Greetings from the Prolacta Team
LATCH… "to acquire understanding of, to comprehend"
Prolacta Bioscience's eNewsletter serves to extend our mission of "making a meaningful difference in the lives of thousands of the most vulnerable infants through world class research and innovative products" by providing the health care professional with a brief overview of evolving research, current clinical issues and emerging strategies relevant to the care of the premature infant and sick newborn.
The year 2012 has been a great year for all professionals who support breastfeeding infants and the use of human milk for premature babies in the NICU. Beginning earlier this year with the publication of the revised policy statement from the American Academy of Pediatrics and moving mid-year into World Breastfeeding Week, increasing number of studies and clinical observations documenting the benefits of human milk have appeared in publication.
In this edition of "Latch" we will overview some of these latest studies and identify other recent findings that positively promote best outcomes of the premature and low birth-weight infants in the neonatal intensive care unit (NICU).
Terry S. Johnson, APN, NNP-BC, MN, CLEC
Neonatal Nurse Practitioner
Editor, Prolacta eNewsletter
20th World Breastfeeding Week
Understanding the Past- Planning the Future: Celebrating 10 Years of WHO/UNICEF's Global Strategy for Infant and Young Child Feeding
20 years ago, the World Alliance for Breastfeeding Action (WABA) launched its first World Breastfeeding Week (WBW) campaign http://worldbreastfeedingweek.org/
It continues to be celebrated from August 1-7 in more than 120 countries around the world and commemorates the Innocenti Declaration made by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) policy-makers in August 1990 to protect, promote and support breastfeeding.
The American Academy of Pediatrics' recently revised policy statement "Breastfeeding and the Use of Human Milk" http://pediatrics.aappublications.org/content/129/3/e827 bridges the recommendations of the World Health Organization, The Joint Commission, the Centers for Disease Control and Prevention, and the US Surgeon General's Call to Action to support the initiation and sustaining of exclusive breastfeeding of newborns and continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.
The new AAP policy also includes expanded recommendations regarding the use of human milk in the premature infant in the NICU. Several significant short term benefits of feeding preterm infants human milk cited in the policy include:
- Lower rates of sepsis and NEC
- Improved feeding tolerance
- Hastened attainment of full enteral feeding
- Fewer hospital readmissions in the first year after NICU discharge
- Reduction of long term growth failure
- Lower rates of severe retinopathy of prematurity
- Less neurodevelopmental disabilities.
Long-term studies suggest that preterm infants fed human milk have:
- Improved leptin and insulin metabolism
- Lower rates of metabolic syndrome
- Lower blood pressure and low-density lipoprotein concentrations in adolescence
The AAP states that the potent benefits of human milk are such that all preterm infants should receive human milk in the form of mother's own milk, fresh or frozen, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If a mother's own milk is unavailable despite significant lactation support, pasteurized donor milk should be used.
NEC: Role of Feeding Protocols and Human Milk Feedings
Necrotizing enterocolitis (NEC) remains a leading cause of mortality and morbidity in the premature and low birth-weight infant. In a review of NEC by Dominguez and Moss appearing in the June 2012 edition of Clinics in Perinatology http://www.perinatology.theclinics.com/article/S0095-5108(12)00027-9/fulltext the authors provide a comprehensive review of both intrinsic and extrinsic factors associated with the development of NEC.
Standardized feeding protocols or feeding guidelines, which typically involve initiation of feeding based on gestational age of the infant and slow gradual advancement of both volumes and concentration, is an extrinsic factor that has been shown to lower the incidence of NEC compared with a non-standardized initiation of feeds. In addition, the use of standardized feeding guidelines has been shown to improve growth, reduce the length of stay, and lower hospital costs (Christensen, Gordon & Besner, 2010).
Likewise, meta-analyses by McGuire& Anthony ( 2003) and by Boyd& Quigley (2007) have suggested that the use of donor human milk reduces the incidence of NEC. A recent randomized, prospective trial by Sullivan et al DOI: 10.1016/j.jpeds.2009.10.040 comparing the exclusive use of human breast milk (mother's own milk and donor human milk) with bovine milk-based products found that the incidence of NEC was 77% lower in infants exclusively fed human breast milk and that the incidence of NEC requiring surgical intervention was also significantly lower.
Dominguez and Moss note that prevention strategies appear to have the greatest potential for avoiding adverse outcomes from NEC than surgical intervention. They conclude that the currently proven strategies of standardized feeding protocols and the use of human milk are additive and likely synergistic in their effect on reducing the incidence of NEC. It has been estimated that together, these two strategies can decrease the incidence of NEC by half. (Christensen, Gordon & Besner, 2010).
Nursing and Outcomes of VLBW Infants
One in 4 very low birth-weight infants (VLBW) dies in the first year of life and nearly all deaths (87%) occur in the first month. Infant mortality in the United States is concentrated in this population. Infants in the NICU are among the most "nurse-intensive" patients in a hospital. In the NICU nurses make complex assessments, implement highly intensive therapies and monitor the infant's response and need for continuing or changing the intervention.
