Author: Amy Mailand Paradis, NNP
My entire nursing career has been in caring for the most vulnerable of patients – the extremely premature and critically ill newborn. As both a nursing student and bedside RN, the neonatal intensive care unit (NICU) has been my home base since 1990. As a Neonatal Nurse Practitioner since 2005, working in a community level III NICU in the Central Valley of California, my passions have always been vascular access and infection control. I have taught and published specifically on clinical strategies to reduce central line-associated bloodstream infection (CLABSI) in the NICU population.
As a Clinical Nurse Specialist, the development of policy, procedures, education, quality improvement strategies, and changing clinical practice are key aspects of my profession. The newly revised Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, third edition,1 is an essential tool to guide clinicians and nurse leaders in providing the best and safest feeding practices for our NICU population.
Chapter 5 of the new guidelines, “Expressed Human Milk Preparation and Handling,” is a key resource for best practices in human milk handling and feeding. Bedside nurses face many challenges in the clinical use of human milk (HM) – be it mother’s own milk (MOM), donor milk (DM), or human milk-based fortifiers. Unfortunately, our NICU does not have a designated milk mixing room, nor a milk/dietary technician.
Logging, labeling, thawing, preparation, administration, and documentation are often the responsibility of the bedside RN. Chapter 5 highlights each of these issues and offers tools to assist nurse leaders with the development of best practices in this setting. The chapter further highlights the importance of early breastmilk expression by the mother, especially while she is at her infant’s bedside. This practice facilitates earlier opportunities to feed fresh MOM. The recommendation remains for a 48-hour expiration period for fresh MOM, unless a centralized, clearly defined handling process is in place, which increases the expiration window to 72-96 hours.
Chapter 7 reviews practices associated with donor milk and donor milk products, along with cautions concerning milk-sharing. Most notable are the various pasteurization techniques used in producing these products. The Human Milk Banking Association of North America (HMBNA) utilizes the Holder pasteurization method, which has been successfully utilized by milk banks for decades. Prolacta utilizes Vat pasteurization, which can be thought of as an in-line version of the Holder process and meets the requirements of the Pasteurized Milk Ordinance. Alternative forms of pasteurization – such as Shelf-stable Processing, which results in a commercially sterile product – are also introduced.
Chapter 11 provides guidance on common clinical issues such as barcode scanning and two-person verification of every container transfer and prior to feeding to avoid administration errors. Appropriate hang time for tube feedings based on diet used are defined. Other practices reviewed in this chapter include enteral feeding delivery through the use of nasogastric or oral gastric tubes. The use of auscultation for tube placement verification is no longer recommended in the revised guidelines.
Strategies to facilitate fat delivery with tube feedings include: use of a small bore tube; shortened feeding and extension tubing; flushing the tubing with sterile water after the feeding is completed; and an aim to initiate early bolus vs. continuous pump feedings when possible. As much as 20% to 74% human milk fat loss may occur during feeding delivery. One technique that may decrease such loss is positioning the syringe in a vertical position rather than horizontal. Lastly, the new ENFit syringe system designed to eliminate the risk of accidentally administering enteral feedings into intravenous (IV) lines or other medical devices is discussed.
The introduction of ENFit has added a new level of concern for safety of low-volume mediations and potential contamination requiring the use of a special cleaning tool. General recommendations for the safe use of ENFit are addressed. Infection control and prevention have been a passion of mine for nearly a decade. Our NICU has been able to achieve an unprecedented ZERO occurrences of CLABSI for over eight years! The provision of an exclusive human milk diet has greatly impacted our total central line days, thereby decreasing our total parenteral nutrition usage. Both of these positive trends have contributed to our ongoing low rate of CLABSI and other infections in our unit.
Chapter 12 provides an overview of infection prevention and covers valuable points concerning sanitation, hand hygiene, feeding preparation, and storage practices to limit contamination. Human milk is a bioactive biologic; it is not sterile. Common normal flora identified in HM include lactic acid bacteria such as Lactobacillus and Streptococci, as well as gram-positive Staphylococci such as S epidermidis. Research findings on the association between HM and microbes are discussed.
The difference between cleaning, sanitizing, and sterilizing are explained along with steps to mitigate the risk of contamination. Routine microbiologic surveillance of facility-prepared feedings is not recommended. These newly updated guidelines offer the clinician a robust tool for the safe feeding of vulnerable infants in the health care setting and clearly supports the use of HM and DM as the gold standard for neonatal nutrition.
1. Pediatric Nutrition Practice Group; Steele C, Collins EA, eds. Infant and Pediatric Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities. 3rded. Chicago, IL: Academy of Nutrition and Dietetics; 2018. Pam Middleton, RN, BSN, MPA