1/1/2018 Objectives What’s New In • Review of the following from 2017: Breastfeeding? • Policy statements from professional organizations • Expert opinion recommendations A 2017 Review • New concepts in breastfeeding medicine Anne Eglash MD, IBCLC, FABM Clinical Professor, Dept of Family and Community Medicine University of Wisconsin School of Medicine and Public Health CDC Guidelines: How to Keep Conflicts of interest your Breast Pump Kit Clean True or False? • Founder and President of The Milk Mob Breast pump parts should be sterilized once a day. True or False? If the pump tubing has milk in it, throw the tubing away and obtain new tubing. https://www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding/breastpump.html CDC Guidelines for Cleaning Pump Parts CDC Guidelines for Cleaning Pump Parts 1 1/1/2018 CDC Guidelines for Cleaning Pump Parts: Sanitizing: Esp for <3 mo infant • Boil for 5 minutes, remove with tong • Steam in a microwave bag or plug-in steam system • Dishwasher on sanitize cycle • Bleach – 1 tsp of bleach in 16 cups of water • Submerge completely and soak for 2 minutes – Do not rinse, to avoid re-contamination • Bleach will break down as it dries and is safe – Dry on a clean paper towel or unused dish towel AAP Banked Donor Milk For High Risk Infants AAP Banked Donor Milk For High Risk Infants • Mothers’ own milk is preferred True or False? • Banked Donor Human Milk(BDHM) ‘may be used’ for high risk infants when mothers’ milk is not available. • HMBANA processes are safe • The AAP policy recommends banked donor human milk • No reported cases of BDHM causing hepatitis or HIV, and risk is extremely small. (BDHM) for infants weighing less than 1500g, not based • BDHM should be pasteurized, and post-pasteurization testing should be on gestational age or illness. T or F performed. • Despite loss of bioactive factors with pasteurization, clinical outcomes support • The AAP statement indicates the importance of pooling the use of BDHM. donor milk ( more than 1 donor represented in a bottle of • Concerns regarding growth should not discourage use of BDHM. Fortification donor milk). T or F should be used. • Families should be discouraged from direct human milk sharing or purchasing • The use of BDHM has been shown to cause a decrease in human milk from the internet because of risks of infection, contamination, meds, mothers’ provision of her own breastmilk. T or F drugs, etc. AAP Banked Donor Milk For High Risk Infants Fish & DHA and the Infant Brain • Use of donor human milk should not be limited by an individual’s ability to pay. • Mothers should be encouraged and supported to provide their own milk. FDA Jan 2017 • There are no clear guidelines on when to stop using donor milk for an infant, such as gestational age. Koletzko, B. Clin Perinatology 44(2017) 85-93 • Little data exists on the benefits of donor milk for other populations such as gastroschisis or congenital heart disease. They acknowledge that they are probably populations that may benefit from BDHM. • Health care providers should advocate for insurance coverage for donor milk • Families of high risk infants should be informed about the current state of research regarding the benefits of human milk to decrease the risks of complications from NEC • Health care providers should advocate for policies regarding the risks and benefits of direct or informal milk sharing without pasteurization. 2 1/1/2018 Fish & DHA and the Developing Infant Brain True or False? • Breastfeeding meets the DHA needs of term infants, but not for preterm infants. Fetal exposure to fish increases the • For VLBW infants high DHA supplementation is associated risk of fish allergy, so DHA with: supplements are preferred over fish. – Enhanced visual and cognitive development T or F – Reduced severe developmental delay – Reduced bronchopulmonary dysplasia – Reduced NEC Premature infants exposed to high – Reduced environmental allergies such as hayfever amounts of DHA have improved visual function by the corrected age • Mothers with VLBW infants need to take DHA supplements. Studies show that 3 grams of tuna oil/day would suffice. of 4 months. T or F Fish & DHA and the Developing Infant Brain • Fish is an important source of protein for pregnant and nursing women, and for children. • Moderate fish consumption during pregnancy is associated with a child’s early verbal development and IQ. – If a pregnant mother eats 8-12 oz of fish a week, her child may gain 3.3 extra IQ points by age 9. – More than 12 oz of week not shown to be beneficial, and increases mercury exposure – Eating less than 3 oz a week is harmful to the fetus • Canned light tuna is the least expensive and safest way to consume the recommended amount of fish each week. True or False? • Diabetic