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Improving Neonatal Outcomeswith Human MilkRoger G. Faix, MDDivision of NeonatologyUniversity of UtahPrimary Childrens Intermountain Medical Center

10DISCLOSUREThe content of this presentation does not relate to any product in which I have a financial interest or potential conflict of interest.

Learning Objectives1- Learn why breast milk is the recommended form of enteral nutrition for all infants.

2- Learn how commercial formulas differ from human breast milk.

3-Appreciate longitudinal and other changes in content of human breast milk.GotBreastMilk?

GotMilk?

Breastfeeding and Use of Human MilkPolicy Statement. Pediatrics 2012;129:e827-841Breastfeeding and use of human milk confer unique nutritional and non-nutritional benefits to infant and mother and, in turn, optimize infant, child, and adult health as well as child growth and development.

Recently published evidence-based studies have confirmed and quantitated risks of not breastfeeding.

Infant feeding should not be considered as a lifestyle choice but rather as a basic health issue.Improving Outcomes with Human MilkLifestyle ChoicesHave a familyHave a careerHave a snowmobileBasic Health IssuesDeliver in a hospitalImmunize your babyUse a car seatInfant feeding (breast milk)

Improving Outcomes with Human Milk in the Nursery and NICUProvider ChoicesSwitch ventilatorsOrder a -natriuretic peptide assayBe nice to residentsBasic Health IssuesTreat respiratory failureTreat sepsisBe nice to staffInfant feeding (breast milk)

Meinzen-Derr J, et al. Role of human milk in extremely low birth weight infants risk of necrotizing enterocolitis or death.J Perinatology 2009;29:57-62o

Each 100 ml/kg increase in HM intake during the first 14 d was associated with decreased risk of NEC or death. (HR 0.87 (95% CI 0.77, 0.97)NEC (7.7%) or death > 14d, 173/1272(13.6%)Ronnestadt A, et al. Late-onset sepsis in a Norwegian national cohort of extremely premature infants receiving very early human milk feedings. Pediatrics 2005;115:e269o

RR of LOS if full feedings not established within a certain age (days)Survival free from LOS according to week when full feedings establishedFeedings started at 1-2 mL q2-3h within a few hours of delivery and advanced 0.5-1 mL q 6-8h80/405 LOS (23%)92% MM6% donorInfectious Diseases Influenced by Infant DietPediatrics 2012;129:e827-841

Infants - ChildrenDiseases and Conditions influenced by Infant Diet

Pediatrics 2012;129:e827-841Basic NutrientsProteinsFatsCarbohydrates

VitaminsMineralsWaterAll are present in milk of all species, but types and proportions vary by species, making each specific and apparently uniquely suited

Breast milk is more than good nutritionMilk ProteinSpecies Specific ContentProteinHuman MilkCows MilkQuantityLow3-4X HigherTypeWhey predominantCasein predominantDigestibilityCurds soft, easy to digestCurds rubbery, harder to digestBrain and Eye developmentTaurine presentTaurine absentBioactive proteinsPresentPresentCalves are mostly muscle and bone. They double their weightin 30 dLysozyme (g)218161Lactoferrin (g)330167IgA (g)3641421) Colostrum (Birth-4d) is high in protein, fat-soluble vitamins, minerals, and immunoglobulins. It is different becausenormal transition requires it.

2) Transitional milk (2d-2wks) includes high levels of fat, lactose, water-soluble vitamins, and contains more calories than colostrumComposition of Cow Milk formulasBased on nutrient content of human milk at 1-3 moProtein: nonfat bovine milk and whey concentrateFat: blend of vegetable oilsCarbohydrate: corn syrup solids and lactoseVitamin and mineral mix

Additional ingredients are manufacturer-based: iron (1959), taurine (1984), DHA (2000), leutein (2012)Content is regulated by the FDA and is based onthe AAP Committee on Nutrition recommendationsMilk ProteinProteinHuman MilkCows Milk FormulaQuantityLow3-4X HigherTypeWhey predominantCasein predominantDigestibilityCurds soft, easyMore intoleranceBioactive proteinsSpecies-specific differences associated with better outcomesDifferent in many ways

oHuman milk protein is not merely for nutrition. It displays medicinal qualities that initiate and modulate development resulting in profound effects on infant survival and healthMilk FatSpecies Specific Content DifferencesFatHuman MilkCows Milk FormulaContent during feedingLow HighConstantContent if feed frequentlyHighConstantDigestibilityLipoproteinBile Salt-stimulated lipaseNo LipasesEssential FA6-10 times HigherLowerARA, DHA (brain/eye)PresentRecent additivesBreastfeeding is associated with improvedchild cognitive development.MA Quigley et al. J Pediatrics 2012;160:25-32Preterm Lipid StudyPediatrics 2001;108:359 371Whether or not formulas designed for the premature infant should be supplemented with long-chain PUFA, including arachidonic acid and docosahexaenoic acid has become one of the most controversial issues in infant nutrition today . . .

