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Improving Neonatal Outcomes with Human Milk

Improving Neonatal Outcomes with Human Milk. Roger G. Faix , MD Division of Neonatology University of Utah Primary Children’s Intermountain Medical Center. 0. DISCLOSURE

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Improving Neonatal Outcomes with Human Milk

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  1. Improving Neonatal Outcomeswith Human Milk Roger G. Faix, MD Division of Neonatology University of Utah Primary Children’s Intermountain Medical Center

  2. 0 DISCLOSURE The content of this presentation does not relate to any product in which I have a financial interest or potential conflict of interest.

  3. Learning Objectives 1- Learn why breast milk is the recommended form of enteral nutrition for allinfants. 2- Learn how commercial formulas differ from human breast milk. 3-Appreciate longitudinal and other changes in content of human breast milk. Got Breast Milk? Got Milk?

  4. Breastfeeding and Use of Human MilkPolicy Statement. Pediatrics2012;129:e827-841 • Breastfeeding and use of human milk confer unique nutritional and non-nutritional benefits to infant and mother and, in turn, optimizeinfant, child, and adult health as well as child growth and development. • Recently published evidence-based studies have confirmed and quantitated risks of not breastfeeding. Infant feeding should not be considered as a lifestyle choice but rather as a basic health issue.

  5. Improving Outcomes with Human Milk Lifestyle Choices • Have a family • Have a career • Have a snowmobile Basic Health Issues • Deliver in a hospital • Immunize your baby • Use a car seat • Infant feeding (breast milk)

  6. Improving Outcomes with Human Milk in the Nursery and NICU Provider Choices • Switch ventilators • Order a β-natriuretic peptide assay • Be nice to residents Basic Health Issues • Treat respiratory failure • Treat sepsis • Be nice to staff • Infant feeding (breast milk)

  7. Meinzen-Derr J, et al. Role of human milk in extremely low birth weight infants’ risk of necrotizing enterocolitis or death.J Perinatology 2009;29:57-62 o NEC (7.7%) or death > 14d, 173/1272(13.6%) Each 100 ml/kg increase in HM intake during the first 14 d was associated with decreased risk of NEC or death. (HR 0.87 (95% CI 0.77, 0.97)

  8. Ronnestadt A, et al. Late-onset sepsis in a Norwegian national cohort of extremely premature infants receiving very early human milk feedings. Pediatrics 2005;115:e269 o 80/405 LOS (23%) Feedings started at 1-2 mL q2-3h within a few hours of delivery and advanced 0.5-1 mL q 6-8h RR of LOS if full feedings not established within a certain age (days) Survival free from LOS according to week when full feedings established 92% MM 6% donor

  9. Infectious Diseases Influenced by Infant Diet Infants - Children Pediatrics 2012;129:e827-841

  10. Diseases and Conditions influenced by Infant Diet Pediatrics 2012;129:e827-841

  11. Basic Nutrients Proteins Fats Carbohydrates Vitamins Minerals Water All are present in milk of all species, but types and proportions vary by species, making each specific and apparently uniquely suited Breast milk is more than good nutrition

  12. Milk ProteinSpecies Specific Content Calves are mostly muscle and bone. They double their weight in <50 days. Humans are designed to grow more slowly, with emphasis on brain growth and social development.

  13. A Partial List of Protein FunctionsNew Peptide Derivatives Continue to be Discovered There are 268 proteins in human milk from which even more bioactive peptides are released. Though some proteins are common to both species, they occur in significantly different quantities. Hetinga K et al. The Host Defense Proteome of Human and Bovine Milk. PLoS One. 2011;6(4):e19433

  14. Sanderson, IR. Dietary Regulation of Gene Expression. Gastroenterology and Nutrition, Saunders, 2008, p28 “The expression of genes can be altered by changing the molecular environment that cells inhabit . . . no single act alters the environment of the cells of the body more than the ingestion of food.”

  15. Gut Transformation after BirthWalker A, J Pediatrics 2010; 156:S3-7 o → FETUS at birth Sterile GI tract Immature epithelium Delayed enterocyte proliferation Sparse lymphoid cells Breast fed NEONATE Bacterial colonization (2-3 hr) Proliferating epithelium All subclasses of enterocytes Abundance of lymphoid tissues

  16. Greater Enterocyte Proliferation with Colostrum than with Mature Breast Milk o Proliferation of enterocytes as measured by the incorporation of 3H-thymidine after exposure to early (3d) or late (57d) breast milk. Tapper et al. J Pediatric surgery 1979;14:803-8

  17. Hernandez-Ledesma B, et al. InterntlDairy Journal 2007;17:42-49 “If peptides derived from gastrointestinal digestion of dietary proteins play a specific role as metabolic or physiological regulators, it seems logical that the biological activity exerted in the newborn by infant formulas or breast milk could be different.”

