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May 2012

Greetings from the Prolacta Team

LATCH… "to acquire understanding of, to comprehend"

On February 27th the American Academy of Pediatrics released a revised policy statement on “Breastfeeding and the Use of Human Milk”. This follows on the Surgeon General’s recent Call to Action to Support Breastfeeding http://www.surgeongeneral.gov/library/calls/breastfeeding/ which emphasized the provision of education and training in breastfeeding for all health professionals who care for women and children and basic support for breastfeeding as a standard of care for midwives, obstetricians, family physicians, nurse practitioners and pediatricians. In this edition of “Latch” we will overview these latest recommendations from the AAP as well as detail other recent articles that describe the use and benefit of human milk feedings in the neonatal intensive care unit (NICU).

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

New AAP Policy Statement on Breastfeeding and the Use of Human Milk

On February 27th the Section on Breastfeeding of the American Academy of Pediatrics released a revised policy statement http://pediatrics.aappublications.org/content/129/3/e827. Full text on “Breastfeeding and the Use of Human Milk”. This recent publication reflects the first revision of recommendations for breastfeeding and the use of human milk by the AAP since its 2005 policy was released. The AAP joins 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 policy describes the dose-response relationship between the duration of breastfeeding and the protective effective from respiratory tract infections, otitis media, gastrointestinal infections, Sudden Infant Death Syndrome (SIDS), allergic diseases, celiac disease, inflammatory bowel disease, obesity, diabetes, childhood leukemia and lymphoma, as well as improved neurodevelopmental outcomes.

Breastfeeding and the Use of Human Milk in the NICU

The AAP’s revised policy http://pediatrics.aappublications.org/content/129/3/e827. Full Text also includes expanded recommendations regarding the use of human milk in the premature infant. The policy notes that meta-analyses of 4 randomized clinical trials performed over the period 1983 to 2005 support the conclusion that feeding preterm infants human milk is associated with a significant reduction (58%) in the incidence of necrotizing enterocolitis (NEC). A more recent study of preterm infants fed an exclusive human milk diet compared with those fed human milk supplemented with cow-milk-based infant formula products noted a 77% reduction in NEC. JPeds Vol 156 No 4 April 2010. One case of NEC could be prevented if 10 infants received an exclusive human milk diet, and 1 case of NEC requiring surgery or resulting in death could be prevented if 8 infants received an exclusive human milk diet. JPeds Vol 156 No 4 April 2010.

The revised policy further states that the potent benefits of human milk are such that all preterm infants should receive human milk. Mother’s own milk, fresh or frozen, should be the primary diet, and it should be fortified appropriately for the infant born weighing less than 1.5 kg. If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used. The Academy’s recommendation for use of human milk for preterm infants is provided below:

Recommendations for Breastfeeding Management for Preterm Infants
1. All preterm infants should receive human milk.
2. Human milk should be fortified with protein, minerals, and vitamins to ensure optimal nutrient intake for infants weighing < 1500 g at birth.
3. Pasteurized donor human milk, appropriately fortified, should be used if mother’s own milk is unavailable or its use is contraindicated.
4. Methods and training protocols for manual and mechanical milk expression must be available to mothers.
5. Neonatal intensive care units should possess evidence-based protocols for collection, storage, and labeling of human milk.
6. Neonatal intensive care units should prevent the misadministration of human milk http://www.cdc.gov/breastfeeding/recommendations/other_mothers_milk.htm
7. There are no data to support routinely culturing human milk for bacterial or organisms.
From http://pediatrics.aappublications.org/content/129/3/e827

Necrotizing Enterocolitis and Long Term Neurodevelopmental Impact

Necrotizing Enterocolitis (NEC) is the most common life-threatening gastrointestinal emergency experienced by premature infants in the NICU. The incidence of NEC is inversely correlated to gestational age and birth weight. This devastating GI disease is associated with severe sepsis, intestinal perforation, and significant morbidity and mortality. The excessive inflammatory process initiated in the highly immunoreactive intestine in necrotizing enterocolitis extends the effects of the disease systemically, affecting distant organs such as the brain and placing affected infants at substantially increased risk for neurodevelopmental impairment (Gregory et al 2011). http://journals.lww.com/advancesinneonatalcare/.

