Club website at the time. Katharina liked this packet of materials, and this is what she wanted to focus on – creating this PROVIDE Compendium. Janet Prince was just instrumental, as was Kay, in working with me with this. 

The budget from the foundation gave us the ability to create these incredibly well done and instructional videos that would not have been possible otherwise. I have pictures that we shot with our iPhones of one of the filmings, of a baby being transferred into skin-to-skin care in a NICU room. We had three cameras on the baby as well as one sound engineer. With a critically ill baby we had one chance to make it right. So it was the ability to have this highly professional crew as well as the work Ron Levinson did editing those videos, and Kristen W. Marzejon, who did so many of the beautiful graphics for us, and then Marcus Geeter, the stylist. It gave us the ability to fairly reciprocate the families. We were able to bring them in by transportation. And then, I really have to acknowledge the back-and-forth work with Kay and with Janet as we were getting ready to publish it on LactaHub – that was huge.

Is there anything else that you would like to add?

I'm so very grateful for the trust that the Foundation put in in me to be able to bring this to fruition. One of the things that was complicated was taking this from Foundation monies and making it happen at the actual site, because all of the different people involved were subcontractors. A lot of the time and budget, in addition to the creative part, went into simply managing those subcontracts. If you think about coming into a NICU room where the babies are so susceptible to so many things, you've got all the privacy concerns, and you fill that NICU room with three cameramen plus the sound engineer – everybody must be consented. This was not easy to do. 

The families that were in the filming being so willing to expose their breasts, to have their baby filmed during a transfer into skin-to-skin care – the families who altruistically shared their experiences so other families would benefit. That is a huge piece, because one of the barriers is, how do you speak to a family and say, we want to bring all these people into your room to do this, and we have to do it on these certain days because that's when the videographer’s coming, and we have to do it according to these policies – all of his equipment has to be checked by biomedical engineering before it went into the NICU. It’s important to mention the things that are behind the scenes that nobody sees.