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 gastric 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

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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

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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 the effects of donor human milk and tact a milk bank for more information), and be formula in preterm infants.16 This systematic review willing to donate at least 100 oz of milk (some included 16 articles from 7 studies including 5 ran- banks have a higher minimum). domized control trials. The combined evidence in A woman cannot donate if she has a positive this meta-analysis suggests that donor human milk blood test result for HIV, human T-lymphotropic reduces the risk of NEC by 79% (95% confidence virus, hepatitis B or C, or syphilis; she or her 16 interval). In settings where NEC rates range from sexual partner is at risk for HIV infection; she 5% to 20%, 18.5 preterm infants would need to be uses illegal drugs; she smokes or uses tobacco fed donor human milk instead of formula to prevent products; she has received an organ or tissue 16 1 case of NEC. transplant or a blood transfusion in the last 12 For infants with gastrointestinal-related diagno- mo; she regularly has more than 2 oz or more ses (ie, congenital anomalies, NEC, and short gut of alcohol per day; she has been in the United / syndrome), the use of human milk and or donor Kingdom for more than 3 mo or in Europe for human milk should always be the first choice for more than 5 y since 1980; she was born in or nutrition due to the protective effects of human milk has traveled to Cameroon, Central Africa 5,12 and decreased risk of feeding intolerance. Donor Republic, Chad, Congo, Equatorial Guinea, human milk should be used to supplement the Gabon, Niger, or Nigeria. mother’s own milk supply instead of supplementing aData from the Human Milk Banking Association with formula or if the mother did not initiate pump- of North America. ing for her child.17

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then treated by Holder pasteurization to eliminate viral calories, calcium, and medium-chain fatty acids for and bacterial pathogens.19 Heat treatment does destroy growth and development. lipases, B lymphocytes, and T lymphocytes; however, In the last fiscal year at the Children’s Hospital of the majority of the beneficial components remain Philadelphia (CHOP), $155,693.71 was spent on intact, including immunoglobulins and long-chain donor human milk. This cost reflects usage for an aver- fatty acids.10,20 After pasteurization, each jar of donor age of 9 to 11 patients per day and a range of 59 to 135 human milk is cultured for bacterial growth. If bacteria oz per day distributed. Considering the cost on a per- are identified within that batch, it will be discarded.19 day or per-patient average, this equals to approximately Human milk banks can process both preterm $426 per day or $47 per patient. Comparing the cost of human milk and term human milk; therefore, a wide donor human milk with the average cost of total paren- variety of vulnerable infants in the NICU can benefit. teral nutrition (TPN) at CHOP is astonishing. Preterm human milk varies from term human milk On average, approximately $1436.46 is spent daily and has been shown to have an increased amount of per patient receiving TPN. The range of cost varies on calories, immunoglobulins, nitrogen, protein, lipids, the volume of TPN needed, from $1044.02 for a medium-chain fatty acids, some vitamins, and trace 250-mL bag to $1990.19 for a 3000-mL bag. On any elements.21 Also, increased levels of epidermal growth given day in the CHOP NICU, approximately 35 factor and enzymes have been identified, which, as patients could receive TPN. On the basis of the aver- previously stated, facilitate gastrointestinal matura- age cost of TPN and the average number of patients, tion.10,22 The calcium level in the human milk of approximately $50,276.10 is spent per day. Therefore, mothers of premature infants increases for the first 3 approximately $18.4 million is spent per year on months.21 Sodium content is elevated in the beginning TPN. Research demonstrates that advancing feeds of milk production but decreases after 2 months.21 with human milk results in better feed tolerance; Potassium, phosphorus, and iron levels are also noted therefore, if more vulnerable infants received exclu- to be increased in preterm human milk.21 Therefore, sive human milk feeds (mother’s own milk or donor it has been hypothesized that separating preterm and human milk), the amount of overall TPN need would term human milk will provide preterm infants with be significantly reduced. improved nutrition, growth, and development.22 If The per year donor human milk cost at our institu- extra fortification is needed to meet the nutritional tion is a fraction of the cost of TPN, thus making needs of the infant, the process is completed within economic sense to invest in the