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Nurses' Views on Using Pasteurized Donor Human Milk for Hypoglycemic Term Infants

Ferrarello, Debi, MSN, MS, RN, IBCLC, NE-BC; Froh, Elizabeth B., PhD, RN; Hinson, Tyonne D., DrPH, MSN, RN, NE-BC; Spatz, Diane L., PhD, RN-BC, FAAN

MCN: The American Journal of Maternal/Child Nursing: May/June 2019 - Volume 44 - Issue 3 - p 157–163
doi: 10.1097/NMC.0000000000000525
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Purpose: The purpose of this study was to explore maternal child nurses' knowledge and beliefs about using pasteurized donor human milk (PDHM) to treat newborns with hypoglycemia. Pasteurized donor human milk has been used for decades in neonatal intensive care units, but its use is relatively new in the well-baby population.

Study Design and Methods: Focus groups of maternal child nurses were conducted to explore this topic.

Results: Six focus groups that included a total 20 nurses were held. Four themes were identified: 1) nurses presumed safety of PDHM but lacked knowledge, 2) nurses' role as patient–family advocate, 3) nurses' logistical concerns about implementation of PDHM, and 4) nurses lacked clarity on formal milk sharing versus PDHM.

Clinical Implications: As the use of PDHM increases for well babies, nurses will need more education about PDHM, its safety profile, its use in breastfeeding support and protection of the infant microbiome, and how PDHM differs from informal milk sharing. Nurses play an important role in helping parents weigh risks and benefits of using PDHM or formula when supplementation is needed during the hospital stay. It is important that nurses feel confident in their own knowledge and ability to address parental concerns so they can advocate for their patients and support parental decision-making.

Pasteurized donor human milk has been used for babies in the neonatal intensive care units for many years but has not been considered an option for treating otherwise healthy term newborns with hypoglycemia. In this study, focus groups of nurses were held to get their views on this practice. Their feedback was used to prepare educational resources for nurses and families about use of pasteurized donor human milk for treating healthy term newborn hypoglycemia.

Debi Ferrarello is Director of Program Development, Women's Health Service Line, Director of Parent Education and Lactation, Penn Medicine's Pennsylvania Hospital, Philadelphia, PA. The author can be reached via e-mail at Debi.Ferrarello@uphs.upenn.edu

Elizabeth B. Froh is Nurse Scientist for Pediatric Nursing Research and Evidence-Based Practice, Children's Hospital of Philadelphia, Philadelphia, PA.

Tyonne D. Hinson is Director, Nursing Diversity Initiatives, Boston Children's Hospital, Boston, MA.

Diane L. Spatz is Professor of Perinatal Nursing & Helen M. Shearer Professor of Nutrition, University of Pennsylvania School of Nursing, Nurse Researcher & Manager of Lactation Program, The Children's Hospital of Philadelphia (CHOP), Clinical Coordinator of the CHOP's Mothers' Milk Bank, Philadelphia, PA.

The authors declare no conflicts of interest.

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Figure

Perinatal leaders in hospitals with birthing services, especially in those designated as Baby-Friendly or accredited by the Joint Commission, are concerned with increasing exclusive human milk feeding for newborns during the hospital stay. Exclusive human milk feeding was endorsed by the National Quality Forum as an evidence-based quality measure and then adopted by the Joint Commission as a Perinatal Care Measure (National Quality Forum, 2012; The Joint Commission, 2017).

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Background

During a skills fair, nurses in the hospital's maternal and infant health division were asked to share their beliefs about reasons breastfed infants receive formula supplements. The majority identified neonatal hypoglycemia as the most frequent medical reason for breastfed infants to be supplemented with infant formula. Neonatal hypoglycemia is a common condition often treated with formula supplementation (Weston et al., 2016). A growing number of hospitals are treating neonatal hypoglycemia with oral dextrose gel as one way to keep mothers and newborns from being separated and to promote breastfeeding (Bennett, Fagan, Chaharbakhshi, Zamfirova, & Flicker, 2016; Weston et al.). Evidence for this practice is evolving (Newnam & Bunch, 2017). The most recent Cochrane review (Weston et al.) was based on only two studies (Chandrasekharan & Lakshminrusimha, 2017; Weston et al.). A recent study by Makker et al. (2018) evaluated the percentage of late preterm infants, small and large for gestational-age infants, and infants of diabetic mothers transferred to the neonatal intensive care unit (NICU) for management of hypoglycemia before and after initiating a glucose gel policy. They found that NICU management decreased and exclusive breastfeeding during the hospital stay increased. However, the neonatologists at our hospital expressed concern that the long-term impact of exposing a newborn to a high concentration of glucose gel is unknown. Nurse leaders proposed offering pasteurized donor human milk (PDHM) as an alternative to infant formula for otherwise healthy, full-term breastfed infants with hypoglycemia to increase exclusive human milk feeding and help breastfeeding women to meet their infant feeding goals.

