1. Evidence & Best Practice for the Use of Human Milk in Premature Babies Elizabeth Jones MPhil, RN, RM University Hospital of North Staffordshire

2. Aims To take you on a neonatal journey Discuss differences: preterm / term mammary physiology Explore basic milk expression problems Provide guidelines for implementing best practice

3. Promotion Swallowing amniotic fluid in the 3 rd trimester promotes maturation of gastrointestinal tract Preterm colostrum is similar to amniotic fluid (growth factors & cytokines) Perfect transition to extrauterine nutrition Mothers own expressed milk reduces the risk of short-and longer term morbidities

4. Potential Benefits to the Neonate Highly bioavailable Immunological protection Developmental outcome Promotes attachment behaviours

5. Challenges & Obstacles Expressing takes time & dedication Skilled support essential Mammary growth may be incomplete Poor rates despite intention

6. Obstacles & Requirements Not included in curricula Knowledge and skills requirement Time and commitment needed from mothers and neonatal staff

7. Mediators of Maternal Behaviour Oxytocin / Prolactin Endorphins Intense bond Protective Sedative  Cortisol (Uvnas-Moberg et al)

8. Six UK Audits Poor information & advice Lack of specialist lactation support Parents advised to change to bottle feeding in order to expedite discharge (BLISS Breastfeeding Survey 2008)

9. BLISS helpline Most common enquires around preterm milk expression Preterm breastfeeding Where to source support, advice and equipment

10. Advocacy The provision of breast milk is a medical treatment – not a social choice Feeding options (from pumping only to establishing breastfeeding) Principles of term lactation support may not apply

11. Truncated mammary development Different milk composition May not be hormonally driven  Markers for secretory activation (lactose / citrate / sodium / total protein) Cregan et al. 2002 Compromised lactation (82%) Cregan et al. 2002 IUGR / Betamethasone

12. Common experience Poor milk supply Dwindling volume Involution Inverse relationship between gestational age & secretory activation

13. Don’t delay until an infant is stable Will need expert support & encouragement through out the journey Avoid doing too little – too late It may be difficult initially & there may be a delay in establishing a supply Compensatory growth can be achieved

14. In the beginning Don’t set up to fail Start with hand expression Express early & often (*don’t drop night expression) The more preterm the more aggressive the regime DETERMINING FACTOR IS VOLUME AT 2 WKS

15. Sequence of breast milk use Feed colostrum in order of expression When on full enteral feeds use fresh milk Freeze unused colostrum for later use if required

16. © Peter Hartmann / Donna Ramsay Increase in fat in milk samples collected every 60 seconds during a 15 minute breast expressing using an electric pump

17. Optimising nutritional intake Use hind milk policy Use EBM from shorter interval expression first Ensure milk warmed to body temperature to avoid fat loss Check protein prior to fortification

18. Impact of freezing on breastmilk Reduces the effect of SIgA Disrupts fat globules and destroys lipase Destroys cellular activity Reduces B6 and C Fresh mothers milk always best!

19. Setting the stage Medical & nursing staff should actively advocate breastmilk Postpartum / NICU should support in consistent and cohesive manner Every mother should be provided with an appropriate pump and given the support to use it effectively

20. Setting the stage (cont) Specific lactation assistance should be available All involved in care should advocate establishing breastfeeding All involved in care should have the knowledge, skills and attitudes necessary to successfully support mothers.

21. Drivers for change Bliss Baby Charter standards – support from appropriately trained staff Poppy Project – family centred care New BFI neonatal standards

22. Drivers Toolkit for high quality neonatal services: Audit against WHO / BFI standards Annual increase in women initiating breastfeeding % reporting good advise, help and support