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Promotion of Human Milk Feeding
in the NICU Setting
Kamtorn Vangvanichyakorn MD
[email protected] Clinical Director of Neonatology
Saint Barnabas Medical Center
BFHI Meeting 12-1-11 NJ
Breast Feeding Report Card
USA 2011
Department of Health & Human Services
Center for Disease Control & Prevention
Breast Feeding Report Card USA 2011
% of breast fed infants receiving formula
before 2 days of age
Rank % State
Top 1 8.0 Montana
Top 2 8.5 Vermont
Top 3 11.6 Wyoming
National Avg 24.5 USA
Bottom 49 32.5 Georgia
Bottom 50 33.2 New York
Bottom 51 38.0 New Jersey
Any Breast Milk @ Discharge
(VLBW Infants Discharged Home)
25
30
35
40
45
50
55
60
65
70
75
80
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
percen
tag
e
SBMC NJ USas of
10-10-11
The Enigma of Necrotizing Enterocolitis
(NEC)
• NEC is the most significant GI emergency affecting 5-
10% of very preterm (very low birth weight) infants.
• Its exact cause(s) is unknown, most likely
multifactorial (ischemia, infection, toxin…etc). Only
prematurity and enteral feeding have been
consistently identified as risk factors in case control
studies.
• Estimated additional cost of care:
1 case of surgical NEC $238,000
1 case of medical NEC $138,000
Necrotizing Enterocolitis
The Role of Human Milk in the Prevention
of NEC
There is increasing evidence that exclusive human milk feeding
reduces NEC and death.
Formula only vs. Human milk only (Lucas 1990)
Odds Ratio: confirmed cases = 6.5 (1.9 : 22) 6.5 x increase
Human milk > 50% vs. < 50% enteral feeding (SISK 2007)
Odds Ratio : NEC -= 0.17 (0.04; 0.68) 83% reduction
Mother’s milk vs. Preterm formula (Schanler 2005)
Odds Ratio : Sepsis / NEC 0.45 (0.24; 0.86) 55% reduction
Benefits of Human Milk for Preterm Infants
Human milk & Subsequent Intellectual Performance at 8y
8.3 IQ points increase (Lucas 1992)
For every 10 ml /Kg/d BM intake
MDI 0.5 points
PDI 0.6 points
Re-hospitalization rate 6%
For intake of 100 ml /Kg/d
MDI 5 points which translates into less need for
special education
VOHR Pediatr 2006; Hack NEJM 2002
1/1/09
Joined
NICQ
2009
Nutrition
Topic
Group
2/5/09
Review
current
practices
4/1/09
Implement
early
trophic
feeds
(VLBW)
6/25/11
Feeding
protocols
as guide
revised-
now placed
on all new
VLBW
charts
4/1/11
Provide
education to
NICU RNs re:
standardized
enteral feeding
protocols
2/1/11
Reduce
empiric
antibiotic
use in
ELBW
11/15/09
Provide
human milk
exclusively 1st 28 days
of life
(VLBW)
4/15/09
Provide
education
for NICU &
OB RNs-
value of
human milk
& pumping
process &
tips
8/30/11
Feeding
protocols
as guide
revised-
now
include
BW &
gestational
age
4/15/11
Use of
standardized
feeding
protocols as
guide for
enteral
feeding
advancement
2/15/11
Begin
trophic
feeds by
48hrs of
life
11/4/09
Implement
Banked
Human
Milk
1/1/11 Joined
NICQ 7 Continue
to work to reduce
NEC
Liquid Gold for NICU Babies
Education Provided to NICU &
OB RNs
Goals of education: 1) Increase percentage of VLBW infants that
continue to receive breast milk (≥ ½ of total feeding
amount daily) throughout their hospitalization to 75%
2) Increase percentage of VLBW infants that
breastfeed during hospitalization to 75%
3) Standardize education for new moms
Liquid Gold for NICU Babies
Our goal
Myths and Facts
Advantages for NICU babies
Initiating pumping
How to set up a double pump
Supporting pumping mothers
Pumping every 3 hours
Kangaroo care
Tips to improve Milk production
Benefits for RNs
NICU Parent Orientation Video
• The importance of breast milk,
pumping and availability of Banked
Human Milk is discussed repeatedly
throughout the video
• Available on SBMC website @
http://tinyurl.com/3gj2lm4 look @
chapter 5: Nutrition for your baby…
Donor’s Human Breast Milk
• Not all mothers can supply 100% of their Preterm infant’s needs in the first few days after birth.
