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