purchase of donor the hospital setting and not at the milk bank facility. human milk for our infants. According to W ight,10 Donor human milk demonstrates clear nutritional, there is a possibility of an increased length of stay for immunological, and developmental benefits. any infant with feeding intolerance and the use of for- However, the use of donor human milk is currently mula, and this is estimated to incur extra costs of not routine in NICUs across the United States, and approximately $9669 per infant. Considering the cost the cost of donor human milk may be considered to of donor human milk, approximately $8800 could be be a barrier. We present cost data that demonstrate saved per infant.14 Reimbursement for the cost of that implementation and utilization of donor human donor human milk is unclear at this time. Hospitals milk are indeed cost-appropriate measures. are reimbursed for care of infants based on diagnosis (International Classification of Diseases, Ninth COST OF DONOR HUMAN MILK AND Revision, code) and not for the cost of individual ITS IMPLICATIONS treatment interventions such as donor human milk. Necrotizing enterocolitis is an extremely expen- Hospitals or individuals purchase donor human sive disease, with a minimum of an additional 14 milk directly from the human milk banks. It is days needed for treatment and an additional $46,200 important to note that the cost of donor milk comes added to the total hospital cost, based on an approx- from the extensive testing and processing that imate charge of $3300 per NICU day.14 On the basis occurs. Currently, the price range is from $3.00/oz of these figures, it is apparent that the savings in to $5.00/oz, with an average price of $4.50/oz hospital costs for each state would be in the millions. (Human Milk Banking Association of North Approximately $74,004 per infant is used to treat America, personal communication, November 3, medical NEC, and approximately $198,040 per 2011). Some milk banks charge more for preterm infant is used to treat surgical NEC, based on the milk, with a range of $4.00/oz to $6.50/oz, average 2011 adjusted incremental cost.23 price of $5.00/oz (Human Milk Banking Association of North America, personal communication, ACHIEVING AN EXCLUSIVE HUMAN November 3, 2011). Although preterm milk is avail- MILK DIET (PROLACT+H2MF) able, it is usually in short supply. Because of supply concerns, preterm milk is predominantly used for Most NICUs use traditional human milk fortifiers severely premature infants who would require extra that are made from bovine milk. Clinicians have

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long been concerned that these fortifiers may pose should be identified to serve as human milk and the same risk of feeding intolerance and NEC as for- breastfeeding champions. An effective way to do this mula diet. Recent research suggests using pasteur- is to establish a unit-based or hospital-wide breast- ized donor human milk–based human milk fortifier feeding committee. The committee can be responsible (ie, Prolact+H2MF) instead of bovine milk–based for education of staff members and implementation of human milk fortifier (ie, Similac or Enfamil Human practice change initiatives. At CHOP, the unit-based Milk Fortifier) to decrease the incidence of feeding breastfeeding committee was responsible for all edu- intolerance and NEC. The price of Prolact+H2MF is cation surrounding the implementation of the donor approximately $6.25/mL, and, in many cases, insur- human milk program and then, in turn, for education ance will cover the cost.23 If the insurance company of families. A donor human milk policy was developed is unwilling to cover the cost of Prolact+H2MF, and reviewed by the hospital-wide breastfeeding com- many hospitals are willing to absorb the cost due to mittee. There is comprehensive intranet site available the cost savings when NEC is prevented.24 In a study, for all CHOP employees that explains the complete an exclusively human milk–based diet decreased human milk donation process and donor human milk medically treated NEC by 50% and surgically policy, which includes a Patient-Family Education treated NEC by 90%.25 To prevent 1 case of medi- sheet. This sheet reviews the importance of donor cally treated NEC, 10 infants would have to receive human milk, the role of HMBANA, the quality and an exclusive human milk diet.25 To prevent 1 case of safety of donor human milk, and the HMBANA surgically treated NEC, 8 infants would have to donor screening criteria. This sheet provides valuable receive an exclusive human milk diet.25 The use of information to families and acts as a tool to facilitate exclusive human milk diet would decrease NEC and questions and informed consent. save an estimated $138,000 to 238,000 per case.25 A key concept that must be emphasized is that mother’s own milk is always preferred once enteral ESTABLISHING A DONOR HUMAN feeds are initiated. If the mother has a delay in the onset MILK PROGRAM of milk production and/or a low milk supply or