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Implementation of a Human Milk Management Center
Abstract
Current hospital practices surrounding the use of human milk and fortification are suboptimal. Safety of milk preparation should be a priority, as should optimization of the milk to meet the nutritional needs of hospitalized infants. This article describes the implementation of a human milk management center (HMMC) at a children's hospital. This centralized center allows for milk to be safely prepared under aseptic technique. In addition, the HMMC staff can analyze milk composition. The widely variable nutrient composition of human milk has been well established and, therefore, should be considered when fortifying human milk. The HMMC staff have the ability to perform creamatocrits on milk, conduct human milk nutrient analysis, and make skim milk for infants. The processes for developing an HMMC are also detailed in this article.
... Spatz et al., 2014 (23) Analisar as atividades-chave na implantação de um centro de gerenciamento de LH em um hospital infantil. ...
... Todos os processos Monitoramento contínuo dos resultados Mapeamento do fluxo (23)(24)26) Todos os processos Monitoramento contínuo dos resultados APPCC (15,20) Prevenir erros e falhas melhoria no estudo identificado, quando analisados os parâmetros da acidez Dornic e análise microbiológica. Embora intuitiva e muito comum, a ação educativa tem surtido um resultado sub-ótimo em função da não retenção de informações críticas pelo paciente (33) . ...
... O mapeamento do fluxo utilizado em três estudos (23)(24)26) e o Ciclo PDCA implantado em outro estudo (26) também permitiram uma visão gerencial mais ampla de todos os processos que envolvem o LH, pois possibilitou detalhar a sequência das atividades, identificar desvios ou falhas que necessitam ser corrigidos para melhorar o desempenho final dos processos e segurança do serviços de BLH. A literatura demonstra o valor do ciclo PDCA como sendo a ferramenta de maior utilidade na implantação de programas de qualidade na área da saúde (37) . ...
Objectives:
to identify the main quality management interventions used by professionals working at Human Milk Banks.
Methods:
a scope review conducted at PubMed, VHL, Scopus, SciELO, CAPES thesis and Google Scholar databases. Primary studies were included that address quality improvement strategies to improve Milk Bank processes in Portuguese, English and Spanish.
Results:
search totaled 192 scientific studies, 17 of which met the objective of the study and inclusion criteria. The main quality management interventions used in the Human Milk Bank addressed tools for continuous improvement. Six were aimed at improving processes, one to prevent errors and failures and two to achieve continuous monitoring.
Final Considerations:
the tools used by professionals working in Human Milk Banks have demonstrated effectiveness in managing the quality of services.
... die benötigte Abpumpdauer pro Tag) für betroffene Mütter optimieren, ohne Abstriche bei der Effektivität, dem Komfort und der einfachen Handhabung zu machen. 16 [19], [27], [169], [170], [232], [233]. [84], [97], [99], [105], [107], [144], [239], [240]. ...
... Derzeit sind beim Umgang mit Muttermilch auf der NICU 2 grundsätzliche Vorgehensweisen verbreitet: Die Vorbereitung der Mahlzeit (einschließlich Anreicherung der Muttermilch) erfolgt entweder außerhalb der Einrichtung durch entsprechendes Fachpersonal, das die Milch alle 24 Stunden an die NICU ausliefert [170], [287], oder direkt auf Station durch das NICU-Pflegepersonal selbst [18], [19] ...
... Several studies provide evidence about best practices for collecting, storing, handling, and feeding HM in the NICU setting [19], [27], [169], [170], [232], [233]. However, the majority of these findings have not been integrated into comprehensive HM feeding programmes specific to NICU infants. ...
... Currently, there are two overall approaches to HM handling in the NICU: Feedings are prepared (including fortification) either offsite by HM technicians and delivered to bedside nurses every 24 hours [170], [287], or at the bedside by the NICU nurse [18], [19]. Advantages of the former include: fewer health care providers handling HM and thus less variation in standardised practices; purported less misadministration errors (e.g., infant receiving HM from the wrong mother); and resource consolidation for cost-effectiveness. ...
... 8,9,15,17,18 We also found some tutorials that mention this topic as an established procedure in human milk banks and pediatric health institution routines. [19][20][21][22] Two clinical reports, set in low-resource settings, were excluded because they used skimmed milk but not human source. 23,24 Only a few case reports, [16][17][18] one retrospective case series, 15 and two small cohort studies 8,9 met the inclusion criteria. ...
... The clinical practice of using modified-fat breast milk as a treatment option for infants with chylothorax has been implemented in a number of pediatric institutions worldwide. [20][21][22] Defatting procedures have been adopted in protocols and clinical guidelines, although externally validated protocols are missing. Nevertheless, breast milk seems to be the best nutritional option especially for preterm CC patients due to multiple advantages. ...
