Perinatal Quality Collaborative of North Carolina 2010-2011Exclusive Human Milk in Newborn Critical Care Centers:Action Plan and Literature Review

Statewide meetingWinston-Salem, NCJan 13, 2011

Could we become first state in the US to insure that all of our VLBW infants receive human milk as their first feed, and as their main enteral nutrition for the first month of feeds?

Aims

•Primary: Increase by 50% the number of babies receiving mom’s milk at 28 days of life in NC newborn critical care units by 9/30/2011

•Secondary: incidence of sepsis, incidence of NEC, and process measures

Human milk preferred for all babies:mother’s milk first choice

• in addition to nutrition, provides enzymes, hormones, growth factors, anti-oxidants, direct immunologic protective factors, immunomodulators, anti-inflammatory factors and other bioactive factors, with new components and interactions being discovered regularly

• early feeds of human milk may allow development of GI biome that will affect short and long-term health

• multiple clinical benefits• allows family to play key role in the care of their baby,

enhancing bonding

Mother’s Breast Milk

•Species-specific•Composition•Growing body of evidence re: short and long-term

health for term babies•Growing body of evidence re: short and long-term

health for preterm babies•New scientific evidence re: importance of human

milk in establishing GI biome integrity

Human milk contains thousands of unique components not found in formula

¶ -sleep peptides

Secretory IgA, IgM, IgG

Lactoferrin

Lysozyme

Polyamines

Casomorphins

Complement C3

Bifidus factor

Antiviral mucins, GAGs

Oligosaccharides

Cytokines &Anti-Inflamatory Factors

Tumor Necrosis Factor

Interleukins

Transforming (TGF)

Platelet-Activating Factor:

acetyl hydrolyase

Insulin

Prolactin

Thyroid Hormones

Corticosteroids, ACTH

Oxytocin

Calcitonin

Parathyroid Hormone

OthersEpidermal (EGF)

Nerve (NGF)

Insulin-Like (IGF)

Anti-Microbial Factors Hormones

TransportersDigestive EnzymesGrowth Factors

Erythropoietin

Interferon

Prostaglandins

a-1 anti-trypsin

a-1 anti-chymotrypsin

Lipoprotein lipase

Ribonuclease

Amylase

Bile acid-stimulating esterase

Bile acid-stimulating lipase

Lactoferrin

Folate Binder

Cobalamin binder

IgF binder

Thryoxine binder

Corticosteroid binder

DNA & RNA

Lutein

Lycopene

MBM: Benefits to term babies• Increased survival/less SIDS• Other short-term benefits:

▫more easily digested▫protection against infections

• Long-term benefits: ▫ less obesity/diabetes/hypertension▫ lower rates of some forms of cancer (lymphoma, leukemia,

Hodgkin’s disease)▫decreased inflammatory bowel disease▫decreased hypertension▫ improved IQ

MBM: benefits for preterm infants

• Improved feeding tolerance (improved gastric clearance, fewer residuals, faster realization of full feeds, improved absorption and utilization of nutrients, faster decrease in intestinal permeability) leading to less time with central lines, and less need for hyperalimentation

• Decreased infections (sepsis/meningitis, UTI’s)• Decreased necrotizing enterocolitis• Decreased mortality• Improved long-term outcomes (higher IQ, less

obesity/hypertension)• Improved mother-infant bonding

Sisk et al. Human Milk Consumption and Full Enteral Feeding Among Infants Who Weigh <1250 Grams. Pediatrics. 2008;121(6):e1528-1533

•Study published in June 2008, from Wake Forest University School of Medicine

•Compared group receiving low amount of mother’s milk (n=34) to high amount, defined as >50% (n=93)

•Avg GA 27-28 wks, avg wt 980-1000 gms•Avg time to start feeds was 3.5 days•Feeds of 150 ml/kg/d were achieved at 27 (LHM) vs

22 days (HHM)

10

‘Survival’ Curves for NEC or death in ELBW’s by amount of MBM (ml/kg/d) received in first 14 days of life

Survival Estimate

0 10 20 30 40 50 60 70 80 90 100 110 120

0.80

0.85

0.90

0.95

1.00

100 ml

50 ml

20 ml

10 ml

0 ml

Postnatal age (d)

*For NEC or Death after 14 days, adjusted for birth weight, race, PDA treatment, ventilation, and siteMeinzen-Derr, et al NICHD Neonatal Network