if the mother never initiated pumping, donor human milk With the clear health benefits and potential cost sav- should be the next option as opposed to formula. Table ings, all NICUs should implement donor human 3 provides recommended steps to assist facilities in milk programs. The first step in this process is to establishing the use of donor human milk in their units. establish a hospital culture that values human milk To document potential need for human milk in and breastfeeding. Although 75% of women in the your institution, determine the pumping initiation United States now initiate breastfeeding, exclusivity and continuation rate in your unit. Being ab le to and duration rates remain alarmingly low, with less than 15% of infants receiving exclusive human milk for the first 6 months.26 Healthcare providers are a TABLE 3. Establishing a Donor Human key barrier to improving the use of human milk and Milk Program breastfeeding in the United States. The “Surgeon Establish a hospital culture that values human General’s Call to Action to Support Breastfeeding” milk and breastfeeding. addresses key action items (#9 and #10) that call for the need for healthcare professionals to receive evi- Establish a unit-based or hospital-wide breast- dence-based breastfeeding education.17 feeding committee for the education of staff Nurses should be the leaders of changing institu- members and implementation of practice tional culture surrounding breastfeeding and the use change initiatives. of human milk. In 2000, CHOP did not embrace Determine the pumping initiation and continua- human milk and breastfeeding; therefore, a compre- tion rate in your unit. hensive model for changing institutional culture was Contact HMBANA and establish a working rela- developed.27 Through the use of nurses and hospital- tionship with a milk bank of your choice. wide education and training, a culture was created Identify a person responsible in ordering and that valued human milk, which allowed for imple- maintaining inventory of the donor human milk. mentation of a donor milk program since 2006.27 Breastfeeding resource nurses (BRNs) are the key Identify a storage space for the donor human milk. change agents for implementation of human milk and Establish a process for thawing the milk, with the breastfeeding initiatives. An ethnographic research availability of a hood for preparation. study conducted in our unit at CHOP demonstrated Establish a process for distribution of the donor that BRNs are the key components in supporting the human milk to the patient. pumping/breastfeeding mother in the NICU.28 The BRNs at CHOP serve as resources throughout Abbreviation: HMBANA, Human Milk Banking Association of North America. the whole organization. At your institution, nurses

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document the human milk rate in your unit is essen- program are real; however, when one considers the tial to determine the average number of infants given negative health and cost consequences of infant for- infant formula. This will dete rmine the amount of mula, donor human milk should be an option in every donor human milk needed, which should only be a NICU across the nation. small proportion of the total human milk usage in your unit, provided that you have created a culture References 1. March of Dimes Foundation. Premature birth. http://www that supports human milk and breastfeeding. .marchofdimes.com/prematurity/21292_29510.asp. Published 2007. Once donor human milk needs are determined, con- Accessed September 12, 2011. tact HMBANA and establish a working relationship 2. Anderson JW, Johnstone BM, Remley DT. Breastfeeding and cogni- tive development: a meta-analysis. Am J Clin Nutr. 1999;70:525-535. with a human milk bank of your choice. In our pro- 3. Rodriguez NA, Miracle DJ, Meier PP. Sharing the science on human gram, we established our relationship with the milk milk feedings with mothers of very low birth weight infants. J Obstet Gynecol Neonatal Nurs. 2005;34(1):109-119. bank in closest geographic region to us; however, this is 4. American Academy of Pediatrics and Workgroup on Breastfeeding. not essential. A fantastic way to initiate the relationship Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506. 5. Hale TW, Hartmann P. Textbook of Human Lactation. Amarillo, TX: is to educate mothers about the ability to donate to the Hale; 2007. milk bank if they have excess human milk or in the 6. Marchbank T, Weaver G, Nilsen-Hamilton M, Playford RJ. Pancreatic event of infant demise.19 If you establish a working rela- secretory trypsin inhibitor is a major motogenic and protective factor in human breast milk. Am J Physiol Gastrointest Liver Physiol. tionship in advance, it will make the process of ordering 2009;296:697-703. donor human milk for your institution seamless. 