infants or toddlers should be on a strict nursing schedule to control their diabetes. T or F • Pre and post feed weights are needed after each feeding at the breast to calculate carb http://www.bfmed.org/protocols intake. T or F 3 1/1/2018 Breastfeeding an Infant or Child European Society for Paediatric with Insulin-Dependent DM Gastroenterology, Hepatology & • Insulin dosing depends on carb intake Nutrition Committee (ESPGHN) – Quite variable in infants/young children Complementary Feeding Position Paper • 100 ml of breastmilk is considered 7 grams of (JPGN 2017;64: 119–132) carbs (mainly from lactose) • Pre/post feed weights are an option to carb ct. • Can determine volume of breastmilk made per day, 70 grams of carbs/Liter, and divide this volume by # of feeds each day • Infants/children who take small amounts of breastmilk frequently could just be treated with insulin based on a blood glucose every 3 hours • Insulin pump use for infants and young children will help to keep sugars balanced. Introduction of Complementary True or False? Foods (CF) Before 6 mo • No deficits on growth or neg effect on allergies if waiting until 6 mo • Introducing gluten during breastfeeding • Earlier return of menses, esp in low-income settings reduces an infant’s risk of celiac sprue. T or F • Risk of increased risk of GI infection in higher-income countries – Seems to be related to formula introduction, not solids • Increased risk of URIs (not LRIs) with CF before 6 mo • Overall evidence about proper timing of CF is lacking • Infants have a lower risk of allergy to nuts, – Different countries have adopted different recommendations based on the sparse data shellfish and eggs if these foods are • Sweden and Norway- ‘small tastes’ at 4-6 mo introduced closer to 12 months of age. T or F • Renal and gut maturation sufficient by 4 mo for solid foods • Neurologic ability to swallow pureeds safely develops at 4-6 mo • CF with iron at 4 mo may improve iron status • Mixed data on the risk of increased BMI with CF introduced at 4 mo vs 6 mo. • No evidence for negative neurocognitive outcomes with CF at 4 mo vs 6 mo. ESPHGN Recommendations Early Allergen Introduction • Countries that give peanuts as weaning foods have lower • Complementary foods should not be introduced before 4 peanut allergies mo and not delayed past 6 mo • Repeated exposure to allergens during a critical window during infancy seems important • Infants at high risk of peanut allergy (those with severe • Egg introduction at 4-6 mo reduces egg allergy (meta- eczema, egg allergy, or both) should have peanut analysis, moderate certainty, 1915 participants) introduced between 4 and 11 months, following evaluation • Peanut introduction at 4-11 mo reduces risk of allergy by an appropriately trained specialist. (meta-analysis, moderate certainty, 1550 participants) • Gluten may be introduced between 4 and 12 months, but – The younger the age, closer to 4-6 mo, the fewer the consumption of large quantities should be avoided during reactions to peanut pin-prick the first weeks after gluten introduction and later during • Early fish introduction reduces allergic sensitization and rhinitis infancy. • Conclusion overall is that there is no need to delay • All infants should receive iron-rich CF including meat allergenic foods past 4 months of age products and/or iron-fortified foods 4 1/1/2018 Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy (LEAP) CF Foods, Breastfeeding & NEJM 2015 372 p. 803 Celiac Disease Exp Rev Gastro & Hepatol March 2017 • In early 2000’s Jewish children in England had 10x risk of peanut allergy as compared to Israeli Jewish kids • Breastfeeding itself and breastfeeding at the time of – 1998-UK recommended no early antigens for infants at risk (none in CF, nor during preg/lactation) gluten introduction are not associated with celiac – Israel- peanuts were part of a normal CF at ~ 7 mo disease or type 1 DM • 640 infants 4-11 mo with severe eczema, egg allergy or – Some smaller studies still hint at a relationship both – Might be confounded by C sections, use of antibiotics, • Randomized, not blind, to no peanut for first 60 mo, vs stomach infections (effect on microbiome) 6gm of peanut protein a week • Introduce gluten at 4-11 months of age – + reactions to baseline challenge were eliminated – Avoid giving large volumes of gluten at one time (amount – Authors assumed early exposure was topical in dust, not specified) no discussion re bmilk • Microbiome of children with celiac disease has more • Primary outcome was peanut allergy at 60 mo, based on a 5gm peanut protein challenge bacteroides, less bifidobact, and less lactobacilli • 13.7% of the avoidance group and 1.9% of the intervention – Unclear if this is due to genetics, or causative