An article in JAMA in April http://jama.jamanetwork.com/article.aspx?articleid=1148194 examined the relationships between hospital recognition for nursing excellence (RNE) and the outcomes of VLBW infants. The American Nurses Credentialing Center (ANCC) developed the Magnet Recognition Program to recognize health care organizations for quality patient care, nursing excellence, and innovations in professional nursing practice. Organizations are evaluated for evidence of transformational leadership, structural empowerment, exemplary professional practice, new knowledge innovations, and improvements and empirical outcomes. The route to recognition is an extensive and rigorous process that usually takes 2 years to complete. Hospitals are required to undergo a re-designation process every 4 years.
The objective was to examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW The objective was to examine the relationships between hospital recognition for nursing excellence (RNE) and VLBW infant outcomes in a cohort of 72,235 VLBW infants weighing 501 to 1500 g from the Vermont Oxford Network (VON). Main outcome measures were seven-day, 28-day, and hospital stay mortality; nosocomial infection; and severe (grade 3 or 4) intraventricular hemorrhage (IVH). Among VLBW infants born in RNE hospitals compared with non-RNE hospitals, there was a significantly lower risk-adjusted rate of death within 7 days, nosocomial infection, and severe intraventricular hemorrhage. All 5 outcomes were jointly significant (P < .001). The results of this study suggest that one way to increase the number of infants that receive high-quality neonatal care would be to increase the number of hospitals that achieve the Recognition for Nursing Excellence status.
National Neonatal Nurses Day: September 15th
We at Prolacta Bioscience honor neonatal nurses for the incredible care they provide to the most vulnerable of patients every day. We are proud to be partnered with you to improve the lives of these babies and their families. We invite you to hear the stories of neonatal nurses in the video clip "Neonatal Nursing: Making a Difference, Changing Lives".
To learn more about neonatal nursing please visit the following organizations:
The National Association of Neonatal Nurses (NANN) http://www.nann.org/ describes neonatal nursing as a subspecialty of nursing that works with newborn infants born with a variety of problems ranging from prematurity and birth defects to infection, cardiac malformations, and surgical problems. The neonatal period is defined as the first month of life; however, these newborns are often sick for months. Neonatal nursing generally encompasses those infants who experience problems shortly after birth, but it also encompasses care for infants who experience long-term problems related to their prematurity or illness after birth. Most neonatal nurses care for infants from the time of birth until they are discharged from the hospital. Founded in 1984, NANN represents the community of neonatal nurses that provides evidence-based care to high-risk neonatal patients. With more than 7,000 members, NANN is recognized as the expert voice that influences standards of practice through advocacy, education, networking, collaboration, and leadership.
The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) is a professional practice organization that promotes the health of women and newborns. AWHONN’s mission is to improve and promote the health of women and newborns and to strengthen the nursing profession through the delivery of superior advocacy, research, education and other professional and clinical resources to nurses and other health care professionals. http://www.awhonn.org/awhonn/
The Academy of Neonatal Nursing (ANN) is a professional practice collaborative that provides and supports neonatal education, publications and research to all newborn health care professionals. ANN achieves this mission through professional, peer-reviewed publications, educational conferences, and text books and other educational materials newborn health care professionals. The Academy is a proud supporter of The Foundation for Neonatal Research and Education (FNRE).
A Human Milk Diet and the Reduction of Probability of Remaining on TPN
Total Parenteral Nutrition (TPN), including glucose, amino acids and lipids, is a recognized standard of care for the low birth-weight, premature or sick newborn infant. TPN provides crucial nutritional support to compensate for diminished placental delivery in utero, as well as increased postnatal needs secondary to various disease states and continued growth and development. The use of TPN necessitates the placement and maintenance of either a percutaneous, umbilical or central catheter for administration and carries an associated risk of Catheter-Associated Blood Stream Infections (CABSI’s).
Powers & Wirtschafter (2010) attributed mortality rates from CABSI’s in the NICU population to vary from 24% in the pre-surfactant to 11% in the post-surfactant era. They further reference follow up studies that demonstrate an association between CABSI’s and sepsis, poor growth, abnormalities in cerebral white matter and adverse neurodevelopmental outcome at 2 years of age in NICU survivors. http://www.perinatology.theclinics.com/article/S0095-5108(10)00015-1/fulltext
Strategies that can support adequate enteral nutrition while decreasing the need for extended days of TPN and central catheter placement are then ideal for the for the premature infant in the NICU. When the paper "An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products" http://www.walc.net/wp-content/uploads/2011/01/SullivanDonorMilk2010.pdf was originally published one of the study endpoints was number of days on total parenteral nutrition (TPN). A reanalysis of that data using an approach that yields the odds of an infant being on TPN “on any given day” for the first 90 days was recently performed. This new paper "An exclusive human milk-based diet in extremely premature infants reduces the probability of remaining on total parenteral nutrition: a reanalysis of the data" was published in BMC Research Notes 2012, 5:188. The analysis demonstrated that the use of a 100% human milk diet significantly reduced the risk of receiving TPN on any given day of life in the first 90 days. Furthermore, if the initial first course of TPN, which is a routine standard of care for this population, is excluded from the analysis, the decrease in odds of needing TPN for the 100% human milk diet group is even greater (24 and 34% lower). This reanalysis and the results discussed above are available for review at http://www.biomedcentral.com/1756-0500/5/188/abstract.
To learn more about Prolacta's human milk products, please go to www.prolacta.com.