7. Heiman H, Schanler RJ. Benefits of maternal and donor human milk for premature infants. Early Hum Dev. 2006;82(12):781-787. A point person must be determined to be respon- 8. Mitoulas LR, Tat Lai C, Gurrin LC, Larsson M, Hartmann PE. Efficacy sible for ordering and maintaining inventory of the of breast milk expression using an electric breast pump. J Hum Lact. 2002;18(4):344-352. donor human milk. Accurate records of intake and 9. Mitoulas LR, Tat Lai C, Gurrin LC, Larsson M, Hartmann PE. Effect of distribution are essential for success. This will ensure vacuum profile on breast milk expression using an electric breast pump. J Hum Lact. 2002;18(4):353-360. that donor human milk is available at all times. A 10. Wight NE. Donor human milk for preterm infants. J Perinatol. storage place must be identified for the donor human 2001;21:249-254. milk, including designated freezer space and a hood 11. Office of the Surgeon General, Centers for Disease Control and Prevention, Office on Women’s Health. The Surgeon General’s Call to for milk preparation. In our institution, the donor Action to Support Breastfeeding. Rockville, MD: Centers for Disease milk program operates under the nutrition depart- Control and Prevention; 2011. 12. Schanler RJ, Lau C, Hurst NM, Smith EO. Randomized trial of donor ment and our donor human milk is prepared and human milk versus preterm formula as substitutes for mothers’ own delivered by trained technicians. milk in the feeding of extremely premature infants. Pediatrics. 2005;116(2):400-406. Physicians, advanced practice nurses, and nurses 13. Schanler RJ. Mother’s own milk, donor human milk, and preterm for- all have the opportunity to introduce the topic of mulas in the feeding of extremely premature infants. J Pediatr donor human milk with families. In our institution, Gastroenterol Nutr. 2007;45:S175-S177. 14. McGuire W, Anthony MY. Donor human milk versus formula for pre- we elected to have families sign informed consent for venting necrotizing enterocolitis in preterm infants: systematic the use of donor human milk. Once the consent is review. Arch Dis Child Fetal Neonatal Ed. 2003;88:F11-F14. 15. Arnold LDW. The cost-effectiveness of using banked donor milk in the obtained, an order can be placed by the frontline clini- neonatal intensive care unit: prevention of necrotizing enterocolitis. J cian. The order is electronically sent to the formula Hum Lact. 2002;18(2):172-177. 16. Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant room, and the trained technicians thaw the milk and formula for preterm infants: systematic review and meta-analysis. individually dose it for each patient order. Donor milk Arch Dis Child Fetal Neonatal Ed. 2007;92:F169-F175. 17. Tully MR. Recipient prioritization and use of human milk in the hospi- is labeled with the patient’s name, medical record tal setting. J Hum Lact. 2002;18(4):393-396. number, the type of donor breast milk (term or pre- 18. Human Milk Banking Association of North America. Donate milk. term), any additives (fortification), and how many http://www.hmbana.org. Accessed September 12, 2011. 19. Woo K, Spatz D. Human milk donation: what do you know about it? calories it contains. This label is double-checked to MCN Am J Matern Child Nurs. 2007;32(3):150-155. ensure that it matches the order. There is constant 20. Tully DB, Jones F, Tully MR. Donor milk: what’s in it and what’s not. J Hum Lact. 2001;17(2):152-155. communication between the nursing staff and the 21. Bauer J, Gerss J. Longitudinal analysis of macronutrients and miner- technicians to ensure delivery of donor human milk als in human milk produced by mothers of preterm infants. Clin Nutr. 2011;30:215-220. on a timely basis, as well as measures to prevent wast- 22. Leaf A, Winterson R. Breast-milk banking: evidence of benefit. age (eg, if the infant is fed nothing by mouth). Pediatr Child Health. 2009;19(9):395-399. 23. Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in CONCLUSION feeding extremely premature infants. Breastfeed Med. 2011;6(0):1-9. 24. Prolacta Biosciences. Knowledge Center. http: //www.prolacta.com/ knowledgecenter.php. Published 2011. Accessed September 20, 2011. The literature is clear that human milk (including 25. Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk- donor human milk) should be the first choice of enteral based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr. nutrition for all infants in the NICU. As nurses and 2010;156(4):562-567.e1. advanced practice nurses, our job is to ensure the best 26. Center for Disease Control and Prevention. Breastfeeding Report Card 2011. http://www.cdc.gov/breastfeeding/data/reportcard2.htm. evidence-based practice for the critically ill infants for Published 2011. Accessed November 3, 2011. whom we care. Donor human milk should be used as 27. Spatz DL, Sternberg A. Advocacy for breastfeeding: making a differ- ence one community at a time. J Hum Lact. 2005;21(2):186-190. a supplement to mother’s own milk or in place of infant 28. Cricco-Lizza R. Formative infant feeding experiences and education formula in the NICU. The cost expenditures for such a of NICU nurses. MCN Am J Matern Child Nurs. 2009;34(4):236-242.

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