J Perinatology, 2009

Decreased neonatal sepsis with use of MBM

• El Mohandes et al. Use of Human Milk in the Intensive Care Nursery Decreases the Incidence of Nosocomial Sepsis. J Perinatology 1997; 17(2):130-134

Sepsis rate Breast milk Formula Day 0-10 5% (2/38 10% (10/107) Day 11-24 9% (4/43) 20% (18/94) Day 25-38 0% (0/19) 15% (11/72)

• Furman. The effect of Maternal Milk on Neonatal Morbidity of VLBW Infants. Arch Ped Adol Med 2003; 157 (1), 66-71▫ Found that at least 50 ml/kg/d of MBM needed to decrease

rate of sepsis in VLBW babies, lowered rate of sepsis by 27% (in prospective study of 119 babies, avg 28 wks, ~1000 gms)

Breastmilk Decreases Time on TPN and Length of Stay

HM PTF diff p

Days on TPN

25 35 10 0.01

Days to discharge

73 88 15 0.03

Schanler. Peds 1999; 103(6):1150-1157

Improved Developmental Outcome with Use of Mother’s Milk

Vohr. Peds 120 (4) e953-9, 2007

Decreased rehospitalization with use of mother’s milk

•Vohr’s 2007 Pediatrics article also showed a decrease in rehospitalization with breast milk in first two years of life, mostly related to less respiratory illness

• If received no breast milk or <50% breast milk during initial hospital stay, ~33% of babies were readmitted with resp illness, if received 60-80%, 27% readmitted, and if received >80%, 16% were readmitted

Preterm milk is especially suited for the preterm infant

Higher levels of protein (highest from mothers with most preterm baby), including higher levels of free amino acids and epidermal growth factor

Higher levels of sodium, chloride, and slightly lower lactose levels compared to term milk

Slightly higher calories/oz Slightly higher

calcium/phosphorous Fortification/supplementation

seems necessary for optimal growth

Human milk: improves integrity of GI biome

• Neonatal gut sterile at birth• Intricate interplay among microbes, diet, mucosal cells,

mucin, immunomodulators to create environment that may affect both short and long-term well-being

• Much interest in impact of single component of milk (taurine, glutamine, nucleotides, fatty acids, arginine, immunoglobulins, EGF or TGF) but interactions must be multifacted and complex

• New interest in “toll-like receptors”

Oligosaccharides

• Oligosacs are result of lactose combining with monosaccharides

• HM has 130 currently-known oligosaccharides

• Serve as decoys -interferes with pathogen binding to intestinal cells

• Also serves as “prebiotic”, setting up environment conducive to growth of commensal bacteria

• Role in neural development

Newburg DS, Walker WA. Pediatric Research 2007;1: 2-4

Complex interplay exemplified by butyrate production and role in GI tract

• “Oligosaccharides in mother’s milk may act as nutrients for beneficial commensal bacteria (a “prebiotic” role) and fermentation of these oligosaccharides and lactose in mother’s milk may lead to the production of short-chained fatty acids that play a “postbiotic” role, especially butyrate, which can be effective as a major fuel for colonocytes, an anti-apoptotic, pro-proliferative agent, that may also aid in the strengthening of intercellular tight junctions, and also stimulate the synthesis of glucagon-like peptide 2 (GLP-2), a hormone that is highly trophic for the intestine” (from Neu. Gastrointestinal maturation and implications for infant feeding. Early Human Development 2007;83:767-775)

Increasing Use of Mother’s Milk in the Newborn Critical Care Units: The Action Plan

Relates to getting the desired results but outside the focus of this collaborative action plan

•Create supportive and family-centered environment

•Optimize nutrition and nutritional monitoring of all infants

•Support the mom and baby to breastfeed•Promote breastfeeding support in the

community

Create supportive and family-centered environment

a. Perform self-assessment and implement family-centered care practices

b. Welcome 24 hour parent care in nurseryc. Develop family support programsd. Provide pumps and pumping rooms for

mothers before and after discharge

Optimize nutrition and nutritional monitoring of all infants

a. Monitor daily intake and parameters of growth

b. Utilize a multidisciplinary team, including neonatal nutritionist and pharmacist

c. Early initiation of TPN (protein with 2 hours, lipids in first 24 hours)

Support the mom and baby to breastfeed

a. Evaluation for oral feeding (baby readiness)b. Teach infant cuesc. When transitioning to exclusive breastfeeding

consider measuring transfer, and use SNS &/or nipple shields as needed

d. In preparation for discharge establish feeding regimen to meet growth requirements and developmental needs, identify and connect to resources, consider rooming in prior to discharge and consider weight scales for use at home to measure intake

