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Evidence & Best Practice for the Use of
Human Milk in Premature Babies
Elizabeth Jones MPhil, RN, RM
University Hospital of North
Staffordshire
Aims
• To take you on a neonatal journey
• Discuss differences: preterm / term mammary physiology
• Explore basic milk expression problems
• Provide guidelines for implementing best practice
Promotion
• Swallowing amniotic fluid in the 3rd trimester promotes maturation of gastrointestinal tract
• Preterm colostrum is similar to amniotic fluid (growth factors & cytokines)
• Perfect transition to extrauterine nutrition
• Mothers own expressed milk reduces the risk of short-and longer term morbidities
Potential Benefits to the Neonate
• Highly bioavailable
• Immunological protection
• Developmental outcome
• Promotes attachment behaviours
Challenges & Obstacles
• Expressing takes time & dedication
• Skilled support essential
• Mammary growth may be incomplete
• Poor rates despite intention
Obstacles & Requirements
• Not included in curricula
• Knowledge and skills requirement
• Time and commitment needed from mothers and neonatal staff
Mediators of Maternal Behaviour
Oxytocin / Prolactin
Endorphins
• Intense bond• Protective• Sedative• Cortisol (Uvnas-Moberg et al)
Six UK Audits
• Poor information & advice
• Lack of specialist lactation support
• Parents advised to change to bottle feeding in order to expedite discharge (BLISS Breastfeeding Survey 2008)
BLISS helpline
• Most common enquires around preterm milk expression
• Preterm breastfeeding• Where to source support, advice
and equipment
Advocacy
The provision of breast milk is a medical treatment – not a social choice
Feeding options (from pumping only to establishing breastfeeding)
Principles of term lactation support may not apply
Truncated mammary development
• Different milk composition
• May not be hormonally driven
• Markers for secretory activation (lactose / citrate / sodium / total protein)
Cregan et al. 2002
• Compromised lactation (82%) Cregan et al. 2002
• IUGR / Betamethasone
Common experience
• Poor milk supply• Dwindling volume• Involution• Inverse relationship between
gestational age & secretory activation
Don’t delay until an infant is stable
• Will need expert support & encouragement through out the journey
• Avoid doing too little – too late• It may be difficult initially &
there may be a delay in establishing a supply
• Compensatory growth can be achieved
In the beginning
• Don’t set up to fail• Start with hand expression• Express early & often (*don’t
drop night expression)• The more preterm the more
aggressive the regime• DETERMINING FACTOR IS
VOLUME AT 2 WKS
Sequence of breast milk use
• Feed colostrum in order of expression
• When on full enteral feeds use fresh milk
• Freeze unused colostrum for later use if required
© Peter Hartmann / Donna Ramsay
Increase in fat in milk samples collected every 60 seconds during a 15 minute breast expressing using an electric pump
Optimising nutritional intake
• Use hind milk policy• Use EBM from shorter interval
expression first• Ensure milk warmed to body
temperature to avoid fat loss• Check protein prior to
fortification
Impact of freezing on breastmilk
• Reduces the effect of SIgA• Disrupts fat globules and
destroys lipase• Destroys cellular activity• Reduces B6 and C
Fresh mothers milk always best!
Setting the stage
• Medical & nursing staff should actively advocate breastmilk
• Postpartum / NICU should support in consistent and cohesive manner
• Every mother should be provided with an appropriate pump and given the support to use it effectively
Setting the stage (cont)
• Specific lactation assistance should be available
• All involved in care should advocate establishing breastfeeding
• All involved in care should have the knowledge, skills and attitudes necessary to successfully support mothers.
Drivers for change
• Bliss Baby Charter standards – support from appropriately trained staff
• Poppy Project – family centred care
• New BFI neonatal standards
Drivers
Toolkit for high quality neonatal services:
• Audit against WHO / BFI standards• Annual increase in women
initiating breastfeeding• % reporting good advise, help and
support
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