Perinatal Quality

Collaborative of North
Carolina 2010-2011
Exclusive Human Milk
in Newborn Critical Care Centers:
Action Plan and Literature Review

Statewide meeting
Winston-Salem, NC
Jan 13, 2011
Could we become first state in the US to insure that all of our
VLBW infants receive human milk as their first feed, and as
their main enteral nutrition for the first month of feeds?
Aims
• Primary: Increase by 50% the number of babies
receiving mom’s milk at 28 days of life in NC
newborn critical care units by 9/30/2011
• Secondary: incidence of sepsis, incidence of NEC,
and process measures
Human milk preferred for all babies:
mother’s milk first choice

• in addition to nutrition, provides enzymes, hormones,

growth factors, anti-oxidants, direct immunologic
protective factors, immunomodulators, anti-inflammatory
factors and other bioactive factors, with new components
and interactions being discovered regularly
• early feeds of human milk may allow development of GI
biome that will affect short and long-term health
• multiple clinical benefits
• allows family to play key role in the care of their baby,
enhancing bonding
Mother’s Breast Milk
• Species-specific
• Composition
• Growing body of evidence re: short and long-term
health for term babies
• Growing body of evidence re: short and long-term
health for preterm babies
• New scientific evidence re: importance of human
milk in establishing GI biome integrity
 Human milk contains thousands of unique components not
found in formula
Cytokines &
Anti-Microbial Factors Anti-Inflamatory Factors Hormones
Secretory IgA, IgM, IgG Tumor Necrosis Factor Insulin
Lactoferrin Interleukins Prolactin
Lysozyme Interferon Thyroid Hormones
Complement C3 Prostaglandins Corticosteroids, ACTH
Bifidus factor a-1 anti-trypsin Oxytocin
Antiviral mucins, GAGs a-1 anti-chymotrypsin Calcitonin
Oligosaccharides Platelet-Activating Factor: Parathyroid Hormone
acetyl hydrolyase Erythropoietin

Growth Factors Digestive Enzymes Transporters Others

Epidermal (EGF) Amylase Lactoferrin Casomorphins
Nerve (NGF) Bile acid-stimulating esterase Folate Binder ¶ -sleep peptides
Insulin-Like (IGF) Bile acid-stimulating lipase Cobalamin binder DNA & RNA
Transforming (TGF) Lipoprotein lipase IgF binder Lutein
Polyamines Ribonuclease Thryoxine binder Lycopene
Corticosteroid binder
MBM: Benefits to term babies
• Increased survival/less SIDS
• Other short-term benefits:
▫ more easily digested
▫ protection against infections
• Long-term benefits:
▫ less obesity/diabetes/hypertension
▫ lower rates of some forms of cancer (lymphoma, leukemia,
Hodgkin’s disease)
▫ decreased inflammatory bowel disease
▫ decreased hypertension
▫ improved IQ
MBM: benefits for preterm infants
• Improved feeding tolerance (improved gastric clearance,
fewer residuals, faster realization of full feeds, improved
absorption and utilization of nutrients, faster decrease in
intestinal permeability) leading to less time with central
lines, and less need for hyperalimentation
• Decreased infections (sepsis/meningitis, UTI’s)
• Decreased necrotizing enterocolitis
• Decreased mortality
• Improved long-term outcomes (higher IQ, less
obesity/hypertension)
• Improved mother-infant bonding
Sisk et al. Human Milk Consumption and Full Enteral Feeding
Among Infants Who Weigh <1250 Grams. Pediatrics.
2008;121(6):e1528-1533

• Study published in June 2008, from Wake Forest

University School of Medicine
• Compared group receiving low amount of mother’s
milk (n=34) to high amount, defined as >50% (n=93)
• Avg GA 27-28 wks, avg wt 980-1000 gms
• Avg time to start feeds was 3.5 days
• Feeds of 150 ml/kg/d were achieved at 27 (LHM) vs
22 days (HHM)
 ‘Survival’ Curves for NEC or death in ELBW’s by
amount of MBM (ml/kg/d) received in first 14 days of life

1.00
Survival
Estimate 0.95 100 ml

0.90 50 ml

20 ml
0.85 10 ml
*For NEC or Death after 14 days,
adjusted for birth weight, race, PDA treatment, ventilation, and site 0 ml
Meinzen-Derr, et al NICHD Neonatal Network
0.80
0 10 20 30 40 50 60 70 80 90 100 110 120

1 Postnatal age (d) J Perinatology, 2009

Decreased neonatal sepsis with use of MBM
• El Mohandes et al. Use of Human Milk in the Intensive Care
Nursery Decreases the Incidence of Nosocomial Sepsis. J
Perinatology 1997; 17(2):130-134

