Neonatal nurse Amy Paradis discusses the strategies used in her NICU to prevent late-onset sepsis and the evidence regarding the use of an Exclusive Human Milk Diet on reducing the incidence of and evaluations for late-onset sepsis.
Amy Mailand Paradis, NNP, nurse practitioner and clinical nurse specialist (Modesto, Calif.), is an advanced practice neonatal nurse with 29 years of experience in a level III NICU with 15 as a neonatal nurse practitioner. She is a frequent lecturer and a researcher on topics related to neonatal care.
Hair AB, Peluso AM, Hawthorne KM, et al. Beyond necrotizing enterocolitis prevention: improving outcomes with an exclusive human milk-based diet [published correction appears in Breastfeed Med. 2017;12 (10 ):663]. Breastfeed Med. 2016;11(2):70-74. doi:10.1089/bfm.2015.0134
Delaney Manthe E, Perks PH, Swanson JR. Team-based implementation of an exclusive human milk diet. Adv Neonatal Care. 2019;19(6):460-467. doi:10.1097/ANC.0000000000000676
Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in extremely preterm infants fed a diet containing cow milk protein products. Breastfeed Med. 2014;9(6):281-285. doi:10.1089/bfm.2014.0024
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 Amy Paradis, a neonatal nurse practitioner and clinical nurse specialist with over 30 years of experience working in neonatal intensive care units (NICUs). Amy is at a level III NICU in central California and is a member of NPAC, Prolacta’s Nursing Practice Advisory Council. I’ve known Amy for many years and it’s a pleasure to speak with her as a trusted friend and neonatal ICU colleague.
Today, we’ll be talking about the role of an Exclusive Human Milk Diet (EHMD) in reducing sepsis in the NICU. Thanks for joining us today Amy.
AP: Thanks for having me on the podcast, Keli. It’s good to hear your voice.
KH: Yours too, Amy. How are you doing, in the midst of everything happening in 2020?
AP: Well 2020 has been interesting to say the least! Such a strange time for us all. I’m fortunate to say all of my family has remained Covid free. We practice all the necessary measures: distancing, hand washing and wear our masks. Shout out to all of those doing your part to keep our communities safe. As we will discuss, infection control practices are important, and they work!
KH: For our listeners who don’t know you as well as I do, tell us a little bit about how you got into neonatal care and your experience in the NICU.
AP: Sure thing, actually my very first nursing job was a student nurse in an NICU! How lucky can you get! I have taken care of NICU babies my entire nursing career. My current NICU hired me as a new grad way back in the 80’s. My practice has included working for Oakland, Los Angeles and Valley Children’s Hospitals, as well as Westchester County Medical Center and Natividad Medical Center. ECMO, transport, charge nurse and educator are just some of the hats of I have worn. Since 2005 I have been a neonatal nurse practitioner (NNP) and clinical nurse specialist (CNS) graduating from University California San Francisco. My home unit is a 35 bed level III community NICU in the Central Valley of California. I excited to chat with you today about one of my passions, sepsis and infection control.
KH: And moving into our topic for today, what do we know about sepsis and its effects on a baby?
AP: Sepsis is an infection in the blood. Most of the time it’s caused by different types of bacteria such as E coli, listeria, and some strains of streptococcus, but it can also be caused by fungi, parasites, or viruses. Sometimes a baby can get infected through the amniotic fluid if the mother has an infection, this is called early onset infection. Low birth weight babies and premature babies are at higher risk of sepsis because they have more immature immune systems that can’t fight off overwhelming infections. Symptoms can range from as mild as not feeding well and reduced body movements to fever, inability to regulate body temperature, diarrhea, and in very severe cases can include swelling throughout the body and possible organ failure. We monitor the babies in the NICU very closely to watch out for early and late onset sepsis and CLABSI.
KH: And for our listeners and so we’re all on the same page, what is CLABSI?
AP: CLABSI stands for Central Line-Associated Blood Stream Infection. That’s the terminology we use in the hospital to identify this type of infection.
KH: Well Amy, sepsis is a serious concern. How has your NICU addressed infection control and prevention of late onset sepsis?
AP: In 2008 our NICU had a high level of CLABSI, greater than 6/1000 line days which was an outlier for a community level III NICU based on the statewide data. We were invited to join a statewide collaborative to address best practices, emerging evidence on infection control and implementation of quality improvement projects. We developed the NICU FBI (Fight Bacterial Infection) with a goal of reaching 100 days without a CLABSI and decreasing our rate of infection by 50% within the year. We developed an infection control bundle, implemented many best practices including a robust hand hygiene change with alcohol-based hand gel, stringent hub care with chlorhexidine gluconate (CHG)-alcohol for all hub access and developed strict criteria for diagnosis and management of BSI. By the next year, we saw a dramatic drop in our infection rates for CLABSI and all BSI. After all of these efforts we have experienced only one CLABSI in 10 years.
KH: Wow, that’s a remarkable success story. And those are practical things that other NICUs can do. So, moving from those hands-on practices, let’s get into nutrition. Tell us about the role of the Exclusive Human Milk Diet in your NICU and its impact on your NICU’s rate of infection?
