Hair AB, Peluso AM, Hawthorne KM, et al. Beyond necrotizing enterocolitis prevention: improving outcomes with an exclusive human milk-based diet. Breastfeed Med. 2016;11(2):70-74. doi:10.1089/bfm.2015.0134. Published correction appears in Breastfeed Med. 2017;12(10):663. doi:10.1089/bfm.2015.0134.correx
Manthe ED, Perks PH, Swanson JR. Team-based implementation of an exclusive human milk diet. Adv Neonat Care. 2019;19(6):460-467. doi:10.1097/ANC.0000000000000676
Hair AB, Bergner EM, Lee ML, et al. Premature infants 750-1250 g birth weight supplemented with a novel human milk-derived cream are discharged sooner. Breastfeed Med. 2016;11(3):133-137. doi:10.1089/bfm.2015.0166
Lapcharoensap W, Bennett MV, Xu X, Lee HC, Dukhovny D. Hospitalization costs associated with bronchopulmonary dysplasia in the first year of life. J Perinatol. 2020;40(1):130-137. doi:10.1038/ s41372-019-0548-x
Assad M, Elliott MJ, Abraham JH. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol. 2016;36(3):216‐220. doi:10.1038/jp.2015.168
The full potential of human milk has yet to be realized. Speaking of Human Milk provides healthcare professionals with information on the latest science and clinical research. Each episode features an interview with a thought leader passionate about uncovering the unknown potential of human milk or better understanding the science of neonatal nutrition.
In addition to hosting Speaking of Human Milk, Keli Hawthorne is the director for clinical research for the Department of Pediatrics at the University of Texas Austin, Dell Medical School. In her current role, she trains faculty and staff on effectively executing high-quality protocols for research. She has authored more than 40 peer-reviewed publications on neonatal nutrition.
Keli Hawthorne (KH): Hey y’all, welcome to Speaking of Human Milk, where we give you bite-size episodes on the latest science and innovation surrounding human milk. This podcast is brought to you by Prolacta Bioscience, a company dedicated to Advancing the Science of Human Milk®. I’m your host Registered Dietitian Keli Hawthorne. Today, we will be speaking with Kim Carmignani, a neonatal nurse and Unit Director with over 34 years of experience working in both urban-based level IV teaching hospitals and community hospitals. I’ve known Kim a few years and it’s always a pleasure to talk to her. Today, we will be talking about the impact of an Exclusive Human Milk Diet on bronchopulmonary dysplasia in preterm infants. Thanks for joining us today Kim.
Kim Carmignani (KC): It’s my pleasure to join you!
KH: First of all, can you talk a little about your experience using Prolacta donor human milk products?
KC: One of my hospitals began using Prolacta donor human milk products in 2015. We started with the standard Texas Children’s guidelines utilizing fortifiers for all babies less than 1250 grams, under 32 weeks, and if one multiple received Prolacta they all did. We followed the weaning guidelines as recommended.
As our experience using Prolacta fortifiers and donor milk proceeded, we began fortifying at 80 ml/kilo/day with Prolact+6 and Prolact+8 and began to incorporate Prolact CR, their cream human milk product for certain cases where the infant was on the lower end of the growth curve. The criteria hanged to only include infants that meet criteria as outlined for both gestational age and weight. We excluded the multiple if they were outside the guidelines.
KH: Let’s dig right into bronchopulmonary dysplasia, or BPD. So we’re all on the same page here, can you describe BPD for us and why it’s such a serious condition for infants.
KC: Bronchopulmonary dysplasia, or BPD, is also known as chronic lung disease of prematurity. It involves abnormal development of lung tissue, and most often occurs among premature babies who are born more than 10 weeks early and weighing less than 1000 grams. There are varying degrees of BPD. An infant with mild BPD is still on oxygen at 28 days of life but is off oxygen at 36 weeks postmenstrual age. Moderate BPD includes those infants that are on oxygen at 28 days and are still on oxygen at 36 weeks adjusted age but require less than 30% FiO2. Severe BPD is defined as the need for supplemental oxygen at 28 days of life and ≥30% oxygen, CPAP, or mechanical ventilation at 36 weeks postmenstrual age. It is associated with an increased risk of cerebral palsy in infants born extremely preterm (<28 weeks gestational age). It’s something that we are always concerned about in the NICU.
KH: And what causes BPD?
KC: Babies are not born with BPD, but rather develop it over time. Extremely premature babies are at a greater risk of developing BPD because they are born when the alveoli or air sacs in their lungs are still developing. Mechanical ventilation, although necessary for many extremely premature infants, can change the development of the alveoli. These babies may never develop as many alveoli as full-term infants and the walls of the alveoli that they do develop are often thicker and stiffer, making gas exchange less efficient. While extreme prematurity and mechanical ventilation are the most common causes, there are several other factors that can influence the development of BPD. Maternal infection can cause problems with lung development before delivery. Infections in the newborn period and oxygen administration lead to inflammatory responses that can affect postnatal lung development.