. . . Several lines of logic suggest that premature infants fed formulas without AA and DHA may be at increased risk of slower development related to suboptimal blood and tissue levels of these fatty acids compared with the term infant.Milk CarbohydrateBreast Milk is not just LactoseOligosaccharides - nonnutritive, the third most common solute in human milk after lactose and fat. Cows-milk formulas contain very little.

Prebiotic agents that encourage the growth of beneficial (probiotic) organisms

Anti-infective in the intestinal, respiratory and urinary tracts. >130 identified pathogen-specific, binding (decoy) inhibitors

Functional components of brain gangliosides essential to nerve cell transmission, memory formation and cell-to-cell communication.

Miller JB. Invited Commentary: Human milk oligosaccharides: 130 reasons to breast-feed. British Journal of Nutrition 1999;82:333335Ballard O and Morrow A. Human Milk Composition. PCNA 2013;60(1)49-74

Milk Vitamins and Minerals Species Specific Content DifferencesAll vitamins and minerals in human milk have a higher bioavailability than in cow milk formula50-75% of Fe in BM is absorbed compared to 4% in formula

To compensate, more is added to formula:

Excess, unabsorbed minerals (especially iron) alter gut flora and facilitate growth of potentially harmful bacteriaHM (T)HM (PT)HM (PT) +HMF 1HM (PT) + HMF 2PF1 - 24PF2 - 24Fe (mg/L)0.3-0.91.214.5815.614.6114.6Vitamin and Mineral Supplementation Pediatrics 2012;129:e827-e841Vitamin K 0.5 to 1.0 mg IM after the first feeding at breast and before 6 hoursVitamin D 400 U/day PO at hospital dischargeNo Fluoride during the first 6 months and thereafter only if [fluoride] < 0.3 ppmIron orally before 6 months if low iron stores

Premature infants need multivitamins and iron until ingesting a mixed diet and growth is normalizedOptimal Source of NutrientsBreast milk content is essential for optimal developmentBasic nutrient and bioactive component content and proportions are species specific. Many differences exist.

Breast milk content can be (and is) altered by individual needs and circumstances. Formula content is fixed.

Formula is not milk. Many components are missing. Content is further altered by pasteurization.

What formula lacks or has in it can make a difference Term vs Preterm Milk ContentNutrient/LTermPretermCal/oz19.5-2120.1Protein, g914.09Fat, g39.0538.93Carb, g7966.4Calcium, mg200-250248Iron, mg0.3-0.91.21Sodium, mg120-250248Zinc, mg1-33.42VitaminsTermPretermVit A, IU22523899Vit D, IU2020Vit E, IU4.110.7Vit K, mcg2-32mOsm/L257255Composition of human milk varies with maternal diet, lactation stage, within feedings, diurnally, and among mothers. Pediatric Nutrition Handbook 2009Morton J, et al. Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants J Perinatol 2012;32:791-796o

Frequency of hand expression in first 3d

Group I < 2 times/dayGroup II 2-5 times/dayGroup III > 5 times/dayIncreased frequency of hand expression in first 3dincreases milk production.Formula contentNeofax 2011, 24th EditionNutrient/LTerm MilkPretermPF-1 20Cal/oz19.5-2120.120Protein, g914.0920Fat, g39.0538.9336.7Carb, g7966.469.7Calcium, mg200-2502481217Iron, mg0.3-0.91.2112.2Sodium, mg120-250248291Zinc, mg1-33.4210.1Because of poorer bioavailability, more is often neededVohr B, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics 2006;118(1)no BM< 20th20-4040-6060-80> 80thpBM (ml/kg) qd0172464111-BM @ discharge022456795124Mean MDI767477788087.004Mean PDI818183848489.003BRS percentile464552505259.028Rehosp < 1y302532262313.046No diff BW, GA, sex, IVH gr 3-4, PVL, NEC, sepsis, BPD, LOS, CP, blindness, hearing loss, weight and OFC @ 18 mo. Adj for mom age, edu, race, incomeFor every 10 ml/kg/d increase in BM, there was an increase in MDI (0.53 points), PDI (0.63 points), BRS (0.82 %ile), and a decreased likelihood of re-hospitalization (6%)Vohr B, et al. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics 2007;120(4)o