AP: We implemented the Exclusive Human Milk Diet in our NICU in 2016. We already had a low incidence of necrotizing enterocolitis (NEC), and had implemented a donor milk program in 2012, but we wanted to try to eliminate NEC and improve growth with an Exclusive Human Milk Diet. By 2017 we were beginning to develop a unit-based feeding protocol and successfully implemented the NICU Feeding Pathway by 2018, and have had extraordinary compliance with entire medical team.
We have found on the Exclusive Human Milk Diet, babies are quicker to full feeds, on average 11 days faster for the 1000-1500 g birth weight cohort. Since we have a low total number of babies born less than 1000 g, the variance in severity of illness makes it difficult to see a true average, but we have seen our central line days decrease in this population. We have also seen a dramatic decrease in feeding intolerance, or having to stop feeds or halt feeding advancement due to residuals, distension, emesis or bloody stools. With a shorter course to full feeds, we have been able to reduce our central line days and total parenteral nutrition (TPN) usage which directly impacts the rate of CLABSI. Fewer line days equals less opportunity for a CLABSI.
KH: Yes, that’s a key take home message. Quicker to full feeds with an Exclusive Human Milk Diet means fewer line days which means less opportunity for those infections. In the study that I did with Dr. Amy Hair at Texas Children’s Hospital along with 3 other large NICUs and almost 1600 babies, we found that the incidence of late-onset sepsis reduced significantly when the babies received an Exclusive Human Milk Diet.1 What other benefits have you seen using the Exclusive Human Milk Diet?
AP: Other benefits we have we seen include stable growth, averaging ~16 g/kg/day on the diet. We transition currently off Prolacta at 1500 g. We have also maintained stable head circumference and length growth. Our Prolacta babies look great at developmental follow-up. This is purely anecdotal as we have not collated growth data for our Prolacta babies post discharge. But this is a project I’m working on for 2021. Also, we stopped checking gastric residual routinely in late 2018, and have seen no evidence of increased NEC. We have had only four incidences of NEC in 4 years.
KH: Oh that’s so great to hear about your very low NEC rates, and exciting to hear about your upcoming project on post-discharge growth. You know I’m always interested in how well preemies are growing. And what about sepsis risks and improving outcomes using the Exclusive Human Milk Diet?
AP: An article recently published in Advances in Neonatal Care in 2019 by Delaney Manthe et al included infants that received an EHMD, and compared them to a control group of similar infants born prior to the availability of an EHMD in their NICU, that received cow milk-based fortifiers. One of the most notable findings, was a substantial reduction in late-onset sepsis evaluations with implementation of an EHMD2 when compared to the control group that received cow milk-based fortifiers from 68.3% to 55.8%. A sepsis evaluation is costly to the baby health-wise, including the pain of multiple venipunctures for blood cultures, intravenous (IV) attempts for antibiotic administration, and the healthcare costs including TPN, pausing feeds, vascular access, medications, x-rays and increased length of stay. Not to mention the risk of a poor outcome or even death.
Another notable paper was published by Abrams and colleagues in 2014 in Breastfeeding Medicine. Their aim was to evaluate the Exclusive Human Milk Diet on the health of extremely preterm (<1250 g birth weight) l babies in the NICU, they evaluated 260 babies from 2 studies and performed a meta-analysis. The significant finding was that for every 10% increase in the volume of milk containing cow milk-based protein (CM) , the risk of sepsis increased by 17.9%.3 Another way to think of this is that the more human milk in the diet, the more likely an extremely premature baby may stay free of late-onset infection.
KH: That’s a major difference. Almost a 20% increase in infection risk for every 10% increase in diet with CM . And that’s something that we can actually change in the NICU. So, what are some other key points to help NICUs improve their rate of infection?
AP: Oh Keli, I’m glad you asked that. Prolacta plans to share a technical bulletin on infection prevention and the Exclusive Human Milk Diet. So, stay tuned. One area that’s highlighted is to initiate early aggressive enteral nutrition with colostrum and human milk. This means prioritizing the use of fresh colostrum and mother’s own milk, beginning colostrum oral feedings early, and being aggressive with enteral nutrition and early trophic feedings. Another section highlights the hands-on practices such as using chlorhexidine gluconate for skin antisepsis, assessing central line dressings daily, judicious hub care, and analyzing every positive blood culture.
And finally, I can’t overstate the importance of antibiotic stewardship. It’s important to limit extended exposure to empiric broad spectrum antibiotics without confirmed laboratory evidence of infection. Neonatal antibiotic use may alter the neonatal microbiome and lead to gut dysbiosis which may lead to a higher risk for late onset infection, necrotizing enterocolitis and increased mortality.
KH: Thanks so much for your time today Amy. Sepsis has been an important topic that has a big impact on babies in our NICU, and I’m glad we could take this podcast time to cover it. Is there anything else you want to make sure our listeners know that I haven’t asked?
AP: Thanks Keli, I would like to acknowledge my friend, mentor and colleague Dr. Janet Pettit. Janet is no longer with us, but she has shaped my entire career and she is the reason I carry the torch in our NICU to prevent sepsis. She used to say, “more babies are celebrating more birthdays because of our efforts to protect them from infection, believe in ZERO”
KH: Thanks again Amy. We know the consequences of sepsis can be devastating, and an Exclusive Human Milk Diet appears to help babies reach full feeds faster with better feeding tolerance so that those IV lines can be removed, and the risks of infections removed along with them. And to 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.