pqcnc hm nccc ls 1 introduction
DESCRIPTION
PQCNC Human Milk NCCC Track Learning Session 1 IntroductionTRANSCRIPT
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Perinatal Quality Collaborative of North Carolina 2010-2011Exclusive Human Milk in Newborn Critical Care Centers:Action Plan and Literature Review
Statewide meetingWinston-Salem, NCJan 13, 2011
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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?
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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
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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
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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
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Human milk contains thousands of unique components not found in formula
¶ -sleep peptides
Secretory IgA, IgM, IgG
Lactoferrin
Lysozyme
Polyamines
Casomorphins
Complement C3
Bifidus factor
Antiviral mucins, GAGs
Oligosaccharides
Cytokines &Anti-Inflamatory Factors
Tumor Necrosis Factor
Interleukins
Transforming (TGF)
Platelet-Activating Factor:
acetyl hydrolyase
Insulin
Prolactin
Thyroid Hormones
Corticosteroids, ACTH
Oxytocin
Calcitonin
Parathyroid Hormone
OthersEpidermal (EGF)
Nerve (NGF)
Insulin-Like (IGF)
Anti-Microbial Factors Hormones
TransportersDigestive EnzymesGrowth Factors
Erythropoietin
Interferon
Prostaglandins
a-1 anti-trypsin
a-1 anti-chymotrypsin
Lipoprotein lipase
Ribonuclease
Amylase
Bile acid-stimulating esterase
Bile acid-stimulating lipase
Lactoferrin
Folate Binder
Cobalamin binder
IgF binder
Thryoxine binder
Corticosteroid binder
DNA & RNA
Lutein
Lycopene
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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
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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
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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)
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10
‘Survival’ Curves for NEC or death in ELBW’s by amount of MBM (ml/kg/d) received in first 14 days of life
Survival Estimate
0 10 20 30 40 50 60 70 80 90 100 110 120
0.80
0.85
0.90
0.95
1.00
100 ml
50 ml
20 ml
10 ml
0 ml
Postnatal age (d)
*For NEC or Death after 14 days, adjusted for birth weight, race, PDA treatment, ventilation, and siteMeinzen-Derr, et al NICHD Neonatal Network
J Perinatology, 2009
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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)
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Breastmilk Decreases Time on TPN and Length of Stay
HM PTF diff p
Days on TPN
25 35 10 0.01
Days to discharge
73 88 15 0.03
Schanler. Peds 1999; 103(6):1150-1157
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Improved Developmental Outcome with Use of Mother’s Milk
Vohr. Peds 120 (4) e953-9, 2007
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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
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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
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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”
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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
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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)
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Increasing Use of Mother’s Milk in the Newborn Critical Care Units: The Action Plan
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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
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Create supportive and family-centered environment
a. Perform self-assessment and implement family-centered care practices
b. Welcome 24 hour parent care in nurseryc. Develop family support programsd. Provide pumps and pumping rooms for
mothers before and after discharge
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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)
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Support the mom and baby to breastfeed
a. Evaluation for oral feeding (baby readiness)b. Teach infant cuesc. 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
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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
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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 guidelinesC. Safety in the use of expressed milkD. Health system leadership
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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
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A. mother’s milk preferred substrate2. 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 techniquesc. Teach hand expression and pumping techniques using
mechanical pumpd. Provide support from lactation consultant or other
breastfeeding experte. Provide daily review of mothers’ pumping records of
pumping and volume expressed
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A. mother’s milk preferred substrate3. 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 breaste. Provide appropriate chairs and privacy screens
for skin-to-skin and breastfeeding opportunities
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A. mother’s milk preferred substrate4. 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
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B. Implement feeding guidelinesa. 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
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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
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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
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D. Health System Leadership1. 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
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D. Health System Leadership2. 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
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Thank you
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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
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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