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Making the Case for Using Donor Human Milk in Vulnerable Infants Taryn M

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Making the Case for Using Donor Human Milk in Vulnerable Infants Taryn M Beyond the Basics Ksenia Zukowsky, PhD, APRN, NNP-BC ❍ Section Editor 2.3 HOURS Continuing Education Making the Case for Using Donor Human Milk in Vulnerable Infants Taryn M. Edwards, MSN, CRNP, NNP-BC; Diane L. Spatz, PhD, RN-BC, FAAN ABSTRACT Vulnerable infants are at an increased risk for feeding intolerance due to immaturity or dysfunction (ie, congenital anomaly or obstruction) of the gastrointestinal system and/or hemodynamic instability. Symptoms of feeding intolerance include vomiting, water-loss stools, increased abdominal girth, and increased gastric residuals. It has been well documented that human milk provides optimal nutrition for infants and decreases the incidence of feeding intolerance. Donor human milk can be used for these at-risk infants to supplement the mother’s own milk supply if insufficient or if the mother has decided not to or is unable to provide human milk for her infant. Establishing a donor human milk program within your institution will allow an opportunity for all vulnerable infants to receive an exclusive human milk diet. Key Words: enteral nutrition, human milk, intensive care, milk banks, neonatal ne in 10 infants born in the United States is BENEFITS OF HUMAN MILK admitted to the neonatal intensive care unit O(NICU), and human milk offers these infants A brief overview of the immunological, nutritional, specific benefits that will improve their health out- and developmental factors of human milk is pro- comes.1 Human milk decreases the incidence and sever- vided. Immunological components of human milk, ity of nosocomial infections and necrotizing enterocolitis which are responsible for the prevention of infections (NEC) and improves visual acuity and neurocognitive as well as for the protection and maturation of the outcomes in at-risk infants.2,3 Because of these benefits, gastrointestinal tract, are α-lactalbumin, epidermal the American Academy of Pediatrics recommends exclu- growth factor (EGF), immunoglobulin A, lactoferrin, sive breastfeeding for the first 6 months of life and con- lysozymes, oligosaccharides, and urea.5 The nutri- tinued breastfeeding for a year or more with the intro- tional components, such as α-lactalbumin, casein, duction of solid foods.4 This article details the benefits of glucose, lactose, and sodium, provide optimal nutri- human milk, indications for donor human milk, the tion and energy for the infant.5 Developmental com- benefits of donor human milk compared with formula, ponents include docosohexaenoic acid, arachidonic the screening and processing of donor human milk, cost acid, EGF, and lactose. Both docosohexaenoic acid considerations, the use of human milk fortifier made and arachidonic acid enhance growth, brain, and from human milk, and the establishment of a donor visual development.5 human milk program within a hospital-based setting. Since human milk has been shown to enhance gas- tric motility, the infant is able to absorb the nutrients 5 Author Affiliations: Newborn/Infant Intensive Care more efficiently by increasing gastric emptying time. Unit, Children’s Hospital of Philadelphia (Ms Edwards), Other human milk properties stimulate gastrointesti- Pennsylvania; and Children's Hospital of Philadelphia nal growth and maturation, as well as provide protec- and University of Pennsylvania School of Nursing tion of the gastrointestinal mucosa. Secretory immu- (Dr Spatz), Philadelphia. noglobulin A has a very specific role in relation to the The authors have disclosed that they have no financial gastrointestinal system of vulnerable infants. It has relationships related to this article. been shown to protect against pathogens in the gas- Correspondence: Taryn M. Edwards, MSN, CRNP, trointestinal tract, thus decreasing the risk of feeding NNP-BC, Newborn/Infant Intensive Care Unit, Children’s intolerance.5 Epidermal growth factor and pancreatic Hospital of Philadelphia, Philadelphia, PA 19104 secretory trypsin inhibitor have been shown to repair ([email protected]). gastric mucosa after injury.5,6 Table 1 provides a sum- Copyright © 2012 by The National Association of mary of human milk components and their functions. Neonatal Nurses Vulnerable infants who require an NICU admis- DOI: 10.1097/ANC.0b013e31825eb094 sion are at an increased risk for feeding intolerance Advances in Neonatal Care • Vol. 12, No. 5 • pp. 273-278 273 Copyright © 2012 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited. AANC200293.inddNC200293.indd 273273 223/08/123/08/12 11:40:40 PPMM 274 Edwards and Spatz TABLE 1. Human Milk Properties Component Role α-Lactalbumin Protein Bactericidal Antitumor Epidermal growth factor