Although the majority of NEC cases are treated medically, an estimated 20% to 40% of infants will require urgent surgical intervention including exploratory laparotomy, bowel resection and ostomy. The case fatality rate associated with surgical intervention is as high as 50%. Infants who survive are at risk for short bowel syndrome, parenteral nutrition-associated cholestasis, prolonged neonatal hospitalization, significantly impaired growth, and poor long-term neurodevelopment. Indeed, an infant recovering from NEC may have nearly a 25% chance of microcephaly and serious neurodevelopmental delays that will transcend concerns that pertain to the gastrointestinal tract. NEC remains one of the most catastrophic co-morbidities of prematurity (Neu & Walker 2011) http://www.nejm.org/doi/full/10.1056/NEJMra1005408.

A recent publication (Ta BDP et al 2011) examined whether surgical factors (primary anastomosis verses enterostomy) were of prognostic value for long-term neurodevelopment in children surviving surgery for NEC (SNEC). https://www.thieme-connect.com/ejournals/abstract/ejps/doi/10.1055/s-0030-1267976. The study evaluated 19 patients (12 boys), median age 9.9 years (range 6.2-13.1), gestational age 31.0 weeks (range 25.2-40), birth weight 1250g (range 780-3175). Infants who had an enterostomy (n=14) scored lower on intelligence than children with a primary anastomosis. Motoric skills were either suspect or clinically impaired in 74%. The results suggest that an enterostomy in SNEC patients could be associated with worse neurodevelopmental outcomes by the age of 6-13 years compared to a primary anastomosis, although the severity of illness was comparable between both groups.

Nutritional and Immunobiological Properties of Human Milk

In a recent publication in the Journal of Obstetric, Gynecologic & Neonatal Nursing, authors Kim & Froh (2011), provide an extensive overview of both the nutritional and immunologic benefits conferred to the infant fed breastmilk.

The nutritional components present in human milk include the macronutrients (fats, proteins and carbohydrates) and the micronutrients (calcium, phosphorus, magnesium, iron, vitamins and trace elements). The authors also address the variability seen in the nutritional content of human milk by accounting for the influence of pumping fraction (hindmilk vs. foremilk), time of day, day of lactation, and degree of breast emptying http://onlinelibrary.wiley.com/doi/10.1111/j.1552-6909.2011.01314.x/pdf.

An exclusive human milk diet also provides the infant with specific elements that enhance the newborn’s immune system. Some of these diverse factors, human milk oligosaccharides and lactoferrin, function as prebiotics facilitating the establishment of the microflora in the newborn gut. Secretory immunoglobulin A, lactoferrin, lysozyme, white blood cells, nucleotides, pancreatic secretory trypsin inhibitor, and xanthine oxidase have anti-infective properties that protect the infant from bacterial, viral and fungal infection. Human milk contains cytokines, antioxidants and anti-proteases which help modulate inflammation. A plethora of growth factors, naturally occurring substances capable of stimulating cellular growth, proliferation, cellular differentiation and regulating cellular processes are also in human milk.

Human milk feedings provide the term and preterm infant with essential nutritive and immune-protective components. In a recent publication in the Journal of Obstetric, Gynecologic & Neonatal Nursing, aAuthors Kim & Froh (2011) recent publication by (Kim & Froh) http://onlinelibrary.wiley.com/doi/10.1111/j.1552-6909.2011.01314.x/pdf notes that, like blood, human milk contains cellular, nutritional and bioactive factors. However, the authors note that the number of bioactive factors far outnumber the nutritional components in human milk.

This review article provides an extensive description of both the macronutrient (fats, protein and carbohydrates) and the micronutrient (calcium, phosphorus, magnesium, iron, vitamins and trace elements) components present in human milk. The authors address the variability seen in the nutritional content of human milk by accounting for the influence of pumping fraction (hindmilk vs. foremilk), time of day, day of lactation, and degree of breast emptying.

An exclusive human milk diet also provides the infant with specific elements that enhance the newborn’s immune system. Some of these diverse factors, human milk oligosaccharides and lactoferrin, function as prebiotics facilitating the establishment of the microflora in the newborn gut. Secretory immunoglobulin A, lactoferrin, lysozyme, white blood cells, nucleotides, pancreatic secretory trypsin inhibitor, and xanthine oxidase have anti-infective properties that protect the infant from bacterial, viral and fungal infection. Human milk contains cytokines, antioxidants and anti-proteases which help modulate inflammation. A plethora of growth factors, naturally occurring substances capable of stimulating cellular growth, proliferation, cellular differentiation and regulating cellular processes are also in human milk.

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