Pasteurized donor human milk has been used for vulnerable infants for several decades and has an impressive safety profile. Most often, milk from two or more women is pooled together, treated with Holder pasteurization, frozen, and stored. Samples from each batch are cultured and tested (O'Connor, Ewaschuk, & Unger, 2015; Updegrove, 2013). The American Academy of Pediatrics (AAP) recommends the use of PDHM for very low birthweight infants if a mother's own milk is unavailable or is contraindicated (AAP, 2012; 2017). Use of PDHM in the well baby population is relatively new, but rising sharply (Belfort et al., 2018; Sen et al., 2018). The Academy of Breastfeeding Medicine endorses use of PDHM when supplementation of well infants is required (Kellams et al., 2017). However, though there is a large body of evidence supporting the use of PDHM in vulnerable infants, including protection from necrotizing enterocolitis and having a microbiome more similar to that of breastfed infants, evidence supporting its health benefits in term infants is lacking. Using PDHM for treatment of hypoglycemia in healthy term babies has the potential to increase exclusive breast milk feeding during the hospital stay.

Nurses who work in the NICU at our hospital have been using PDHM for 5 years. However, introducing PDHM to well infants in labor and delivery or the mother–baby units represents a significant practice change. A review of the literature revealed that little is known about nurses' beliefs and knowledge about PDHM either in vulnerable or term infants. Therefore, prior to undertaking this practice change, we sought to explore nurses' views of PDHM for healthy term infants through focus group methodology.

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Review of the Literature

Mannel and Peck (2018) studied a large cohort of late preterm infants (n = 183) to determine the influence of type of milk supplementation (PDHM vs. infant formula) on length of stay or breastfeeding status at hospital discharge. Breastfed infants supplemented with formula were 16% less likely to be breastfeeding at discharge than those supplemented with PDHM (Mannel & Peck). Belfort et al. (2018) surveyed lactation experts at 71 hospitals in the Northeast region of the United States to study trends in the practice of using PDHM for babies in the well-baby nursery. They examined characteristics of hospitals using PDHM in this way as well as the knowledge and beliefs of clinicians about the practice (Belfort et al.). There was a significant increase in use of PDHM in the well-baby study population between 2008 and 2016 from less than 5% to 32%. Hospitals using PDHM had higher exclusive breast milk feeding rates and were more likely to be designated Baby-Friendly (Belfort et al.). Survey respondents noted that their clinician colleagues believed “studies show health benefits of providing PDHM to healthy full term infants,” “the cost of donor milk is justified by the benefits in healthy infants,” “parents are receptive to using PDHM for healthy babies in the well baby nursery,” and “nurses are receptive to using donor milk” (Belfort et al., p. 38). However, the beliefs of the person responsible for the PDHM program may not be generalizable to their colleagues as they may be more likely to favor use of PDHM. More than 80% of survey respondents saw “donor milk is an effective way to increase their hospital's exclusive breastfeeding rate” (Belfort et al., p. 39).

Kair and Flaherman (2017) conducted semistructured interviews with 30 postpartum parents of full-term healthy infants who gave supplements of either infant formula or PDHM to their infants during the hospital stay to explore maternal perceptions related to PDHM and formula supplementation. Both PDHM and infant formula were readily available. Four themes were identified including “donor milk is temporary whereas formula is an ongoing plan,” “formula is familiar whereas donor milk is unfamiliar,” “donor milk is costly and challenging logistically,” and donor milk is healthier” (Kair & Flaherman, pp. 712-713).

