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Human Milk in the NICU: The SPIN Program and Human Milk Banking in Eastern Canada

Human Milk in the NICU: The SPIN Program and Human Milk Banking in Eastern Canada. Jae Kim MD PhD UCSD Medical Center Division of Neonatal-Perinatal Medicine Division of Pediatric Gastroenterology, Hepatology and Nutrition. The Preterm Infant. Factors for Poor Milk Supply.

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Human Milk in the NICU: The SPIN Program and Human Milk Banking in Eastern Canada

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  1. Human Milk in the NICU: The SPIN Program and Human Milk Banking in Eastern Canada Jae Kim MDPhD UCSD Medical Center Division of Neonatal-Perinatal Medicine Division of Pediatric Gastroenterology, Hepatology and Nutrition

  2. The Preterm Infant

  3. Factors for Poor Milk Supply • Maternal factors: stress, illness (hypertension), endocrine, unable to access medical care (for mastitis, domperidone) • Infant factors: illness, continuous feeds, specialty formula • Physical barriers: geographical distance, cost of pump, language barriers • NICU factors: barriers between mom and baby, lack of privacy to pump at bedside, multi-patient rooms

  4. HMBANA (Human Milk Banking of North America) Existing Milk Banks Cities Served by Milk Banks 1.4 million ounces of milk annually Adapted from http://hmbana.org/index/locations

  5. Human Milk Processing Images from Toronto SickKids Archives

  6. Opens 2012 HUMAN MILK:YOU CAN BANK ON IT!A feasibility proposal for the creation of a Human Milk Bank in Toronto to serve the premature and surgical newborn population The Ontario Human Milk Bank is committed to ensuring that human donor breast milk is safely collected, processed, and stored so that it can be made available to all very low birth weight preterm infants and surgical neonates in eastern Ontario. www.womenscollegehospital.ca

  7. The Toronto Initiative • Began with interdisciplinary team (Sunnybrook • Health Sciences Centre, SickKids Hospital, • Mount Sinai Hospital) • Regulatory approvals sought (Health Canada, • CFIA, Public Health) • Canadian Paediatric Society position statement • Funding obtained: Rogers Foundation and the Ontario Ministry of Health and Long-term Care

  8. Canadian Paediatric Society Statement Reversed position of the CPS

  9. Canadian Human Milk Banking • Vancouver • Calgary (opened 2012) • Toronto (opening 2013) • Future • Edmonton • Regina • Montreal

  10. CPS Human Milk Banking Statement • Pasteurized human donor milk is a recommended alternative when mother’s own milk is not available • Should be prioritized to compromised preterm and selected ill term newborns • Informed consent • Milk banking should be adopted as a cost effective nutritional source for hospitalized neonates • There is a need for prospective studies to evaluate the benefits of banked human milk • The CPS does not endorse the sharing of unprocessed human milk

  11. Criteria for Donor Milk Use • Very low birth weight babies (<1500g) • Gastrointestinal surgery in the newborn period • Canadian (4 weeks of feeds and then transition to alternate over 3 days) • SPIN (up to 34 weeks adjusted age and then transition to formula over 2 days)

  12. WARNING: Formula milk may cause NEC!

  13. This is the way babies are supposed to be nourished

  14. That is not going to work for this 600 gram baby! But she really needs her mother’s milk!

  15. Vulnerabilities of the preterm infant • Decreased immunoglobulin ✔ • Poor neurocognitive outcomes ✔ • Increased risk of NEC ✔ • Increased risk for infection ✔ • Increased intestinal permeability ✔ • Poor intestinal motility ✔ • Abnormal gut colonization ✔ • Delayed gastric emptying ✔ These are human milk benefits to the preterm infant

  16. What are some of our challenges in the NICU? • Infection • Necrotizing enterocolitis • Growth restriction • Feeding intolerance • Poor developmental outcomes • Long hospital stay • Readmission

  17. Started in 1991 10 step plan for quality improvement Multidisciplinary approach Education for parents Education of all staff Minimize formula company exposure Evidenced based improvement Initial self assessment QI process BABY FRIENDLY HOSPITAL INITIATIVE 1990 Innocenti Declaration on Breastfeeding Promotion UCSD was home to origins of BFHI but it took another 15 years to get designation Pablo Picasso

  18. SPIN PROGRAM MISSION STATEMENT “To create a Center of Excellence in neonatal nutrition focused on the provision, analysis, and research of human milk to improve nutritional and long-term health outcomes of premature babies”