The principal effects of BM in children at 30months CA are on cognition and behavior.Cost to UseBreast milk (no cost)

Expressed ($15/mo pump)

Donor ($3.50/oz + freight)

Commercial ($30.00/oz)

PF1 ($1.18/oz)

Elemental 1 ($1.77/oz)

Elemental 2 ($2.48/oz)

HMF/packet ($1.08-1.50)

Cost to Not Use Breast MilkIf 90% of US families followed guidelines to BF exclusively for 6 mo, the US would annually save $13 billion from reduced medical and other costs. Bartick, M. Pediatrics 2010;125:e1048-e1056 (2007 dollars)

Health care costs for newborns are three times lower for babies whose mothers participate in the companys employee maternity and lactation program. www.surgeongeneral.gov/topics/breastfeeding/

CDCStartAny BF 6 moAny BF 12 moExclusive 3 moExclusive 6 moUS74%43%21%32%12%Utah90%60%26%43%17%Healthy People 201075%50%25%40%17%2012 AAP Policy90%( *p 20 kcal/oz

** Ziegler EE. Ann Nutr Metab 2011;58(suppl 1):8-18415 samples from 273 donors nationwideHuman milk protein, fat and energy content may be lowerEffect of breastfeeding vs formula feedingon childhood obesityArenz et al.,Int J Obes Relat Metab Disord 2004;28:1247-1256 j

The mechanisms for the association betweenbreastfeeding and obesity are unclearDe Onis M, et al. Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr 2010;92(5):1257-64o

Children age 0-5 years> 2SD weight for height median1990 1995 2000 2005 2010 2015 2020Standards for Normal Growth have Changedwww.cdc.gov/growthcharts/

All young children have the potential to grow similarly, regardless of their ethnic group or place of birth, if they are in a healthy environment and receive adequate nutrition.8000 InfantsCharacteristics and Potential Functionsof Human Milk AdiponectinProtein hormone produced by adipose tissue which enhances fatty acid metabolism and reduces inflammation

Low levels are associated with obesity, type 2 diabetes, dyslipidemia, and cardiovascular disease

Higher levels in human milk are associated with lower infant weight in the first 6 months of life in BF infants and may attenuate inflammatory processesNewburg DS et al. J Pediatr 2010;156:S41-6Adequate GrowthSummaryHistorically, preterm infants gain weight faster on formula than on human milk (breast or donor).

Because protein and energy content of human milk vary, more than standard fortification may be needed to achieve short-term growth standards.

However, faster early growth may be associated with higher rates of obesity. Growth norms (mostly formula-fed infants) are too high.

Despite slower growth, breastfed infants have better neurodevelopmental outcomes. Consider these Suggestions:What % of your NICU infants receive all BM to discharge?Make lactation support a part of parent interactionsEducate all mothers on the value of human milkExplain the need for breastfeeding mothers to pump and express milk early and often (8-12 times daily)Know they are doing it and doing it effectively

Strongly encourage exclusive human milk feedings (as you would treatment for presumed sepsis)

Providing up to 12 weeks unpaid leave only applies to companies with 50 or more employeesFewer than 11% of US working parents receive paid leave when a child is bornHuman Milk Banking Associationof North America www.hmbana.orgo

Milk Bank Donor RequirementsIn good health.

Non-smoker. No use of any Nicotine products.

Negative blood test for viruses (Prenatal results are NOT used).

Using no medications during the time milk is collected for donation, except for: vitamins and minerals; food supplements, progestin-only birth control, or replacement hormones: thyroid, insulin

Limited use of caffeine; and a waiting period is required after alcohol use before donating milk

Willing to donate a minimum of 150 ounces total during the time they are a donorHow is Donor Milk Processed?http://www.milkbankcolorado.org/Milk from 3-5 donor mothers is thawed, transferred to glass flasks, and mixed.o

How is Donor Milk Processed?http://www.milkbankcolorado.org/Milk samples are cultured during the pasteurization process then frozen at -4F and storedCulture-positive milk is discarded

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Milk is shipped frozen overnight to hospitals and individualsTypes of Donor Milk AvailableEarly Full Term: from first 7-10 days post partum - 2 oz bottles (when available)

Preterm: for infants under 1500 grams and/or less than 36 weeks gestation - 2 oz bottles (when available)

Full Term: (20 cal or higher) for infants at or over 36 weeks gestation - 4 oz bottles (Also used routinely for premies when preterm not available )

Non-fat: for chylothorax therapy (0.0 - 0.3% fat) - 2 oz bottles

Each Batch is also Analyzed for Macronutrient Content