  18. Colostrum is Part of Transition 1) Colostrum (Birth-4d) is high in protein, fat-soluble vitamins, minerals, and immunoglobulins. It is different because normal transition requires it. 2)Transitional milk (2d-2wks) includes high levels of fat, lactose, water-soluble vitamins, and contains more calories than colostrum

  19. Composition of Cow Milk formulasBased on nutrient content of human milk at 1-3 mo • Protein: nonfat bovine milk and whey concentrate • Fat: blend of vegetable oils • Carbohydrate: corn syrup solids and lactose • Vitamin and mineral mix • Additional ingredients are manufacturer-based: iron (1959), taurine(1984), DHA (2000), leutein (2012) Content is regulated by the FDA and is based on the AAP Committee on Nutrition recommendations

  20. Milk Protein o Human milk protein is not ‘merely for nutrition.’ It displays medicinal qualities that initiate and modulate development resulting in profound effects on infant survival and health

  21. Milk FatSpecies Specific Content Differences Breastfeeding is associated with improved child cognitive development. MA Quigley et al. J Pediatrics 2012;160:25-32

  22. Preterm Lipid StudyPediatrics2001;108:359 –371 “Whether or not formulas designed for the premature infant should be supplemented with long-chain PUFA, including arachidonic acid and docosahexaenoic acid has become one of the most controversial issues in infant nutrition today . . .” “. . . Several lines of logic suggest that premature infants fed formulas without AA and DHA may be at increased risk of slower developmentrelated to suboptimal blood and tissue levels of these fatty acids compared with the term infant.”

  23. Milk CarbohydrateBreast Milk is not just Lactose • Oligosaccharides - nonnutritive, the third most common solute in human milk after lactose and fat. Cow’s-milk formulas contain very little. • Prebiotic agents that encourage the growth of beneficial (probiotic) organisms • Anti-infective in the intestinal, respiratory and urinary tracts. >130 identified pathogen-specific, binding (decoy) inhibitors • Functional components of brain gangliosides essential to nerve cell transmission, memory formation and cell-to-cell communication. Miller JB. Invited Commentary: Human milk oligosaccharides: 130 reasons to breast-feed. British Journal of Nutrition 1999;82:333–335 Ballard O and Morrow A. Human Milk Composition. PCNA 2013;60(1)49-74

  24. Milk Vitamins and MineralsSpecies Specific Content Differences • All vitamins and minerals in human milk have a higher bioavailability than in cow milk formula • 50-75% of Fe in BM is absorbed compared to 4% in formula • To compensate, more is added to formula: Excess, unabsorbed minerals (especially iron) alter gut flora and facilitate growth of potentially harmful bacteria

  25. Vitamin and Mineral SupplementationPediatrics 2012;129:e827-e841 • Vitamin K 0.5 to 1.0 mg IM after the first feeding at breast and before 6 hours • Vitamin D400 U/day PO at hospital discharge • NoFluoride during the first 6 months and thereafter only if [fluoride] < 0.3 ppm • Iron orally before 6 months if low iron stores Premature infants need multivitamins and iron until ingesting a mixed diet and growth is normalized

  26. Optimal Source of NutrientsBreast milk content is essential for optimal development • Basic nutrient and bioactive component content and proportions are species specific. Many differences exist. • Breast milk content can be (and is) altered by individual needs and circumstances. Formula content is fixed. • Formula is not milk. Many components are missing. Content is further altered by pasteurization. What formula lacks or has in it can make a difference

  27. Term vs Preterm Milk Content Composition of human milk varies with maternal diet, lactation stage, within feedings, diurnally, and among mothers. Pediatric Nutrition Handbook 2009

  28. Morton J, et al. Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants J Perinatol2012;32:791-796 o Frequency of hand expression in first 3d Group I < 2 times/day Group II 2-5 times/day Group III > 5 times/day Increased frequency of hand expression in first 3d increases milk production.

  29. Formula contentNeofax 2011, 24thEdition Because of poorer bioavailability, more is often needed

  30. VohrB, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics 2006;118(1) No diff BW, GA, sex, IVH gr 3-4, PVL, NEC, sepsis, BPD, LOS, CP, blindness, hearing loss, weight and OFC @ 18 mo. Adj for mom age, edu, race, income For every 10 ml/kg/d increase in BM, there was an increase in MDI (0.53 points), PDI (0.63 points), BRS (0.82 %ile), and a decreased likelihood of re-hospitalization (6%)

  31. Vohr B, et al. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics 2007;120(4) o The principal effects of BM in children at 30 months CA are on cognition and behavior.

  32. Cost to Use Breast milk (no cost) Expressed ($15/mo pump) Donor ($3.50/oz + freight) Commercial ($30.00/oz) PF1 ($1.18/oz) Elemental 1 ($1.77/oz) Elemental 2 ($2.48/oz) HMF/packet ($1.08-1.50)

  33. Cost to Not Use Breast Milk • If 90% of US families followed guidelines to BF exclusively for 6 mo, the US would annually save $13 billion from reduced medical and other costs. Bartick, M. Pediatrics 2010;125:e1048-e1056 (2007 dollars) • Health care costs for newborns are three times lowerfor babies whose mothers participate in the company’s employee maternity and lactation program. www.surgeongeneral.gov/topics/breastfeeding/

  34. Ganapathy V, et al. Breastfeeding Med 2012;7(1):29-36 ( *p<0.0001, 95% confidence interval, $4,405–$11,930) “The analyses presented in this article may assist healthcare providers and institutions to justify an increased use of human milk and human milk products to promote better health outcomes in EP infants.”

