Appropriate Breastmilk Warming in a Neonatal ICU Ashley Early and Kate Weber University of Virginia School of Nursing May 10, 2012

Objectives To explain the evidence-based benefits of breastmilk To demonstrate the breastmilk warming protocol and temperature collection To show the results of the temperature collection data To see the clinical implications, results, and ongoing questions

So who’s ready to talk breastmilk? I am!

Evidenced-Based Benefits of EBM Infection Risk Necrotizing enterocolitis (NEC), respiratory disease, bacteremia, bacterial meningitis, urinary tract infections, otitis media & gastroenteritis GI function Chemical Composition Cost Reduces Infection Risk Lower respiratory infections, bacteremia, bacterial meningitis, urinary tract infections, necrotizing enterocolitis (NEC) acute otitis media Prevlanece of these factors help to prevent NEC (ie, immunoglobulins A and G, platelet activating factor-acetylhydrolase, polyunsaturated fatty acids, EGF, interleukin-10, and intestinal colonization with the favorable microbes of the Bifidobacteria and Lactobacilli species). Neonatal nurses even providing small amounts of colostrum and breast milk to infants in their oral mucosa and buccal membranes who are not yet being provided oral feeds has been shown to provide added infection protection for the infant, which is naturally provided to an infant that is put to breast Aids in digestion Several components of human milk stimulate gastrointestinal growth and motility (gastric emptying), which enhance the maturity of the gastrointestinal tract. Decrease the intestinal permeability early in life in premature infants - Better composition than formula EXAMPLE: Breastmilk contains 0. 65 g/dL of complex oligosaccharides where formula only has traces of these. These have properties that allow them to adhere to receptor sites on the epithelium, which decreases the sites available for bacteria and viruses to bind Human breastmilk also has active enzymes that cannot be properly replicated in artificial formula. Certain enzymes (lysozyme and peroxidases) function with anti-infective qualities. These particular enzymes get destroyed or inactivated in the processing of artificial formula and at this point, these enzymes cannot be re-added. There is also an antigen specific response that breastmilk helps the infant to initiate. By receiving breastmilk, the infant is able to recognize infectious agents that the mother has built up antigens to. STUDY EX: “The bowel content of infants fed breastmilk is considerably more acidic and contains 1000-fold less pathogenic organisms than bowel contents of infants fed artificial breastmilk” Reduce Costs: The rate of hospitalization and outpatient visits during the first year of life is lower among breast-fed infants costs for preterm or low birth weight infants added to $58 billion which was 47% of the cost for hospitalizations of all infants. The yearly additional hospital charges for NEC in the United States are estimated in excess of $6. 5 million  want to reduce NEC example: in one hospital: using donor breastmilk would have saved $200,000 for the twenty one cases of very low birth weight premature infants that they treated that year given the cost of NEC and sepsis

Understanding the protocol and collection process

Preparation Area

Specific Pod Storage Fridge Storage Freezer Specific Pod Storage Fridge

Temperature Control Sink Automatic Sink Temperature Control Sink

The Infrared Thermometer “Glove in Cup” Method The Infrared Thermometer

Initial Temp Time Final Median 14.43 45.03 12:01 31.175 Mode 15.55 30.7 Mean 14.53 44.35 14:48 31.18 MAX 23.9 56.2 38:16 40.2 MIN 5.5 28.65 3:54 22.4 Max Amt = 50 Min Amt = 5

Initial Temp Time Final Median 14.43 45.03 12:01 31.175 Physiologic Temp Room temp Initial Temp Time Final Median 14.43 45.03 12:01 31.175 Mode 15.55 30.7 Mean 14.53 44.35 14:48 31.18 MAX 23.9 56.2 38:16 40.2 MIN 5.5 28.65 3:54 22.4 Max Amt = 50 Min Amt = 5

Findings Initial EBM Temp of H2O Amt of Time Final EBM Maximum 23.9 C 38:16 mins 40.2 C Minimum 5.5 C 28.65 C 3:54 mins 22.4 C Mean 14.52 C 44.35 C 14:48 mins 31.18 C Median 14.43 C 45.03 C 12:01 mins Mode 15.55 C n/a 30.7 C Initial Temp Time Final Median 14.43 45.03 12:01 31.175 Mode 15.55 30.7 Mean 14.53 44.35 14:48 31.18 MAX 23.9 56.2 38:16 40.2 MIN 5.5 28.65 3:54 22.4 Max Amt = 50 Min Amt = 5 N = 40 > 35 C > 36.5 C 15% 7.5%

Example Measurement #1: Amt Initial H2O Time Final Extra 33ml 13.35C 12:47 33.1C 24 kcal Measurement #2 Amt Initial H2O Time Final Extra 28ml 18.5C 47.7C 12:08 35.25C 22 kcal

Implications for Practice Is there an “acceptable” temperature range? What are the physiological effects of cold (or hot) milk? Do EBM temperatures need to be measured before every feed? Shockingly, the answer is… We need process improvement. What is an “acceptable” temperature range? - If we’re saying the milk is too cold, is there a too hot? What would an acceptable range for the milk to be heated to be? Trying to always hit 37 with the current process is unrealistic as nurses do not have any parameters to measure by nor do they know the temperature of the warming water they are using. Currently there is not a set standard for the correct temperature What are the physiological effects of cold milk…or milk that is too hot? Is this all about LOS? …not just about the cost, about safety and having healthy babies. How do we do this without adding steps and layers to the RN? Intolerance: no real definition Does this affect our ability to advance feeds? Which affects LOS. Could we view this via gastric emptying study to see gut motility? Should we look at physiological responses like HR, RR, O2 Sats, Core temperature… How does this affect specific populations? Are we only worried about GI babies, etc What if this cut down our infection rates? Should we measure EBM temperatures? -Initially we were hoping we could set a time for the warming process: such as if we warm for x amount of time the milk will be ready, but saw from Kate’s examples that there are factors that probably do not allow general standards. So is it the amount of milk that matters, the temperature of the water, do we need to address the refrigerator temperatures, how do we account for fortifiers? Coffee urn – this would control for the water temperature Shockingly, the answer is : we need further research and process improvement. WHAT ARE THE GOALS HERE? We don’t have answers….confirmation that the practice needs to be improved We have supporters!

Questions?

References Bisquera, J., Cooper T. & Berseth, C. (2002). Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birthweight infants. Pediatrics, 109(3), 423-428. Lucas,A. & Cole, T. (1990). Breastmilk and neonatal necrotizing enterocolitis. Lancet, 336, 1519–1523. Newton, E. (2004). Breastmilk: the gold standard. Clinical Obstetrics & Gynecology, 47(3), 632-642. Russell, R. et al. (2007). Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics, 120(1), e1-9. Schandler, R. (2012). Infant benefits of breastfeeding. Uptodate:Waltham, MA. UVa Neonatology. (2010). http://www.healthsystem.virginia.edu/internet/neonatology/ Wright, N. (2001). Donor human milk for preterm infants. Journal Of Perinatology, 21(4), 249- 254.