Although the majority of American mothers indicate breastfeeding as their feeding preference, only one third meet their infant feeding goals (Perrine, Scanlon, Li, Odom, & Grummer-Strawn, 2012). Supplementation with infant formula during the hospital stay is strongly correlated with shortened breastfeeding duration (Belfort et al., 2018; Perrine et al.). It is unknown if supplementation with PDHM will help mothers meet their feeding goals, perhaps by serving as a “bridge” to breastfeeding, rather than a road diverging from the path (Kair & Flaherman, 2017). Belfort et al. found that clinicians in their study share the view of mothers interviewed by Kair and Flaherman that use of PDHM in the healthy infant population may help to meet the goal of exclusive breastfeeding during the hospital stay (Belfort et al.).

Nurses play an important role in providing education, advocacy, and support for their patients. Nurses' knowledge and beliefs may influence parental decision making. With the growing interest in using PDHM in a healthy term population, study of nurses' perceptions and beliefs about PDHM is warranted.

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Study Design and Methods

The study was deemed exempt by the University of Pennsylvania's Institutional Review Board.

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Setting

This study was conducted at a large Baby-Friendly designated birthing facility with an average of over 5,000 births per year, approximately 80% of which are admitted to the well nursery. It is a high-risk perinatal center, yet also has a birthing suite with midwifery care to support low-intervention childbirth. The population is diverse and approximately one third are covered by Medicaid insurance. Pasteurized donor human milk has been used in the hospital's 45-bed NICU for 5 years. However, PDHM was not offered to any infant in the well nursery. Nurses working in Labor and Delivery and the Mother Baby Unit had not been exposed to PDHM or its use in the well-baby population.

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Participants

Study participants were registered nurses working in either the Labor and Delivery Unit or the Mother Baby Unit. As per the Baby Friendly Hospital Initiative (BFHI) guidelines (Baby-Friendly USA, 2016), all of the nurses had received a minimum of 20 hours of breastfeeding education. This education included information about PDHM for preterm infants in the NICU setting, but did not include information about providing PDHM for otherwise well babies experiencing hypoglycemia.

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Study Design

We used focus groups to seek to understand nurses' knowledge and beliefs about the use of PDHM for otherwise healthy, full-term infants who have hypoglycemia in the first hours or day of life. Focus groups were chosen because we wanted to reduce the influence of the interviewer and to capture data salient to the nurses' opinions, attitudes, knowledge, beliefs, and perceptions (Denzin & Lincoln, 2000; Krueger & Casey, 2018). The focus group questions were designed by the research team, all of whom have expertise in breastfeeding in the context of hospitalization, the role of nursing in supporting breastfeeding, and PDHM. The focus group semistructured guide addressed the following elements: knowledge and exposure to PDHM; nurses' beliefs about the use of PDHM; sourcing and safety of PDHM; and actual practice of infant feeds with PDHM (Table 1).

TABLE 1

TABLE 1

Nurses were recruited in-person, through email and through study flyers posted in the applicable units. The focus groups were facilitated by three nurse researchers experienced in qualitative research methods. All groups were facilitated by the same lead nurse researcher with the second and third alternating taking field notes during the groups. Each focus group session was digitally audio recorded by the main facilitator.

At the beginning of each focus group session, the purpose of the study was explained to the nurse participants and written informed consent was obtained. All nurses were able to choose a pseudonym to remain anonymous. They were informed that there were no right or wrong answers to the questions and that the researchers were seeking to understand their beliefs and perceptions. Nurses attended the focus group session during their assigned shifts.

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Data Analysis

We used conventional content analysis (Burnard, 1991; Krippendorff, 2004; Polit & Beck, 2006; Sandelowski, 2010) to analyze data from the focus groups. Following the completion of the focus groups, the authors listened and relistened to the audio files from each focus group. The first author was responsible for first-level coding and initial coding was then repeated independently by the second author. Data were managed using the software program, NVivo Pro (version 11), and the final first-level coding was attached directly to each focus group's audio file. After the first-level coding was verified between authors, the second author condensed the first-level coding into second-level codes. The study group met collectively to condense the second-level coding into categories. Categories were shared and the team once again listened to all the audio file segments. Themes were generated from the categories. Final themes were kept salient to the participants' overall responses.

