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.
This has been a busy couple of months here at Prolacta Bioscience and I want to take a moment to share some of the news with you. Prolacta Bioscience has moved into a new, office and support service space in the City of Industry. New state-of-the-art milk processing facilities will be opened at the new location in 2013. The growing body of research and clinical practice supporting the use of an "exclusive human milk diet" for premature and low birth-weight infants is dramatically increasing which has created the need nationally for both standardized donor human milk and Prolact+H2MF® exclusive human milk fortifiers in the neonatal intensive care unit (NICU). Our new facility, growing staff and expanding services will enable Prolacta to continue to meet its commitment to "make a meaningful difference in the lives of thousands of the most vulnerable infants through world class research and innovative products".
|Prolacta’s new office and milk processing facility:
Terry S. Johnson, APN, NNP-BC, MN, CLEC
Editor, Prolacta eNewsletter
Transfusion-Associated Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) a potentially fatal condition characterized by intestinal necrosis occurs predominately in premature infants who have received enteral feedings. The incidence of NEC in very low birth weight (VLBW) infants is 3% to 10%. The finding of NEC is associated with complications such as intestinal perforation, short bowel syndrome and an increased risk of adverse neurodevelopmental outcome. Transfusion-associated necrotizing enterocolitis (TANEC) describes the presentation of NEC within 48 hours of plasma transfusion and has be shown to be associated with 25% to 35% of NEC cases (Mohammed A, Shah PS 2012 Pediatrics 2012;129(3):529-540). Researchers have hypothesized that this adverse reaction to plasma transfusion, transfusion-related acute gut injury (TRAGI) may be secondary to an abnormal response to mesenteric plasma flow velocity in the posttransfusion state whereby the mechanisms of feeding contributes to gut injury.
In survey of attending neonatologists and NICU directors, 56% claim to have experienced TRAGI or TANEC. However, of those surveyed (83%-86%) do not withhold enteral feedings before, during or after transfusion (Calo J, Blau J, LaGamma E. E-PAS 2009; 2009:400). Christensen and colleagues (Christensen RD, Lambert DK, Henry E Transfusion (Paris) 2010;50(5):1106-1112) report that infants with TANEC accounted for 35% of their surgical NEC cases and were significantly more likely to have been fed large volumes of milk in the 24 hours before and during transfusion (P=.04), especially if it was formula (P=.004) than those who developed NEC not associate with transfusion.
Neonates are among the most transfused patients in the hospital, but adherence to transfusion guidelines and adoption of unit specific guidelines vary significantly. A summary of current evidence and recommendations for transfusion practice and feeding practice by Gephart was published this year.
While the evidence is not conclusive about the best approach to feeding during transfusion, preliminary evidence suggests a protective effect of holding feedings before and during transfusion. Additional practice recommendations to reduce TANEC include (1) encouraging mothers to provide human milk as soon as possible by initiating early pumping; (2) consider feeding pasteurized donor milk if mother’s milk is not available; and (3) consider changing practice to exclusive human milk or nothing by mouth during transfusion and measure the impact on unit-specific NEC rate.
Neonatal Short Bowel Syndrome
Neonatal short bowel syndrome (SBS) is a catastrophic consequence of small bowel intestinal loss or resection secondary to NEC. It is a subset of neonatal intestinal failure which is defined as intrinsic bowel disease resulting in an inability to sustain growth, hydration, or electrolyte balance. In clinical practice both terms are used interchangeably. A recent review of neonatal SBS by Guiterrez, Kang, and Jaksi (2011) appeared in Seminars in Fetal and Neonatal Medicine http://www.researchgate.net/publication/50376380_Neonatal_short_bowel_syndrome.
The Center for Advanced Intestinal Rehabilitation at Children’s Hospital Boston identifies NEC (35%), intestinal atresia (25%), gastroschisis (18%), malrotation with volvulus (14%) and the rarer diagnoses (2%) as the etiologies for SBS. Residual small bowel length remains the prime predictor of eventual intestinal failure as well as parenteral nutrition (PN) dependence. The mortality associated with SBS has a bi-modal distribution. Mortality in the early post-operative period is from complications from the underlying disease and attendant medical procedure. Late mortality is more commonly associated with intestinal failure-associated liver disease (IFALD), sepsis from catheter infection (CABSI), and small bowel bacterial overgrowth (SBBO).
