1. Breast Milk QI
March 09, 2017

2. Objectives Overview of Maternal Human Milk Components Differences
Best NICU practices

3. 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

4. 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

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

6. 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)

7. 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

8. 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

9. 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

10. 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 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?

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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):
Meier PP, Engstrom JL. Evidence-based Practices to Promote Exclusive Feeding of Human Milk in Very Low-birthweight Infants. NeoReviews 2007; 8(11): e
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.