Breast Milk QI March 09, 2017

Objectives Overview of Maternal Human Milk Components Differences Best NICU practices

Colostrum Stimulates rapid growth in GI mucosa (if first feeding) Use for trophic feedings Use in order it is produced High concentrations of Protective secretory IgA Growth factors (EGF, TGFß) Lactoferrin Anti-inflammatory cytokines Oligosaccharides Concentration of most protective components inversely proportional to gestational age

Lactoferrin High antimicrobial and antifungal properties Eradicates ingested pathogens Blocks adherence of bacteria to gut endothelium Binds endotoxin Binds iron that may support microbe growth Growth promoting Anti-inflammatory

Preterm milk vs. Term milk Increased Protein Immune factors Fats Calories Growth factors

Donor milk vs. Maternal breast milk Pasteurized Rapid heating, maintain temp constant, then rapid cooling 62.5 C for 30 min (Holder pasteurization method) Unchanged components Most free amino acids Many growth factors (EGF, TGFß1,2) Most polyunsaturated, monounsaturated, and saturated fatty acids Total lipid content Fat soluble vitamins Oligosaccharides (prebiotic effects)

Donor milk vs. Maternal breast milk Increased components GM-CSF Lactulose Some amino acids (leucine, arginine, glutamine) Reduced components IgA, IgM, IgG Lactoferrin Lysozyme IGFs Water soluble vitamins Effect unclear IgG subcomponents Cytokines

Donor milk Decreased rates of NEC, CLD as compared to preterm formula Bovine milk fortifiers possible negative effect on this reduction unclear Slower growth rate (vs. formula) Overall decreased morbidities with mother’s own milk vs. donor milk

Education on Maternal Breast Milk Share the scientific evidence with mothers Decreased rates of Necrotizing Enterocolitis Decreased Late Onset Sepsis Improved Neurodevelopmental Outcomes Different stages of Lactation

Considerations during NICU stay Amounts and time periods of human milk feeding Feeding history throughout NICU stay May be more important than “breast milk feeding at discharge” Most important period is the first 30-60 days Exclusive breast milk vs. formula during this time period Daily dose and exposure period Think percentages and days Growth Formula fed infants grow faster than breast milk fed infants (but why?) How much volume does baby actually take in breast feeding Differing caloric content between feeds (not all feeds 20 calorie) Inadequate protein?

Best NICU Practices Encourage mother to provide milk for her infant Lactation support for families and NICU staff Prioritizing initiation, establishment and maintenance of maternal milk volumes Lactation technologies to manage human milk feeding problems

Encourage mother to provide milk Mothers and families rely on provider education on breast milk Independent of social and ethnic backgrounds Research does not indicate breast milk promotion makes mothers feel “guilty” Focus on providing milk for VLBW (short-term and intermediate- term pumping) rather than long-term goal of breast feeding

Lactation Support for Families/NICU Staff Cost-effective Provide evidence-based guidance Lactation and NICU providers/nursing staff must resolve inconsistencies prior to talking with parents Standardize policies and procedures based on evidence NICU lactation programs should be under guidance of APN, dietitian or neonatologist Become knowledgable in inititation, establishment and maintenance of volume in pump-dependent mothers

Lactation Support for Families/NICU Staff Physical resources Hospital grade dual electric breast pump Pump kit and instruction for adequate milk removal Volume-based containers for storing expressed milk Colostrum (11 ml) Breast milk (60 ml) Refrigerator and freezer space for on-site milk storage Custom-fitted breast shields to promote milk transfer Infant scales to perform test weights Research shows more cost-effective than donor milk or formula feedings during hospital stay

Lactation Support for Families/NICU Staff Non-physical resources 24 hour access to infant Skin-to-skin holding (kangaroo care) Daily “tasting” of milk (suckling at emptied breast) after extubation Review of maternal milk volume records at least twice weekly Identify pumping patterns Detect and treat potential problems Non-pharmacological and pharmacological interventions Observation of mothers using pump in NICU at least once weekly Detection and treat problems Technique Incorrectly fitted breast shields Complete breast emptying

Breastfeeding peer counselors Can assist lactation consultants and teach mothers how to Use breast pumps Clean collection Kit Collect, label, store, transport milk Cultural and Ethnic training Often preferred to health care professional by mothers Empower mothers

Prioritizing initiation, establishment and maintenance of maternal milk volumes Most important lactation priority Mothers are breast-pump dependent if infant VLBW May experience delayed lactogenesis, inadequate milk volume Consideration factors Doesn’t rely on infant stimulus for “coming to volume” Ineffective breast pump Improperly fitting nipple shields Infrequent pump use Ending pumping session prior to all available milk removed Stress, fatigue and down-regulation of prolactin Post-birth contraceptive management Need volume targets and daily monitoring At least 350 ml/day by end of 2nd week Higher volumes (500 to 1000 ml per day) more desirable

Lactation technologies To diagnose and manage NICU problems Crematocrit Lipid and caloric concentration of expressed human milk Uses hematocrit centrifuge with capillary tube Test-weights

Considerations after NICU discharge Balancing short-term growth and versus long-term outcomes Breast milk Higher IQ scores Less infections Less eczema Less adult morbidities

References Meier PP, Engstrom JL, Patel AL, et al. Improving the Use of Human Milk During and After the NICU stay. Clin Perinatol 2010; 37(1): 217-245. Meier PP, Engstrom JL. Evidence-based Practices to Promote Exclusive Feeding of Human Milk in Very Low-birthweight Infants. NeoReviews 2007; 8(11): e467-477. Kantorowska A, Wei JC, Cohen RS, et al. Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates. Pediatrics 2016; 137(3) Peila C, Moro GE, Bertino E, et al. The Effect of Holder Pasteurization on Nutrients and Biologically-Active Components in Donor Human Milk: A Review. Nutrients 2016; 8: 477.