This issue of Advances in Neonatal Care is part 1 in a 2-part series on Human Milk Science. The use of human milk, which includes both mother's own milk (MOM) and donor human milk (DHM), is considered standard-of-care and this series spotlights the use of human milk to support high-risk infants. The aim of this series does not focus on “breastfeeding” at-risk infants, but explores the science of human milk including ways to enhance the use of human milk to optimize infant outcomes, evidence-based caregiving practices surrounding the use of human milk, and information neonatal nurses and other providers need to make the best decisions surrounding the use of human milk.
Consuming MOM decreases prematurity-specific complications including necrotizing enterocolitis, late-onset sepsis, retinopathy of prematurity, bronchopulmonary dysplasia, and neurodevelopmental delays.1–7 However these health benefits are not limited to preterm very low-birth weight (VLBW) infants. Breastfeeding and consumption of MOM also reduce complications and improve the health of all infants including those born at higher gestational ages and those with congenital defects. While far less superior to MOM, DHM also improves the health of preterm infants and, in 2012, the American Academy of Pediatrics published recommendations that all premature infants weighing less than 1500 g be fed MOM and, if unavailable, should be fed DHM.8 In order to support these recommendations, it is necessary for neonatal nurses to be knowledgeable regarding the science surrounding human milk.
Although DHM is recommended for use when MOM is unavailable, it is far inferior to the individual infant's MOM.9,10 Pasteurization reduces and/or eliminates many of the protective elements found in MOM including immunoglobulins, cytokines, growth factors, and beneficial bacteria.11,12 In addition, growth of infants fed DHM may be diminished due to decreased protein content and less fat absorption from inactivation of bile salt-stimulating lipase by pasteurization.11,13–16 Therefore, optimizing the amount of MOM fed to infants is essential.
Unfortunately, formalized lactation support from internationally board-certified lactation consultants and other designated lactation personnel is often limited in the neonatal intensive care unit (NICU) where mothers often need round-the-clock lactation support. Neonatal nurses are therefore often called upon to provide lactation support and education to mothers. In order to provide mothers with the best possible care, it is necessary for neonatal nurses to understand barriers mothers face when providing MOM to their infant in the NICU. Using in-depth semi-structured interviews, Fernández Medina and colleagues describe the experiences of mothers of extremely preterm infants regarding barriers to providing MOM to their infants.
Because mothers of infants in the NICU often struggle with an insufficient MOM supply, nurses must often provide lactation support focused on increasing MOM production. Being aware of women at risk for lactation difficulties allows neonatal nurses the opportunity to provide anticipatory guidance to mothers who will likely require significant lactation support. Obesity is now a national epidemic and is a known risk factor for compromised lactation success including initiation of expression/breastfeeding, MOM production, and sustained lactation.17 Robinson and colleagues provide a summary of the state of the science regarding not only implications of maternal overweight and obesity on successful lactation but also how these conditions may change the actual composition of MOM.
While not universal, many NICUs require informed consent before providing DHM to infants. Unfortunately, because it is often bundled with standardized NICU treatment consents and obtained either before or soon after delivery, maternal retention and comprehension may be limited. Furthermore, findings of decreased MOM consumption when DHM is available suggest informed consent alone is insufficient and ongoing maternal education is essential.18 McGlothen-Bell and her collaborators provide an overall review of the ethics surrounding the consent process for providing DHM as well as an argument for the use of consistent and standardized consent for the use of DHM in the NICU.
Nurses often focus on promoting breastfeeding and MOM consumption in mothers delivering VLBW preterm infants. However, mothers of infants not born preterm and with other diagnoses including congenital anomalies such as myelomeningocele may also be at risk for breastfeeding difficulties that may limit the amount of MOM their infant consumes. Using an evidence-based feeding pathway, Spatz and Froh describe the enteral feeding practices of infants with myelomeningocele including whether mothers had a personalized prenatal nutrition consultation, whether infants received human milk as their first feed, and whether they breastfed.
Neonatal nurses partner with families in the NICU to provide infants with optimal evidence-based care. To provide this care, nurses need to provide families with evidence-based practical information regarding lactation, which has been adapted according to the family's specific educational and emotional needs. We hope you find this issue to be informative and that it assists you in providing lactation support to mothers of high-risk infants. Please stay-tuned for the next collection of articles regarding the science of human milk in the next issue of Advances in Neonatal Care.
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2. Cortez J, Makker K, Kraemer DF, Neu J, Sharma R, Hudak ML. Maternal milk feedings reduce sepsis, necrotizing enterocolitis and improve outcomes of premature infants. J Perinatol. 2018;38(1):71–74.
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4. Zhou J, Shukla VV, John D, Chen C. Human milk feeding as a protective factor for retinopathy of prematurity: a meta-analysis. Pediatrics. 2015;136(6):e1576–e1586.
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7. Huang J, Zhang L, Tang J, et al Human milk as a protective factor for bronchopulmonary dysplasia: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2019;104:F128.
8. American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–841.
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10. Corpeleijn WE, de Waard M, Christmann V, et al Effect of donor milk on severe infections and mortality in very low-birth-weight infants: the early nutrition study randomized clinical trial. JAMA Pediatr. 2016;170(7):654–661.
11. Peila C, Moro GE, Bertino E, et al The effect of holder pasteurization on nutrients and biologically-active components in donor human milk: a review. Nutrients. 2016;8(8).
12. Ewaschuk JB, Unger S, O'Connor DL, et al Effect of pasteurization on selected immune components of donated human breast milk. J Perinatol. 2011;31(9):593–598.
13. Colaizy TT, Carlson S, Saftlas AF, Morriss FH Jr. Growth in VLBW infants fed predominantly fortified maternal and donor human milk diets: a retrospective cohort study. BMC Pediatr. 2012;12:124.
14. Montjaux-Regis N, Cristini C, Arnaud C, Glorieux I, Vanpee M, Casper C. Improved growth of preterm infants receiving mother's own raw milk compared with pasteurized donor milk. Acta Paediatr. 2011;100(12):1548–1554.
15. Hard AL, Nilsson AK, Lund AM, Hansen-Pupp I, Smith LEH, Hellstrom A. Review shows that donor milk does not promote the growth and development of preterm infants as well as maternal milk. Acta Paediatr. 2019;108(6):998–1007.
16. Lloyd ML, Malacova E, Hartmann B, Simmer K. A clinical audit of the growth of preterm infants fed predominantly pasteurised donor human milk v. those fed mother's own milk in the neonatal intensive care unit [published online ahead of print April 5, 2019]. Br J Nutr. doi:10.1017/S0007114519000357.
17. Nommsen-Rivers LA. Does insulin explain the relation between maternal obesity and poor lactation outcomes? An overview of the literature. Adv Nutr. 2016;7(2):407–414.
18. Parker L, Cacho N, Engelmann C, et al Consumption of mother's own milk by extremely preterm infants following implementation of a donor human milk program: a retrospective cohort study [published online ahead of print May 3, 2019]. J Pediatr. doi:10.1016/j.jpeds.2019.03.040.