Promotion of Human Milk Feeding

in the NICU Setting

Kamtorn Vangvanichyakorn MD

kvangvanichyakorn@barnabashealth.org Clinical Director of Neonatology

Saint Barnabas Medical Center

BFHI Meeting 12-1-11 NJ

Breast Feeding Report Card

USA 2011

Department of Health & Human Services

Center for Disease Control & Prevention

Breast Feeding Report Card USA 2011

% of breast fed infants receiving formula

before 2 days of age

Rank % State

Top 1 8.0 Montana

Top 2 8.5 Vermont

Top 3 11.6 Wyoming

National Avg 24.5 USA

Bottom 49 32.5 Georgia

Bottom 50 33.2 New York

Bottom 51 38.0 New Jersey

Any Breast Milk @ Discharge

(VLBW Infants Discharged Home)

25

30

35

40

45

50

55

60

65

70

75

80

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

percen

tag

e

SBMC NJ USas of

10-10-11

The Enigma of Necrotizing Enterocolitis

(NEC)

• NEC is the most significant GI emergency affecting 5-

10% of very preterm (very low birth weight) infants.

• Its exact cause(s) is unknown, most likely

multifactorial (ischemia, infection, toxin…etc). Only

prematurity and enteral feeding have been

consistently identified as risk factors in case control

studies.

• Estimated additional cost of care:

1 case of surgical NEC $238,000

1 case of medical NEC $138,000

Necrotizing Enterocolitis

The Role of Human Milk in the Prevention

of NEC

There is increasing evidence that exclusive human milk feeding

reduces NEC and death.

Formula only vs. Human milk only (Lucas 1990)

Odds Ratio: confirmed cases = 6.5 (1.9 : 22) 6.5 x increase

Human milk > 50% vs. < 50% enteral feeding (SISK 2007)

Odds Ratio : NEC -= 0.17 (0.04; 0.68) 83% reduction

Mother’s milk vs. Preterm formula (Schanler 2005)

Odds Ratio : Sepsis / NEC 0.45 (0.24; 0.86) 55% reduction

Benefits of Human Milk for Preterm Infants

Human milk & Subsequent Intellectual Performance at 8y

8.3 IQ points increase (Lucas 1992)

For every 10 ml /Kg/d BM intake

MDI 0.5 points

PDI 0.6 points

Re-hospitalization rate 6%

For intake of 100 ml /Kg/d

MDI 5 points which translates into less need for

special education

VOHR Pediatr 2006; Hack NEJM 2002

1/1/09

Joined

NICQ

2009

Nutrition

Topic

Group

2/5/09

Review

current

practices

4/1/09

Implement

early

trophic

feeds

(VLBW)

6/25/11

Feeding

protocols

as guide

revised-

now placed

on all new

VLBW

charts

4/1/11

Provide

education to

NICU RNs re:

standardized

enteral feeding

protocols

2/1/11

Reduce

empiric

antibiotic

use in

ELBW

11/15/09

Provide

human milk

exclusively 1st 28 days

of life

(VLBW)