Sepsis rate Breast milk Formula

Day 0-10 5% (2/38 10% (10/107)
Day 11-24 9% (4/43) 20% (18/94)
Day 25-38 0% (0/19) 15% (11/72)

• Furman. The effect of Maternal Milk on Neonatal Morbidity of

VLBW Infants. Arch Ped Adol Med 2003; 157 (1), 66-71
▫ Found that at least 50 ml/kg/d of MBM needed to decrease rate of sepsis
in VLBW babies, lowered rate of sepsis by 27% (in prospective study of
119 babies, avg 28 wks, ~1000 gms)
Breastmilk Decreases Time on TPN
and Length of Stay
HM PTF diff p

Days on 25 35 10 0.01
TPN
Days to 73 88 15 0.03
discharge

Schanler. Peds 1999;

103(6):1150-1157
Improved Developmental Outcome with Use of Mother’s
Milk

Vohr. Peds
120 (4)
e953-9,
2007
Decreased rehospitalization with
use of mother’s milk
• Vohr’s 2007 Pediatrics article also showed a decrease
in rehospitalization with breast milk in first two years
of life, mostly related to less respiratory illness
• If received no breast milk or <50% breast milk during
initial hospital stay, ~33% of babies were readmitted
with resp illness, if received 60-80%, 27%
readmitted, and if received >80%, 16% were
readmitted
 Preterm milk is especially suited for the preterm infant

 Higher levels of protein (highest

from mothers with most preterm
baby), including higher levels of
free amino acids and epidermal
growth factor
 Higher levels of sodium,
chloride, and slightly lower
lactose levels compared to term
milk
 Slightly higher calories/oz
 Slightly higher
calcium/phosphorous
 Fortification/supplementation
seems necessary for optimal
growth
Human milk:
improves integrity of GI biome
• Neonatal gut sterile at birth
• Intricate interplay among microbes, diet, mucosal cells,
mucin, immunomodulators to create environment that
may affect both short and long-term well-being
• Much interest in impact of single component of milk
(taurine, glutamine, nucleotides, fatty acids, arginine,
immunoglobulins, EGF or TGF) but interactions must
be multifacted and complex
• New interest in “toll-like receptors”
Oligosaccharides
• Oligosacs are result of lactose
combining with
monosaccharides
• HM has 130 currently-known
oligosaccharides
• Serve as decoys -interferes with
pathogen binding to intestinal
cells
• Also serves as “prebiotic”,
setting up environment
conducive to growth of
commensal bacteria
• Role in neural development

Newburg DS, Walker WA. Pediatric Research 2007;1: 2-4

Complex interplay exemplified by
butyrate production and role in GI tract

• “Oligosaccharides in mother’s milk may act as nutrients for

beneficial commensal bacteria (a “prebiotic” role) and
fermentation of these oligosaccharides and lactose in
mother’s milk may lead to the production of short-chained
fatty acids that play a “postbiotic” role, especially butyrate,
which can be effective as a major fuel for colonocytes, an
anti-apoptotic, pro-proliferative agent, that may also aid in
the strengthening of intercellular tight junctions, and also
stimulate the synthesis of glucagon-like peptide 2 (GLP-2),
a hormone that is highly trophic for the intestine” (from Neu.
Gastrointestinal maturation and implications for infant feeding. Early Human
Development 2007;83:767-775)
Increasing Use of Mother’s Milk in the Newborn
Critical Care Units: The Action Plan
Relates to getting the desired results but outside
the focus of this collaborative action plan

• Create supportive and family-centered

environment
• Optimize nutrition and nutritional monitoring of
all infants
• Support the mom and baby to breastfeed
• Promote breastfeeding support in the
community
Create supportive and
family-centered environment

a. Perform self-assessment and implement family-

centered care practices
b. Welcome 24 hour parent care in nursery
c. Develop family support programs
d. Provide pumps and pumping rooms for
mothers before and after discharge
Optimize nutrition and nutritional
monitoring of all infants

a. Monitor daily intake and parameters of growth

b. Utilize a multidisciplinary team, including
neonatal nutritionist and pharmacist
c. Early initiation of TPN (protein with 2 hours,
lipids in first 24 hours)
Support the mom and baby
to breastfeed

a. Evaluation for oral feeding (baby readiness)

b. Teach infant cues
c. When transitioning to exclusive breastfeeding
consider measuring transfer, and use SNS &/or nipple
shields as needed
d. In preparation for discharge establish feeding regimen
to meet growth requirements and developmental
needs, identify and connect to resources, consider
rooming in prior to discharge and consider weight
scales for use at home to measure intake
Promote breastfeeding support
in the community

a. Emphasize breastfeeding in group prenatal patient

education
b. Collaborate to assure breastfeeding support groups
for outpatients
c. Promote breastfeeding support in the greater
community, with special attention to underserved
groups
Action Plan for PQCNC:
four main areas of activity

