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FEBRUARY 2012

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.

"Milk as Medicine", a phrase that has appeared in both medical literature and public presentations over the past few years, has been used to describe the health benefits of human milk feeding/diet for both the full-term, premature, and  low birth weight infant. In this edition of “Latch” we will overview this concept and its potential applications for infants in the NICU.

Terry S. Johnson, APN, NNP-BC, MN
Neonatal Nurse Practitioner
Editor, eNewsletter

"Milk as Medicine"

Human Milk and Antioxidants

The term and preterm infant are uniquely at risk for oxidative stress (OS) secondary to the excessive production of reactive oxygen species (ROS). ROS can be generated when preterm infants are exposed to high oxygen concentrations during resuscitation and mechanical ventilation and secondary to hyperoxia during the reperfusion phase of hypoxic-ischemic insults. ROS are also released by macrophage and neutrophil activation as part of the physiological response secondary to infection and inflammation.

Oxidative stress has been implicated in neonatal diseases such as periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and necrotizing enterocolitis (NEC).Trindade & Rugolo. NeoReviews 2007;8;e522-e632.

Lee and Davis describe the evolution of biologic systems that provide a protective array of enzymatic and non-enzymatic antioxidants to neutralize the deleterious effects of excessive free radical production, http://www.ncbi.nlm.nih.gov/pubmed/21150443. Term and preterm infants have low levels of antioxidants at birth, secondary to limited placental transfer of these factors. Zarban et al. have reported that colostrum and human milk are rich sources of antioxidants for the infant with the highest level of total antioxidant capacity in colostrum followed by decreasing capacity as milk matures over the first months of life http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735626/. The safety and feasibility of fresh colostrum feedings within the first 48 hours of life has further been described in the extremely low birth weight (ELBW) infant by Rodriquez, Meier et al. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924875/). Early colostrum feedings, even in the ventilated premature infant, offers a potential route of antioxidant administration for this population.

"Milk as Medicine"

Reduction in Sepsis in Premature Infants

“Lack of breast milk may be the most common immunodeficiency of infancy.”"

This statement, made by Lars Hanson from the Department of Clinical Immunology, Göteborg University in Sweden, may help explain the role of breastfeeding in reducing infant mortality and protecting infants from the co-morbidities of septicemia and meningitis (http://www.ncbi.nlm.nih.gov/pubmed/17637091. A subsequent recent publication by Tarnow-Mordi et al. uses the assertion to introduce the concept of breast milk as an adjunctive immunologic intervention in neonatal sepsis.

Human milk is rich in a variety of immune, nonimmune, and anti-inflammatory components. Breast milk provides protective secretory IgA antibodies to pathogenic microbes present in the mother’s gastrointestinal tract and in the postnatal environment. These antibodies act on the gut lumen to prevent the binding of microbes on the mucosal surface, reduce the risk of bacterial translocation and prevent proinflammatory activation. The milk protein lactoferrin can also destroy microbes and modulate inflammatory responses.

Non-absorbed milk oligosaccharides (also known as “prebiotics”) block attachment of microbes to the infant's mucosal surfaces, limiting bacterial translocation, preventing infection, as well as providing nutrients that promote the growth of commensal or beneficial organisms in the gut. Secretory immunoglobulin A present in breast milk prevents bacteria and viruses from binding to mucosal surfaces, neutralizes microbial toxins and increases viral excretion in the newborn Hosea Blewett et al. http://www.sciencedirect.com/science/article/pii/S1043452607000022. These and other mechanisms may explain the strong inverse associations between breast milk feeding and gastroenteritis, septicemia, meningitis, and necrotizing enterocolitis in low birth weight or preterm infants.

Their article may be reviewed in full at http://www.perinatology.theclinics.com/article/S0095-5108(09)00111-0/fulltext.

"Milk as Medicine"

Prevention of NEC

The role of human milk (HM) to decrease the incidence of NEC in the premature, low birth weight infant has been well substantiated in literature. Although investigators have focused on the potential health contributions of receiving human milk, few have evaluated a potential "dose–response relationship".

Early work by Lucas & Cole http://www.ncbi.nlm.nih.gov/pubmed/1979363 demonstrated the efficacy of an all human milk diet on reducing the incidence of NEC in low birth weight infants. However, Lucas & Cole were unable to provide essential fortification to these infants’ human milk diet to promote post-natal growth needs. The subsequent development of cow milk-based human milk fortifiers provided a mechanism to introduce additional fat, protein and minerals to mother’s own milk and/or donor milk. Cow-based human milk fortifiers, while improving growth of the low-birth weight infant, did not reduce the incidence of NEC in this population.

The clinical question of a "dose–response relationship". between percentage of human milk feeding and the incidence of NEC remains appealing. Sullivan S, Schanler RJ, Kim JH et al. published on the beneficial effect of an “exclusively human milk-based diet” that utilized a human milk-based fortifier from donor human milk J Pediatr 2010 DOI: 10.1016/j.jpeds.2009.10.040. In a population of 207 infants with birth weights of 500 to 1250 g findings demonstrated that an infant receiving any bovine product had an 8 times higher odds of requiring surgery for NEC. The number needed to treat (NNT) to prevent one case of NEC was 7.7 babies. The potential for clinicians to provide an “exclusive human milk-based diet” with fortification strategies utilizing an exclusive human milk-based fortifier is now a clinical possibility.

"Milk as Medicine"

"In Your Hands" Video

The use of colostrum and human milk "as medicine" in the preterm infant can only be accomplished by having mother’s milk and colostrum immediately and consistently available in the neonatal intensive care unit (NICU). The role of the NICU medical, nursing and lactation staff is essential to engage mothers early in providing milk for their infants. “In Your Hands" is an educational video produced and available through the Rush Mother’s Milk Club at Rush Medical Center in Chicago, Illinois. The video relates the stories of families who provided colostrum and breast milk for their infants in the NICU at Rush Medical Center. The video emphasizes the role of the medical staff on influencing this decision by the mothers and the role of nursing and lactation services in maintaining mother’s continued milk production and ultimately, successful breastfeeding of their premature infant. The video is available for preview and purchase at http://www.rushmothersmilkclub.com/index.cfm?p=educational-materials

*This product was not produced by, sponsored by, endorsed by, or affiliated with Prolacta Bioscience in any way, nor does Prolacta receive any funding from them.

To learn more about Prolacta's human milk products, please go to www.prolacta.com.