  35. Ziegler EE. Meeting the Nutritional Needs of the Low-Birth-Weight Infant. Ann NutrMetab 2011;58(suppl 1):8-18 Growth failure is associated with impaired neurocognitive development Human milk must be fortified with nutrients in order to enable adequate growth

  36. Carlson SJ, Ziegler EE. Nutrient intakes and growth of very low birth weight infants. J Perinatol 1998; 18: 252–258. Olsen IE, et al. Intersite differences in weight growth velocity of extremely premature infants. Pediatrics 2002; 110: 1125–1132. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics 2003; 107: 270–273. When growth of preterm infants lags behind expected growth (that is, growth like the fetus), it is almost always protein that is limiting growth

  37. Arslanoglu S, Moro GE, and Ziegler EE. Adjustable fortification of human milk fed to preterm infants: does it make a difference? J Perinatology 2006;26:614-621 o End Point 2000 g 14 8 16 bovine whey protein concentrate

  38. Arslanoglu S, Moro GE, and Ziegler EE. Adjustable fortification of human milk fed to preterm infants: does it make a difference? J Perinatology 2006;26:614-621 o Optimal Intakes: Intrauterine protein intake of fetuses weighing the same as the mean body weights of study infants for each week. 3.4 2.8

  39. Arslanoglu S, Moro GE, and Ziegler EE. Preterm infants fed fortified human milk receive less protein than they need. J Perinatology 2009;29:489-492 Adjusted Standard The inadequate levels of actual protein intakes observed in the present study offer an explanation of why preterm infants fail to grow adequately in spite of receiving adequate energy intakes.

  40. Wojcik KY, et al. Macronutrient Analysis of a Nationwide Sample of Donor Breast Milk. J Am Diet Assoc2009;109:137-140 415 samples from 273 donors nationwide *majority mature milk, but also a “sizable amount” of premature milk, 65% < 20 kcal/oz and 35% > 20 kcal/oz ** Ziegler EE. Ann NutrMetab 2011;58(suppl 1):8-18 Human milk protein, fat and energy content may be lower

  41. Effect of breastfeeding vsformula feedingon childhood obesityArenz et al.,Int J Obes Relat Metab Disord 2004;28:1247-1256 j The mechanisms for the association between breastfeeding and obesity are unclear

  42. De Onis M, et al. Global prevalence and trends of overweight and obesity among preschool children. Am J ClinNutr 2010;92(5):1257-64 o 1990 1995 2000 2005 2010 2015 2020 Children age 0-5 years > 2SD weight for height median

  43. Standards for Normal Growth have Changedwww.cdc.gov/growthcharts/ 8000 Infants “All young children have the potential to grow similarly, regardless of their ethnic group or place of birth, if they are in a healthy environment and receive adequate nutrition.”

  44. Characteristics and Potential Functionsof Human Milk Adiponectin • Protein hormone produced by adipose tissue which enhances fatty acid metabolism and reduces inflammation • Low levels are associated with obesity, type 2 diabetes, dyslipidemia, and cardiovascular disease • Higher levels in human milk are associated with lower infant weight in the first 6 months of life in BF infants and may attenuate inflammatory processes Newburg DS et al. J Pediatr2010;156:S41-6

  45. Adequate GrowthSummary • Historically, preterm infants gain weight faster on formula than on human milk (breast or donor). • Because protein and energy content of human milk vary, more than standard fortification may be needed to achieve short-term growth standards. • However, faster early growth may be associated with higher rates of obesity. Growth norms (mostly formula-fed infants) are too high. • Despite slower growth, breastfed infants have better neurodevelopmental outcomes.

  46. Consider these Suggestions:What % of your NICU infants receive all BM to discharge? • Make lactation support a part of parent interactions • Educate all mothers on the value of human milk • Explain the need for breastfeeding mothers to pump and express milk early and often (8-12 times daily) • Know they are doing it and doing it effectively • Strongly encourage exclusive human milk feedings (as you would treatment for presumed sepsis)

  47. Fewer than 11% of US working parents receive paid leave when a child is born Providing up to 12 weeks unpaid leave only applies to companies with 50 or more employees

  48. Human Milk Banking Associationof North America www.hmbana.org o

  49. Milk Bank Donor Requirements • In good health. • Non-smoker. No use of any Nicotine products. • Negative blood test for viruses (Prenatal results are NOT used). • Using no medications during the time milk is collected for donation, except for: vitamins and minerals; food supplements, progestin-only birth control, or replacement hormones: thyroid, insulin • Limited use of caffeine; and a waiting period is required after alcohol use before donating milk • Willing to donate a minimum of 150 ounces total during the time they are a donor

  50. How is Donor Milk Processed?http://www.milkbankcolorado.org/ Milk from 3-5 donor mothers is thawed, transferred to glass flasks, and mixed. o

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