Promote breastfeeding support in the community

a. Emphasize breastfeeding in group prenatal patient education

b. Collaborate to assure breastfeeding support groups for outpatients

c. Promote breastfeeding support in the greater community, with special attention to underserved groups

Action Plan for PQCNC:four main areas of activity

A. Promote and use mother’s milk as the preferred nutritional substrate for infants

B. Implement feeding guidelinesC. Safety in the use of expressed milkD. Health system leadership

A. “mother’s milk as preferred substrate”1. Assess feeding intention and establish expectations related to premature birth upon admission

a. Inform all mothers at time of birth of benefits of their milk for their baby, including mother’s milk “as medicine”

b. Use language that distinguishes providing milk from breastfeeding

c. Encourage early initial visit to facilitate communication and assistance to obtain colostrum and milk

A. mother’s milk preferred substrate2. provide early and continuous support to obtain mother’s colostrum and milk

a. Provide mother with access to appropriate pump (hospital-grade with double pumping kit) and provide necessary supplies

b. Teach breast massage and relaxation techniquesc. Teach hand expression and pumping techniques using

mechanical pumpd. Provide support from lactation consultant or other

breastfeeding experte. Provide daily review of mothers’ pumping records of

pumping and volume expressed

A. mother’s milk preferred substrate3. promote regular maternal skin-to-skin contact

a. Provide parent and staff education to promote skin-to-skin

b. Encourage early maternal visits to include touch and skin-to-skin as soon as possible

c. Encourage breast pumping immediately after each skin-to-skin interaction

d. Encourage non-nutritive sucking at the breaste. Provide appropriate chairs and privacy screens

for skin-to-skin and breastfeeding opportunities

A. mother’s milk preferred substrate4. Provide age-appropriate oral stimulation program

a. Encourage non-nutritive sucking at the breast or use pacifiers

b. Consult specialist as needed to include but not be limited to OT, PT, feeding/speech therapist or developmental specialist

B. Implement feeding guidelinesa. Provide early small volume “feeds” using mom’s

colostrum every chance you get as soon as you get it

b. Consider using pasteurized donor milk until mom’s milk is available

c. Develop unit-specific systematic feeding advancement guidelines including but not limited to volume, fortification, use of additional protein and an algorithm for residuals

C. Safety in the use of expressed milk

1. Labeling, storage and administration of breast milk

a. Adopt and follow national guidelines to include, but not be limited to type of containers, labeling protocols, and refrigerator/freezer temperatures

b. Develop policies for the administration of breast milk to include, but not be limited to recipes and policies for fortification, warming, bolus feedings and assuring correct milk for each baby

C. Safety in the use of expressed milk

2. Use of donor milk a. Use only screened pasteurized milk b. Consider strategies to optimize growth in

babies receiving donor milk c. Track batch number of milk given to

infant

D. Health System Leadership1. Educational intervention for staff and providers:

should include using patient experience and data to achieve support of medical and administrative leadership, communication of comprehensive written policies to all staff, insuring adequate staffing, providing regular continuing education, and address competency (attitude, skills and knowledge) in areas of lactation support

D. Health System Leadership2. Measure what matters: establish aims, collect data

on initiation, duration of feedings, exclusivity and patient experience, create dashboard of indicators to follow trends and measure improvement, and round regularly with a multidisciplinary group on this data

3. Market health: refrain from accepting and distributing any infant formula marketing materials, purchase and record use of formula and bottles

Thank you

Oligosaccharides and Commensal Bacteria Protect Synergistically

• Oligosaccharides▫ Promote bifidobacterial

growth in gut▫ Bind pathogens rendering

them less able to bind to receptors on mucosal cell surface

▫ Serve as receptors for commensal bacteria that colonize the gut and form a biofilm

• These processes provide multiple layers of synergistic defense

Newburg DS, Walker WA. Pediatric Research 2007;1: 2-4

Systemic Inflammatory Response Syndrome

• Hypothetical scheme• Bacteriostatic, anti-inflammatory components, commensal bacteria• Effects on dampening intestinal production of proinflammatory mediators

such as IL-8• Subsequent prevention of propagation of this inflammatory mediator to

proximal (intestine) as well as distal organs (lung and brain).

Caicedo RA, Schanler RJ, Neu J. Pediatr Res 2005;58:625