Polypeptide Gastric repair after injury Stimulates DNA synthesis Antibacterial Fucosyloligosaccharides Carbohydrate Antidiarrheal Glycans Carbohydrate Stimulates colonization Alters mucosal immunity Protects against pathogens Haptocorrin Protein Inhibits Escherichia coli in gastrointestinal tract Lactoferrin Protein Binds with free iron Inhibits bacterial growth Lactoferricin B Peptide Broad antibacterial activity Lysozyme Enzyme Destroys bacterial cell walls Oligosaccharides Carbohydrate Antibacterial Prebiotic Pancreatic secretory trypsin inhibitor Peptide Protects gastric mucosa Gastric repair after injury Secretory immunoglobulin A Immunoglobulin Protects against pathogens in the gastrointestinal tract Superoxide dismutase Enzyme Antioxidant Triglycerides Fatty acid Inhibits viruses, bacteria, and protozoans due to prematurity, congenital anomalies, and/or develop NEC than those infants receiving human hemodynamic instability. Feeding intolerance can milk diets alone.7 present as abdominal distention, emesis and/or increased volume of gastric aspirates (bilious or non- INDICATIONS FOR DONOR bilious), bloody stools, loose or water-loss stool, HUMAN MILK metabolic acidosis, temperature instability, apnea, and/or blood glucose instability.7 A major cause of A mother’s own milk should always be the first morbidity and mortality in the NICU is NEC. Infants choice for vulnerable infants, with donor human receiving formula are 6.5 times more likely to milk being the second choice. A mother’s own milk www.advancesinneonatalcare.org Copyright © 2012 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited. AANC200293.inddNC200293.indd 274274 223/08/123/08/12 11:40:40 PPMM Donor Human Milk for Vulnerable Infants 275 has advantages over donor human milk, and donor DONOR HUMAN MILK PROCESS human milk has significant advantages over infant AND SAFETY formula. For mothers with infants admitted to an NICU, a Human milk banks collect, pasteurize, store, and mother must rely on a hospital-grade double electric distribute the human milk that has been donated. breast pump to initiate and maintain her milk sup- There are currently 12 donor human milk banks ply. Although there have been advances in breast across North America.18 The Human Milk Banking pump technology, pumping mothers may continue Association of North America (HMBANA) has to struggle with low milk supply.8,9 For those moth- strict guidelines to ensure that the donor human ers with low milk supply, donor human milk can be milk is both safe and maintains its nutritional com- used to supplement the mother’s own milk supply ponents. Because human milk is a path of viral trans- instead of formula to decrease the risk of feeding mission, every mother who wishes to donate her intolerance.10 human milk must be screened and meet the criteria In 2011, the Office of the Surgeon General report set forth by HMBANA.11,18 Following a comprehen- “The Surgeon General’s Call to Action to Support sive verbal and written screen, all donor mothers Breastfeeding” encourages the establishment of evi- undergo laboratory testing for HIV, hepatitis B and dence-based clinical guidelines for the use of banked C, syphilis, and human T-lymphotropic virus. The donor human milk.11 These guidelines will allow expense of this testing is covered by the milk bank. health care professionals to easily identify vulnera- Table 2 provides an overview of the human milk ble infants who would benefit from an exclusively donation process and the HMBANA guidelines. human milk–based diet by using donor human milk Although HMBANA requires that its members and a pasteurized donor human milk–based human adhere to these guidelines, they are not enforced by milk fortifier.11 the Food and Drug Administration. Donated human milk is mixed from various donors and placed in small jars for pasteurization. The milk is BENEFITS OF DONOR HUMAN MILK COMPARED WITH FORMULA TABLE 2. Human Milk Donation The use of donor human milk has been demon- Process and Guidelinesa 10 strated to decrease morbidity, nosocomial infec- The screening process begins with a short inter- 7,12-14 7,12-15 7,12-14 tions, NEC, urinary tract infections, view over the telephone. gastroesophageal reflux disease,15 diarrhea,7,12-14 and length of hospital stay.4,13 In a systematic review by Mothers wishing to donate must be currently lac- McGuire and Anthony14 that used 4 primary tating and have a surplus of human milk. research studies, the authors concluded that infants Donor mothers must be generally in good health, who received donor human milk were 4 times less be willing to have laboratory blood studies likely to have confirmed NEC than infants who done (at the milk bank’s expense), not regularly received formula. The systematic review of Boyd using medication or herbal supplements (con- et al16 examines
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