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Results

Six focus groups were conducted with a total of 20 nurses over a 2-month period. Each focus group consisted of three or four nurses from the Labor and Delivery Unit and the Mother-Baby Unit. Sessions lasted 20 to 30 minutes. Nurses shared their thoughts and experiences about use of PDHM in the context of supplementation for term infants with hypoglycemia. Four themes were identified: 1) nurses' presumed safety of PDHM but lack of knowledge, 2) nurses see their role as patient and family advocate, 3) logistical concerns about implementation of PDHM for healthy term infants with hypoglycemia, and 4) nurses lacked clarity related to informal milk sharing versus PDHM.

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Nurses' Presumed Safety of PDHM but Lack of Knowledge

Nurses stated that PDHM was likely to be safe and regulated but felt they lacked knowledge about PDHM, I don't know enough about it, I mean, I can only assume it must be safe if you guys are asking to bring it in to give to infants so it must be safe and I don't know enough about it, but, for the two of you to be here and doing focus groups, the standards must be pretty high to have it on the shelves here. These comments suggest that the nurses trusted that the PDHM would be safe not because they had personal knowledge about its safety profile, but rather that they trusted the hospital to do its due diligence in bringing in products that are safe.

Some nurses were more familiar with the procedures of nonprofit HMBANA milk banks than other nurses as articulated in the following quotes, You had to qualify under certain requirements to make donations. They don't take just anyone's milk and I know the moms have to go through testing and blood work prior to the organization accepting their breast milk. There's a whole procedure done before it hits the shelves. Nurses verbalized that they had some knowledge about the safety of PDHM and milk bank procedures, Standardization of pasteurization is true and we know that it is actually effective in killing the organisms that we do not want but does not damage the health providing properties of the milk. The evidence is positive. One participant noted, It is heat treated to kill any bacteria that could be harmful.

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Nurses' Role as Patient and Family Advocate

Nurses reported wanting to have better options for mothers whose infants required supplementation. Some nurses expressed that parents can feel defeated and dissatisfied if their intention is to breastfeed and a medical situation, such as hypoglycemia, takes them off the path of exclusive breastfeeding during the hospital stay. From caring for a mom that desires breastfeeding I feel if they are very focused on ‘my baby must be breastfed for these reasons so these things don't happen to my baby,’ they feel in the moment, it's like defeat, instant. I personally think it would be nice to have an alternative especially for that community, for preference sake and it's always best to have just the one thing instead of exposure to a ton of things. Especially when your body, you know you're a newborn baby, and you're exposed to all these crazy things.

Other nurses spoke as advocates for the infant, expressing that PDHM is a healthier alternative than formula for newborns. I feel like if there's an alternative, to using formula that's a good source, a good safe source, of human milk, that would be better. It would be better suited for the baby and the baby's nutrition needs. One nurse noted, It's a great alternative, it sounds safe and if a mom exclusively wants to breastfeeding then it's definitely a great alternative than just shoving formula down the throat... you know it's better for the baby.

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Nurses' Concerns about Implementation of PDHM for Healthy Term Infants with Hypoglycemia

Although some nurses were knowledgeable about PDHM as an alternative to infant formula, many nurses expressed the need for education as well as concerns about the impact of this practice change on the workload of the nursing staff. They verbalized that staff, as well as parents, need education about PDHM should a practice change be implemented. Education needs to be provided to the staff and to the parents just in general. One participant said, In terms of education, it just needs to be provided. We as nurses have a distrust of things that we don't understand, or if we don't think they might be safe, so we need to see the evidence.

Nurses expressed concerns about work flow and how practice changes impact their time. The following two quotes illustrate the concerns of clinical nurses in implementing a PDHM practice in their work area. Honestly, the first thing I thought was how much more scanning does this involve? How much more work is this going to be for us to offer this to our patients? Because everything takes time, especially with the electronic record and the barcodes and all this stuff. It's you go through swiping through doors, you have to put codes in, everything takes a lot of time. That was my first concern. And What will the work be? Right now, we just pull the bottle {of formula} out of the pyxis and give it to them. We don't have to scan it, defrost it, we don't need the water.