Introduction:
Congenital chylothorax (CC) is a rare and life-threating condition. Since its treatment is founded on the elimination of long-chain fatty acids from the diet, breastfeeding has been traditionally contraindicated. However, breast milk could be very beneficial due to its immunological and nutritional benefits. Only limited research has been published about the usage of modified-fat breast milk (MBM) in chylothorax treatment.
Methods and Results:
Systematic review methods were used by two independent reviewers. Only a few case report studies (quality assessment on the domains of the GRADE approach), two small controlled studies, a retrospective study, and some test-tube-based laboratory research met the inclusion criteria. Despite this, we have observed a widespread clinical adoption of this novel treatment in health institutions. Data suggest that modified-fat breast milk does facilitate the resolution of chylothoraces. Refrigerated centrifuge (2°C, 3,000 rpm for 15 minutes) and syringe fat removal methods were the most efficient options in terms of fat reduction.
Conclusions:
Feeding of human milk is advisable in CC and feasible by means of a simple milk defatting procedure. Open questions remain, related to length and degree of fat restriction and need for individualized fortification of defatted breast milk.
... However, growth is a concern generally among infants with post-surgical chylothorax and we previously reported infants fed MFBM experienced a more significant decline in weight-for-age and length-for-age z-scores over a !6-week treatment duration compared to those fed a high MCT-containing formula. Although some pediatric institutions have implemented MFBM for treatment of chylothorax during hospitalization [7,9,10], to our knowledge, there is no published literature describing the ideal method of energy and nutrient fortification of the MFBM to address the nutritional losses associated with chylothorax or how to support optimal growth. The purpose of this study was to develop and evaluate two comprehensive MFBM feeding protocols designed to support optimal growth in cardiac infants and to compare these growth outcomes with that of cardiac infants fed a high MCT formula (standard of care) for the treatment of chylothorax. ...
Background & aim
Previously we showed that modified fat breast milk (MFBM) facilitated resolution of post-surgical chylothorax in cardiac infants, but their weight-for-age and length-for-age z-scores declined over the ≥6-week treatment duration. Our aim was to evaluate the growth of infants diagnosed with post-surgical chylothorax and fed according to one of two proactive feeding protocols using MFBM or a high medium triglyceride (MCT)-containing formula (standard of care).
Methods
In this open-label trial, infants who were receiving >50% of their enteral feeds as breast milk prior to chylothorax diagnosis were randomized to receive their enteral feeds according to one of two proactive MFBM protocols: Target Fortification (n = 8), where the protein concentration of defatted breast milk was measured weekly and multi- and single-nutrient modulars were added to provide 3.5 g/kg/day of protein; or Higher Initial Concentration (n = 8), where defatted breast milk was initially fortified to an energy and nutrient level higher than that of unmodified breast milk (80kcal/100 ml; 2.2 g/100 ml protein). A third nonrandomized group of infants (n = 8) received high MCT formula (68kcal/100 ml; 2.3 g/100 ml protein). The intervention lasted for a minimum of 6-weeks after chest tube removal and continued after discharge. Weekly weight, length and head circumference (HC) measurements were completed.
Results
At enrolment, there was no statistically significant differences in mean (±SD) weight-for-age (−1.6 ± 0.9, n = 24), length-for-age (−1.3 ± 0.8), or HC-for-age (−0.9 ± 1.0) z-scores among groups. Changes in mean weight- (−0.3 ± 0.9, n = 23), length- (0.1 ± 0.6) and HC-for-age (0.2 ± 0.6) z-scores did not differ among groups over the treatment period. There was no difference in duration or volume of chest tube drainage across groups.
Conclusion
Use of proactive MFBM feeding protocols both resolve chylothorax and support growth in infants following cardiothoracic surgery.
Trial registration
ClinicalTrials.gov (NCT02577419).
... Several commercial programs in use have the ability to integrate with electronic medical records, whereas others are completely separate databases that require hospitals to enter and remove each patient. & Kinzler, 2014). The original milk lab, known as the Mother's Own Milk Bank, was established by Texas Children's Hospital in 1984 (Hurst, Myatt, & Schanler, 1998). ...
The past 20 years have seen dramatic growth of hospital lactation programs. There are few regulatory guidelines leaving advocates for lactation services to justify need, safety, and best practice to implement changes. The professional networking group, Children's Hospital Lactation Network, was surveyed about breast milk facilities and practices. Analysis of survey responses will provide lactation programs with information needed to identify improvements and recognize priorities for lactation practice and safe, effective breast milk management. Lactation programs need specific regulations to guide practice to enable them to receive funding for equipment and staffing and support to make decisions on policies and best practices. Specific recommendations, consistent between regulatory agencies and across the United States, would be beneficial to optimizing lactation support for hospitalized infants and their families.