This review supports the necessity of a multidisciplinary effort to manage this population. Therapies and strategies addressed in the article include parenteral nutrition, prokinetic agents, controlling stool and ostomy output, and hormonal therapy for improved mucosal surface area adaptation. Surgical interventions that potentially improve long term outcome in the infant with SBS includes, initial bowel conservation, intestinal bowel lengthening operations including serial transverse enteroplasty operation (STEP) and intestinal transplantatio. The authors note that successful transition to enteral nutrition is the most important intervention in infants with SBS as it obviates IFALD and CABSI and improves growth. The authors note that while ideal enteral nutrition for neonates with SBS remains controversial, it has been shown that both breast milk and elemental formulas are associated with a reduction in length of time of PN dependence.
Effect of Breast Milk on Hospital Costs and Length of Stay
Advances in medical technology and treatment modalities have dramatically increased survival of very low birth-weight (VLBW) infants weighing less than 1500 g. The cost of hospitalization is inversely related to birth weight and gestational age making the care provided to VLBW infants to be exceedingly expensive (Gilbert WM et al Obstet Gynecol. 2003;102(3):488-492). A recent publication from the University of Florida and the Medical University of South Carolina in Advances in Neonatal Care, describes the effect of breast milk on hospital costs and length of stay http://www.ncbi.nlm.nih.gov/pubmed/22864006.
The authors indicate that more recent findings indicating average length of hospitalization for VLBW infants to be between 35.6 and 68.1 days and that hospital costs for VLBW infants have been shown to range from $52,300 to $250,569 depending on gestational age and birth weight. Complications that prolong length of stay and increase hospital costs in this population include necrotizing enterocolitis, late-onset sepsis and feeding intolerance issues.
The authors conducted a retrospective analysis of 80 infants weighing less than 1500 g born prior to 32 weeks’ gestation between January 2004 and January 2009. The purpose was to assess whether provision of at least 50% breast milk feedings will affect days to discharge and cost of hospitalization. No significant differences were found between total costs, length of stay, or discharge weight. Although not statistically significant, infants who received at least 50% breast milk feedings weighed slightly less than those infants fed formula (997.9 g vs. 1090.85 g) and were born at a slightly lower gestational age (27.4 weeks vs. 28.2 weeks). The authors discuss whether the end point of at least 50% breast milk feedings was sufficient and whether a higher percentage of human milk feedings may have resulted in a shortened length of stay. They also posited whether extending the study’s cope beyond the initial NICU hospitalization may have also resulted in a further reduction of costs through the first year of life.
Finally, the potential expense of providing breast milk to VLBW infants was not taken into account in the study. The authors note that formula is provided by formula companies without charge in most NICU’s. Provision of human milk to infants in the NICU may be more expensive because of the associated costs from hospital-grade breast pumps, containers, nursing time for maternal teaching and support, feeding preparation, milk freezers and the use of lactation consultants. The authors note that little research has been reported concerning the total cost of providing human milk to infants in the NICU.
Breastfeeding Protects Against Current Asthma
The protective effect of breastfeeding on the development of asthma has been conflicting. A prospective birth cohort study (Silvers, et al 2011) detailing information about infant feeding and duration of “exclusive breastfeeding” and “any breastfeeding”. 1105 infants enrolled in the study. This data was matched with a primary outcome of “current asthma” and “current wheezing” at 2,3,4,5, and 6 years of age as a secondary outcome measurement .information about wheezing and current asthma was collected. http://www.sciencedirect.com/science/article/pii/S0022347611012297
Results supported that breastfeeding, especially exclusive breastfeeding, continued to protect against current asthma from 2 to 6 years of age. The degree of protection for each month of exclusive breastfeeding across the whole cohort decreased from 21% at 15 months to around 9% at 6 years. The authors note that if every infant in the cohort had been exclusively breastfed for 6 months, as is currently recommended by the World Health Organization (and the American Academy of Pediatrics), current asthma would have been reduced by 50% at 2 years, 42% at 3 years, 30% at 4 years, 42% at 5 years and 32% at 6 years. Further exploration of the data revealed that protection associated with exclusive breastfeeding was more pronounced in atopic children beyond 3 years of age.
To learn more about Prolacta's human milk products, please go to www.prolacta.com.