4/15/09

Provide

education

for NICU &

OB RNs-

value of

human milk

& pumping

process &

tips

8/30/11

Feeding

protocols

as guide

revised-

now

include

BW &

gestational

age

4/15/11

Use of

standardized

feeding

protocols as

guide for

enteral

feeding

advancement

2/15/11

Begin

trophic

feeds by

48hrs of

life

11/4/09

Implement

Banked

Human

Milk

1/1/11 Joined

NICQ 7 Continue

to work to reduce

NEC

Liquid Gold for NICU Babies

Education Provided to NICU &

OB RNs

Goals of education: 1) Increase percentage of VLBW infants that

continue to receive breast milk (≥ ½ of total feeding

amount daily) throughout their hospitalization to 75%

2) Increase percentage of VLBW infants that

breastfeed during hospitalization to 75%

3) Standardize education for new moms

Liquid Gold for NICU Babies

Our goal

Myths and Facts

Advantages for NICU babies

Initiating pumping

How to set up a double pump

Supporting pumping mothers

Pumping every 3 hours

Kangaroo care

Tips to improve Milk production

Benefits for RNs

NICU Parent Orientation Video

• The importance of breast milk,

pumping and availability of Banked

Human Milk is discussed repeatedly

throughout the video

• Available on SBMC website @

http://tinyurl.com/3gj2lm4 look @

chapter 5: Nutrition for your baby…

Donor’s Human Breast Milk

• Not all mothers can supply 100% of their Preterm infant’s needs in the first few days after birth.

• Human Donor’s Milk can be used to fill in the gap until mother’s milk flow is established.

• Meta-analysis of trials show Donor milk significantly reduced NEC compared to Formula.

Quigley Cockrane Syst Rev 2007

Joint Statement from WHO & UNICEF 2008

The best food for a baby who cannot

breast feed is milk expressed from

the mother’s breast or from another

healthy mother.

Process for Use of

Banked Human Milk (BHM)

• Neonatologist discusses use of BHM with

parents prior to or in 1st few days of life-

prevent need for formula if insufficient

supply

• BHM fact sheet given to parents

• Obtain assent for BHM use

• Order BHM with initial feedings

Prior to Delivery: counseling by neonatologist

on benefits of providing

breast milk

Day of life 1: swab oropharyngeal (bucchal)

with colostrum

Day of life 2 -3: trophic feeding with exclusive

mothers own milk, if not

available or insufficient use

Day of life 28 Donor Milk

Feeding Protocol in ELBW &

VLBW Infants

Promotion of Human Milk Feeding

• Create breast milk feeding culture

• Education, education and education

• Implementation of Banked Human Milk

supplementation

• Strict feeding protocol for ELBW > VLBW

infants

Exclusive Use of Human Milk 1st 28days of life

0

10

20

30

40

50

60

70

80

90

100

before

BHM

Dec

-09

Jan-

10

Feb-1

0

Mar

-10

Apr-

10

May

-10

Jun-1

0

Jul-1

0

Aug-

10

Sep-1

0

Oct

-10

Nov-

10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-

11

May

-11

Jun-1

1

Jul-1

1

Aug-

11

Sep-1

1

pe

rce

nta

ge

%tage VLBW Received exclusive Human Milk (MOM&/orBHM) 1st 28 days of life

Received exclusive MOM 1st 28days of life

%tage VLBW Received Human Milk for >50% of feeding volume/day during 1st 28

days of life

SBMC NEC Cases

0

2

4

6

8

10

12

14

16

2007 2008 2009 2010

nu

mb

er

of

cases

Medical NEC Surgical NEC Total cases

Extremely LBW Infants Long-Term Follow-Up

Severe Disability Rate at 24 Months of Age

SBMC vs. VON (2002 – 2006)

SBMC VON

Period ‘02 – 06’ ’01 – 05’

n. Evaluated 253 5012

Follow-up rate 69% 48%

Bilaterally Blind 0% 1.0%

Hearing Amplification 0% 2.0%

Cerebral Palsy 4.0% 8.0%

MDI < 70 6.0% 18.0%

Any Severe Disability 9.0% 31.0%

Extremely Low Birth Weight = Birth Weight less than 1000g Gestational Age < 28 Weeks

VON = Vermont Oxford Network (An international network of 750 NICUs)

If 90% of US families could breastfeed

exclusively for 6 months, USA would save

$13 billion per year and prevent an excess

911 deaths & SIDS, NEC, Pneumonia…etc.

The Burden of Suboptimal

Breastfeeding in USA

A Pediatric Cost Analysis

M Bartick MD, Harvard Med School

Pediatrics, online April 5, 2010

For additional information contact:

Eileen Steffen RNC

NICU Quality & Research Coordinator @

esteffen@barnabashealth.org