• Human Donor’s Milk can be used to fill in the gap until mother’s milk flow is established.
• Meta-analysis of trials show Donor milk significantly reduced NEC compared to Formula.
Quigley Cockrane Syst Rev 2007
Joint Statement from WHO & UNICEF 2008
The best food for a baby who cannot
breast feed is milk expressed from
the mother’s breast or from another
healthy mother.
Process for Use of
Banked Human Milk (BHM)
• Neonatologist discusses use of BHM with
parents prior to or in 1st few days of life-
prevent need for formula if insufficient
supply
• BHM fact sheet given to parents
• Obtain assent for BHM use
• Order BHM with initial feedings
Prior to Delivery: counseling by neonatologist
on benefits of providing
breast milk
Day of life 1: swab oropharyngeal (bucchal)
with colostrum
Day of life 2 -3: trophic feeding with exclusive
mothers own milk, if not
available or insufficient use
Day of life 28 Donor Milk
Feeding Protocol in ELBW &
VLBW Infants
Promotion of Human Milk Feeding
• Create breast milk feeding culture
• Education, education and education
• Implementation of Banked Human Milk
supplementation
• Strict feeding protocol for ELBW > VLBW
infants
Exclusive Use of Human Milk 1st 28days of life
0
10
20
30
40
50
60
70
80
90
100
before
BHM
Dec
-09
Jan-
10
Feb-1
0
Mar
-10
Apr-
10
May
-10
Jun-1
0
Jul-1
0
Aug-
10
Sep-1
0
Oct
-10
Nov-
10
Dec
-10
Jan-
11
Feb-1
1
Mar
-11
Apr-
11
May
-11
Jun-1
1
Jul-1
1
Aug-
11
Sep-1
1
pe
rce
nta
ge
%tage VLBW Received exclusive Human Milk (MOM&/orBHM) 1st 28 days of life
Received exclusive MOM 1st 28days of life
%tage VLBW Received Human Milk for >50% of feeding volume/day during 1st 28
days of life
SBMC NEC Cases
0
2
4
6
8
10
12
14
16
2007 2008 2009 2010
nu
mb
er
of
cases
Medical NEC Surgical NEC Total cases
Extremely LBW Infants Long-Term Follow-Up
Severe Disability Rate at 24 Months of Age
SBMC vs. VON (2002 – 2006)
SBMC VON
Period ‘02 – 06’ ’01 – 05’
n. Evaluated 253 5012
Follow-up rate 69% 48%
Bilaterally Blind 0% 1.0%
Hearing Amplification 0% 2.0%
Cerebral Palsy 4.0% 8.0%
MDI < 70 6.0% 18.0%
Any Severe Disability 9.0% 31.0%
Extremely Low Birth Weight = Birth Weight less than 1000g Gestational Age < 28 Weeks
VON = Vermont Oxford Network (An international network of 750 NICUs)
If 90% of US families could breastfeed
exclusively for 6 months, USA would save
$13 billion per year and prevent an excess
911 deaths & SIDS, NEC, Pneumonia…etc.
The Burden of Suboptimal
Breastfeeding in USA
A Pediatric Cost Analysis
M Bartick MD, Harvard Med School
Pediatrics, online April 5, 2010
For additional information contact:
Eileen Steffen RNC
NICU Quality & Research Coordinator @