A. Promote and use mother’s milk as the preferred

nutritional substrate for infants
B. Implement feeding guidelines
C. Safety in the use of expressed milk
D. Health system leadership
A. “mother’s milk as preferred substrate”
1. Assess feeding intention and establish expectations
related to premature birth upon admission

a. Inform all mothers at time of birth of benefits of

their milk for their baby, including mother’s milk
“as medicine”
b. Use language that distinguishes providing milk from
breastfeeding
c. Encourage early initial visit to facilitate
communication and assistance to obtain colostrum
and milk
A. mother’s milk preferred substrate
2. provide early and continuous support to obtain mother’s
colostrum and milk

a. Provide mother with access to appropriate pump

(hospital-grade with double pumping kit) and provide
necessary supplies
b. Teach breast massage and relaxation techniques
c. Teach hand expression and pumping techniques using
mechanical pump
d. Provide support from lactation consultant or other
breastfeeding expert
e. Provide daily review of mothers’ pumping records of
pumping and volume expressed
A. mother’s milk preferred substrate
3. promote regular maternal skin-to-skin contact

a. Provide parent and staff education to promote

skin-to-skin
b. Encourage early maternal visits to include touch
and skin-to-skin as soon as possible
c. Encourage breast pumping immediately after
each skin-to-skin interaction
d. Encourage non-nutritive sucking at the breast
e. Provide appropriate chairs and privacy screens
for skin-to-skin and breastfeeding opportunities
A. mother’s milk preferred substrate
4. Provide age-appropriate oral stimulation program

a. Encourage non-nutritive sucking at the breast or use

pacifiers
b. Consult specialist as needed to include but not be
limited to OT, PT, feeding/speech therapist or
developmental specialist
B. Implement feeding guidelines
a. Provide early small volume “feeds” using mom’s
colostrum every chance you get as soon as you
get it
b. Consider using pasteurized donor milk until
mom’s milk is available
c. Develop unit-specific systematic feeding
advancement guidelines including but not
limited to volume, fortification, use of additional
protein and an algorithm for residuals
C. Safety in the use of expressed milk

1. Labeling, storage and administration of breast

milk
a. Adopt and follow national guidelines to
include, but not be limited to type of containers,
labeling protocols, and refrigerator/freezer
temperatures
b. Develop policies for the administration of
breast milk to include, but not be limited to
recipes and policies for fortification, warming,
bolus feedings and assuring correct milk for each
baby
C. Safety in the use of expressed milk

2. Use of donor milk

a. Use only screened pasteurized milk
b. Consider strategies to optimize growth in
babies receiving donor milk
c. Track batch number of milk given to
infant
D. Health System Leadership
1. Educational intervention for staff and providers:
should include using patient experience and data to
achieve support of medical and administrative
leadership, communication of comprehensive
written policies to all staff, insuring adequate
staffing, providing regular continuing education, and
address competency (attitude, skills and knowledge)
in areas of lactation support
D. Health System Leadership
2. Measure what matters: establish aims, collect data
on initiation, duration of feedings, exclusivity and
patient experience, create dashboard of indicators to
follow trends and measure improvement, and round
regularly with a multidisciplinary group on this data
3. Market health: refrain from accepting and
distributing any infant formula marketing materials,
purchase and record use of formula and bottles
Thank you
Oligosaccharides and Commensal
Bacteria Protect Synergistically

• Oligosaccharides
▫ Promote bifidobacterial growth
in gut
▫ Bind pathogens rendering
them less able to bind to
receptors on mucosal cell
surface
▫ Serve as receptors for
commensal bacteria that
colonize the gut and form a
biofilm
• These processes provide
multiple layers of synergistic
defense

Newburg DS, Walker WA. Pediatric Research 2007;1: 2-4

Systemic Inflammatory Response Syndrome
• Hypothetical scheme
• Bacteriostatic, anti-inflammatory components, commensal bacteria
• Effects on dampening intestinal production of proinflammatory mediators
such as IL-8
• Subsequent prevention of propagation of this inflammatory mediator to
proximal (intestine) as well as distal organs (lung and brain).

Caicedo RA, Schanler RJ, Neu J. Pediatr Res 2005;58:625