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Nurses Lack Clarity Related to Informal Milk Sharing versus PDHM

Nurses reported having exposure to informal milk sharing both in the community and at work. In some cases, nurses brought up informal milk sharing during discussions of PDHM. If someone in their neighborhood or community could not breastfeed but then they would give them their extra milk whether it was stored or fresh. If someone was ill they would have done that or also like adoptive families taking milk from someone else, like their family member, maybe, who has pumped for them. Another nurse was clear that informal milk sharing was not recommended but seemed much less clear about why. So informally sharing, would be something that is not necessarily recommended by the medical community. But, perhaps a family that couldn't breastfeed their infant for one reason or another would take milk from a friend who had extra supply to offer.

One nurse implied similarity in the two types of processes We didn't have it {PDHM} and then we have it now, a lot, it's like and then a lot of people are saying ‘yes’ and then we also have people bringing in other people's breast milk in an using it for their babies, too. They just put their own labels on it, I'm not going to know whose it is, so, but like I know she's not pumping [laughter], but you're like ‘okay.’

Several nurses could recall specific situation in which informal milk sharing occurred. I had a patient before that had cardiac issues, she was high risk, so she was not doing well, so breastfeeding was kind of on the back-burner. So, her friend brought milk in, while she was here, and she used that. But again, it wasn't pasteurized. It was just on trust basis that it was all good. Another nurse noted, I had a patient I had forgotten, she had cancer and was in treatment when she had her baby, so it was it was a faith-based community member that brought milk. So that was once that I had experienced it.... I don't even know, we didn't do any scanning [laughter] it was just that this is for her baby, so I was like ‘okay, so yeah.’ One nurse stated, I've actually, I've not heard about it, except from my sister-in-law for my cousin has adopted a baby and had asked her to pump for her or something.

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Discussion

Nurses' views suggest hospital policies and education of nurses and patients must have specific language that clearly articulates the differences between PDHM and informally shared milk. Despite nurses having had breastfeeding-specific education as part of the BFHI designation process, nurses in this study had relatively little knowledge of or exposure to PDHM. Discussion about offering PDHM to term, otherwise healthy infants experiencing hypoglycemia revealed that most nurses felt this would be a good option, but do not have enough knowledge about PDHM to be able to educate parents or advocate for its use. Many nurses were uncertain about the safety of PDHM and how it differs from informal milk sharing. This lack of clarity leaves them feeling ill-prepared to provide complete and objective education for parents of breastfed infants requiring supplementation.

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Limitations

This research was conducted at one center. We did not compare nurses' responses with their own breastfeeding history, age, length of service at the institution, or any demographic data. It is possible that nurses' personal breastfeeding experience, age, ethnicity, and years of experience may influence their knowledge and beliefs about the use of PDHM.

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Clinical Implications

Using PDHM in a well-baby population may help mothers meet their breastfeeding goals, provide physiologic benefits to the infant, and help hospitals to improve their rates of exclusive human milk feeding. Instead of using glucose gel or infant formula to treat hypoglycemia in healthy term babies, PDHM may be an equally beneficial option. Knowledge gained from focus groups with nurses was used to develop an education module for nurses to prepare them to educate parents about PDHM and its use for term, otherwise healthy infants experiencing hypoglycemia. As the use of PDHM increases in well-baby populations, nurses will need more education about PDHM, its safety profile, use in breastfeeding support, and how PDHM differs from informal milk sharing.

Nurses play an important role in helping parents weigh risks and benefits of using PDHM or formula when supplementation is needed during the hospital stay. It is important that nurses feel confident in their own knowledge and ability to address parental concerns in order for them to advocate for their parents and support parental decision-making.

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Clinical Implications

  • As hospitals strive to increase the rates of exclusive breastfeeding, the use of PDHM in well infants has increased.
  • Hypoglycemia in term infants is common, and often results in supplementation with formula. Using PDHM provides a human milk alternative that may increase exclusive breastfeeding and avoid exposure to formula.
  • Maternal child health nurses may not have a working knowledge of PDHM.
  • Nurses need education about PDHM and clarity as to work flow to fulfill their role as patient educators and advocates.
  • Hospital policies and both patient and staff education must have specific language that clearly articulates the differences between PDHM and informally shared milk.
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Keywords:

Breastfeeding; Human; Hypoglycemia; Milk; Newborn

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