  19. Born Summer 2007 SPIN name adopted Made timeline Met frequently Agreement on goals Division of labor Equipment needs Neonatology support Administrative support 2 FTE: Lactation and Milk Tech Program roll-out March 2008 PLANNING THE SPIN PROGRAM

  20. Nutrition Director Lactation Director NICU F/U Neo NICU CNS Lactation OT NICU Dietician Research RN NICU Staff RN THE SPIN team

  21. SPIN Program NICU Inpatient PINC Outpatient Clinic SPIN Program Community Outreach Nutrition Research

  22. Team Building to Make More Milk NUTRITION LACTATION IMPORTANT TO BRIDGE TWO DISCIPLINES

  23. “Human Milk” vs “Breast Milk” • Preterm infants start feeding by nasogastric or orogastric tube • Many preterm infants are just starting to breastfeed by the time they are discharged • Many preterm infants will only be fed human milk from a bottle for their infancy • Preterm infants require additional nutrient supplementation for optimal growth at home; this often requires pumping and mixing of milk • Overall goal remains exclusive breastfeeding by 6 months

  24. Have a NICU nutrition/human milk policy Educate all mother/baby staff in SPIN 10-steps Educate NICU families about optimal premature infant nutrition Prevent extra-uterine growth restriction Standardize enteral feeding procedure Aim for 100% human milk nutrition Maximize mothers’ milk production Optimize milk quality Encourage skin-to-skin care and breastfeeding Plan a nutritional discharge from NICU SPIN PROGRAM GOALS

  25. Benefits of Human Milk for the Very Low Birth Weight Preterm Infant • Less NEC • Less infection • Quicker attainment of full feeds • Shorter NICU stay • Less hospital readmission • Higher IQ

  26. Improving Milk Processing In NICU: Milk Technician • Milk technician position: dietary tech • Collect morning milk order • Use standard recipe to mix 24 hour feedings • Milk feeding put in syringes, or large bottle once orally feeding • Milk analysis will be incorporated into practice to further improve optimal milk product • Benefits of milk tech: • Ease RN workload • Consistent preparation • Minimize milk transfers • Encourage use of fresh milk

  27. Exclusive human milk reduces NEC and NEC surgery Sullivan et al (2010) J Pediatr. 2010;156:562-7

  28. Human Milk Fortification Bovine HMF Human HMF Human Milk Human Milk Standard Exclusively Human

  29. Results This is the first randomized double-blind trial in infants of exclusive diets of HM vs PF. The significantly shorter duration of TPN and lower rate of surgical NEC support major changes in the strategy to nourish EP infants in the NICU.
 Cristafalo et al. H2MF group 2011, unpublished

  30. MILK TRAFFIC

  31. Routine Human Milk Analysis in the NICU • Human milk is best, but: • Varies in composition by • mothers • time of day, week, month • timing of pumping • delivery system • Current fortification methods are BLIND! • Error margin at least 50%

  32. Ideal Features of a Milk Analyzer • Point-of-care • Accurate • Measures Protein, Fat, and Carbohydrates • Uses only a small volume of milk • Affordable • Fast • Small footprint

  33. NIR Milk Analysis • NIR analysis compared to reference chemistry • Excellent correlation with protein, fat and carbohydrates Sauer et al 2010 J Perinatol.

  34. Caloric variability of human milk

  35. Results: nutrient content individual vs pooled Calories vary by 29%

  36. Oral Feeding Systems

  37. Thawing milk • What method • Water bath • In fridge • Dry heater • What time period- 24-36 hours after thawing • How to keep it safe?

  38. Review current policies and procedures Chart review of nutritional measures for VLBW Literature review Search for best practices VON feeding data UCSD 2006 SELF ASSESSMENT

  39. SPIN Impact study baseline data

  40. * * * * p <0.05

  41. Feeding Milestones * * * First Feeding First Fortification Max Calories BW regained Feeds stopped

  42. Growth pre- and post SPIN WT Birth WT at DC HC Birth HC at DC L Birth L at DC

  43. Z-scores pre- and post SPIN WT Birth WT at DC HC Birth HC at DC L Birth L at DC

  44. SPIN PROGRAM AT UC SAN DIEGOMEDICAL CENTER spinprogram.ucsd.edu

  45. QUESTIONS?

  46. Jae H. Kim, Associate Clinical Professor of Pediatrics neojae@ucsd.edu 619-543-3759 Human Milk Bank Processes: UC San Diego, San Diego, CA

  47. Background info

  48. Process

  49. Process

  50. Equipment/Location

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