... 9 Following the inauguration of the HMMC, a multidisciplinary team was established to participate in weekly HMMC rounds. 10 This team includes the HMMC Manager, HMMC technicians, Clinical Supervisor of the Lactation Program, Director of the Lactation Program, International Board Certified Lactation Consultants (IBCLC), a nursing representative, lactation student nurse co-ops, formula/human milk safety coach, Director of Clinical Nutrition, and a registered dietitian (RD). The purpose of this multidisciplinary team is to improve communication regarding use of fortified or modified human milk to effectively support pumping/ breastfeeding mothers and ultimately, improve patient safety with a proactive approach to infant feeds. ...
Optimization of nutrition is key in infant development and it is well documented that human milk is the ideal form of nutrition for infants during the first year of life. However, unaltered maternal human milk may not be sufficient to meet the nutritional demands of premature infants. Under these circumstances, addition of a fortifier to the maternal human milk has become standard practice. In one newborn/infant intensive care unit (N/IICU) located in Philadelphia, fortification and modification of human milk is handled within the Human Milk Management Center (HMMC). A multidisciplinary team rounds weekly on all infants receiving fortified or modified human milk. Feeding orders and maternal milk supply are discussed to ensure the feeding is ordered correctly, the final caloric concentration is correct and a backup feeding order is in place for low maternal milk supply. Through this multidisciplinary discussion, the team has been able to identify and resolve potential errors from reaching the patient. Improvement in patient safety while providing human milk remains of utmost importance and the central goal of the HMMC collaborative.
... This is a significant finding, as CHOP has used nursing student interns for 10 years. The main lactation-based services include (a) consultation with an International Board-Certified Lactation Consultant (IBCLC), (b) communication with/assistance from lactation-based nursing students interns (for questions regarding human milk management or breastfeeding equipment rentals), (c) communication with the human milk management center (for the storage, modification, and fortification of human milk), and (d) referral to the Group of Empowered Mothers (GEMs) Support Group (monthly support group for breastfeeding/pumping mothers within the hospital) (Kristoff, Wessner, & Spatz, 2014;Spatz, Schmidt, & Kinzler, 2014). ...
To describe and understand the Breastfeeding Resource Nurse (BRN) role and program.
The primary study was a multimethod prospective study in which quantitative surveys and qualitative interviews of nurses who received education through the BRN program were used. Results presented herein are from the quantitative arm of the primary study.
A large free-standing urban children's hospital with a birthing unit for specialized deliveries and a primary and specialty care network.
A total of 425 of 600 nurses who took the BRN course responded to the survey. These nurses worked in all settings throughout the enterprise.
The research team created a Survey Monkey interview that was e-mailed to all current nurses with valid hospital e-mail addresses who had taken the BRN course. Monthly e-mail reminders were sent and nurse managers were asked to encourage their staff to fill out the survey.
Nurses who received specialized education through BRN course integrated the provision of evidence-based breastfeeding support and care into their daily routines. Furthermore, nurses became breastfeeding advocates and supported family, friends, and members of their communities in their breastfeeding experiences.
The type of education needed for nurses who work at children's hospitals and in neonatal intensive care units is different than traditional breastfeeding education for birth hospitals. Implementation of the BRN course resulted in positive outcomes for staff; the course is transferrable to other facilities worldwide.
© 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.
Background: Infants with congenital heart disease (CHD) are at risk for feeding-related morbidity and mortality, with growth failure and oral feeding problems associated with poor outcomes. The benefits of human milk (HM) for preterm infants have been well documented, but evidence on HM for infants with CHD has recently begun to emerge. Objectives: Our primary aim was to examine the impact of HM feeding on outcomes for infants with CHD. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. The quality of each study was assessed using the Joanna Briggs Critical Appraisal Tools. A total of 16 studies were included. Results: There was evidence that an exclusive HM diet reduces the risk of necrotizing enterocolitis (NEC) for infants with CHD. Evidence with a higher risk for bias indicated that a well-managed HM diet may be associated with improved growth, shorter length of stay, and improved postoperative feeding and nutritional outcomes. Chylothorax outcomes were similar between modified HM and medium-chain triglyceride formula. The studies had significant limitations related to power, lack of control for covariates, and inconsistent delineation of feeding groups. Conclusions: Based on the reduced risk for NEC and given the conclusive benefits in other vulnerable populations, we recommend that clinicians and institutions prioritize programs to support HM feeding for infants with CHD. Large high-quality studies are needed to validate these results. Future work should clarify best practices in managing an HM diet to support optimal growth and development for these infants.