KH: How is BPD treated?
KC: Our primary focus should be on decreasing the risk of developing BPD. Ventilation strategies have changed in recent years to include more CPAP and non-invasive ventilation to decrease the damage caused by ventilator use. Administration of antenatal steroids has also been shown to decrease the risk of BPD. Treatment for BPD is focused on providing continued respiratory support until the baby is able to maintain adequate oxygenation on its own. Some babies with BPD require long-term support including home ventilators, oxygen, and/or medications such as bronchodilators, diuretics, and corticosteroids.
KH: And how does having BPD put a baby at higher risk for other problems?
KC: Having BPD puts babies at higher risk of multiple rehospitalizations for respiratory problems in the first few years of life and an increased risk of asthma in childhood. Infants with BPD may have greater airway obstruction on lung function testing in later childhood and an increased risk of developing chronic obstructive pulmonary disease (COPD) in adulthood. And studies show there is a correlation between BPD and development. Infants with BPD are at increased risk of poorer neurodevelopment and academic progress in childhood, and an increased risk of ADD.
KH: And how does nutrition affect the respiratory status and BPD?
KC: Appropriate nutrition is critical. Human breastmilk is so important to infants and the benefits are even more pronounced for the premature baby. As I said earlier, infection and inflammation can both contribute to the development of BPD. Breastmilk decreases the risk of infection and also has anti-inflammatory properties. Because of the special nutritional requirements of the preterm infant, fortification of breastmilk is necessary to meet those needs. Studies have shown that the risk of developing BPD is decreased in premature infants who are fed Prolacta’s human milk–based fortifiers as part of their Exclusive Human Milk Diet (EHMD) when compared to infants who receive cow milk–based fortifiers.1,2 Prolacta’s fortifiers added to breastmilk provides nutritional benefits that address the short-term needs for acutely ill premature infants.
KH: When I was at Texas Children’s Hospital, we looked at BPD rates, and the study I worked on with Dr. Amy Hair and Dr. Steve Abrams in Houston back in 2016 showed that babies who got an Exclusive Human Milk Diet had about a 9% reduction in the incidence of BPD when compared to babies receiving cow milk–based human milk fortifiers.1 It’s really just incredible to see a change in a respiratory disease based on the nutrition being provided, and of course as a registered dietitian, I was so happy to be part of that.
KC: Yes it really does remind you about the importance of nutrition and the impact good nutrition can have over the whole body of these tiny premature babies. In 2019, another study came out from the University of Virginia that also showed the use of donor human milk–based fortifiers as part of an Exclusive Human Milk Diet reduced rates of BPD by 16.5% in their NICU.2
KH: That’s really great considering what we’ve discussed regarding the acute and long-term risks associated with BPD.
KC: And I think you were also part of the study that looked at Prolacta’s human milk cream product in babies with BPD.
KH: Yes, in the cream study that we published in 2016, half the babies were randomized to receive the Prolacta cream product if their mother’s own milk or donor milk was <20 kcal/oz. We added enough cream to bring the caloric content up to 20 kcal/oz, then we added the Prolacta fortifier and fed the baby. The other half were randomized to our control group and didn’t receive any cream. Our analysis showed that there was a trend towards significance showing a shorter length of stay among babies with BPD who received cream vs those who didn’t. Again, all we changed was adding cream to make sure that they were actually getting the calories that we assume are in human milk, that 20 kcal/oz estimation. The BPD babies had about a 2.5 week shorter length of stay, which was really incredible.3
Resource allocation is a concern for hospitals. How has the use of an Exclusive Human Milk Diet shown to be beneficial for cost savings?
KC: During the first year of life, very low birth weight infants with a diagnosis of BPD have longer hospital stays and more rehospitalizations than very low birth weight infants without a diagnosis of BPD. This translates to about 54% increase in hospitalization costs for these babies.4 Dr. Assad’s 2015 study showed 9% lower BPD rates5 and a more recent study done at the University of Virginia NICU achieved a 16.5% decrease in BPD in preterm infants receiving Prolacta’s products as part of an Exclusive Human Milk Diet when compared to preterm infants receiving mom’s own milk with cow milk–based fortifiers.2 When used as part of an Exclusive Human Milk Diet, Prolacta’s products have been shown to improve outcomes for premature infants while simultaneously being cost-effective because of those better outcomes.
KH: Thanks so much for joining us today Kim. Before we go, do you have anything else you want to be sure our listeners know about BPD and donor human milk products for NICU babies?
KC: We continue to gain knowledge about the relationship between nutrition, the EHMD, and the comorbidities associated with prematurity. With the significant improvement in outcomes the studies are showing it becomes even more evident that an EHMD is the right way to provide nutrition for or VLBW babies.
KH: Well thank you so much Kim for joining us today! It was a pleasure talking with you. For our listeners, links to information discussed will be available in the show notes, and as always, we look forward to bringing you future topics on the science of human milk.