Objective
To determine clinical consensus and non-consensus in regard to evidence-based statements about feeding infants with complex CHD, with a focus on human milk. Areas of non-consensus may indicate discrepancies between research findings and practice, with consequent variation in feeding management.
Materials and Methods
A modified Delphi survey validated key feeding topics (round 1), and determined consensus on evidence-based statements (rounds 2 and 3). Patients (n=25) were an interdisciplinary group of clinical experts from across the United States of America. Descriptive analysis used SPSS Statistics (Version 26.0). Thematic analysis of qualitative data provided context for quantitative data.
Results
Round 1 generated 5 key topics (human milk, developing oral feeding skills, clinical feeding practice, growth failure, and parental concern about feeding) and 206 evidence-based statements. The final results included 110 (53.4%) statements of consensus and 96 (46.6%) statements of non-consensus. The 10 statements of greatest consensus strongly supported human milk as the preferred nutrition for infants with complex CHD. Areas of non-consensus included the adequacy of human milk to support growth, need for fortification, safety, and feasibility of direct breastfeeding, issues related to tube feeding, and prevention and treatment of growth failure.
Conclusions
The results demonstrate clinical consensus about the importance of human milk, but reveal a need for best practices in managing a human milk diet for infants with complex CHD. Areas of non-consensus may lead to clinical practice variation. A sensitive approach to these topics is needed to support family caregivers in navigating feeding concerns.
Background:
Human milk is a life-saving medical intervention. Infants with congenital heart disease are at an increased risk for necrotizing enterocolitis, chylothorax, feeding difficulties, and growth failure. In the absence of evidence-based care, their mothers are also at risk for low milk supply and/or poor breastfeeding outcomes.
Purpose:
Summarize the role of human milk and clinical outcomes for infants with congenital heart disease (CHD). Summarize methods of ideal breastfeeding support.
Methods/search strategy:
PubMed, Cochrane Library, and CINAHL were the databases used. The terms used for the search related to CHD and necrotizing enterocolitis were "human milk" and "necrotizing enterocolitis" and "congenital heart disease." This resulted in a total of 17 publications for review.
Findings:
Infants receiving exclusive human milk diet are at a lower risk for necrotizing enterocolitis and will have improved weight gain. Infants with chylothorax who receive skimmed human milk have higher weight-for-age scores than formula-fed infants. Maternal breastfeeding education correlates with decreased risk of poor breastfeeding outcomes.
Implications for practice:
Human milk is the ideal source of nutrition for infants with CHD and should be encouraged by the care team. Evidence-based lactation education and care must be provided to mothers and families prenatally and continue throughout the infant's hospitalization. If a mother's goal is to directly breastfeed, this should be facilitated during the infant's hospital stay.
Implications for research:
Evaluate the role between human milk and the incidence of necrotizing enterocolitis, feeding difficulties, and clinical outcomes in the population of infants with CHD.
A report released by the World Health Organization states that worldwide less than 10% of birth occur in hospitals certified through the Baby-Friendly Hospital Initiative. Furthermore, the Baby-Friendly Hospital Initiative's primary focus is on breastfeeding for healthy, mother-infant dyads. This article provides alternative models for implementing evidence-based care during maternal-infant separation so that mothers can achieve their personal breastfeeding goals. These include the Spatz 10-step model for human milk and breastfeeding in vulnerable infants and the Breastfeeding Resource Nurse model. Clinical outcome data are provided to demonstrate the effectiveness of the models as well as a road map of strategies to implement the models and measure outcomes.
Background:
Neonatal intensive care nurses have historically been responsible for preparing enteral feedings-a costly and time-consuming process that may require leaving the bedside. To address these concerns, the Milk Technician Program was implemented at a major military treatment facility. Milk technicians were specially trained and responsible for handling, storing, and preparing enteral feeds.
Purpose:
To determine effectiveness of the Milk Technician Program, changes in length of time required to first attain full feeds, cost of feeding preparation, adherence to feeding preparation procedures, and nurse and milk technician role variables were evaluated.
Methods:
A pre-/postdesign was used to compare length of time to full enteral feedings and cost. A plan-do-study-act design was used to evaluate protocol adherence and to identify and evaluate nurse and milk technician role variables. Data were collected via surveys, direct observations, and retrospective chart reviews to determine the overall effectiveness of this intervention.
Results:
The average time for extremely and very preterm infants (<28 to 31 weeks) to first reach full feeds decreased from 32 to 19 days, t (33.1) = 2.33, P = .026, d = 0.704. Estimated feeding preparation cost savings for all infants admitted to the unit was $767 per day. Observed milk technician adherence to preparation procedures was 95.5%. Most nurses reported that the program saved time (97%) and all milk technicians reported improved job satisfaction. Nurses expressed concerns about accuracy and safety of preparation. Milk technicians reported concerns with communication, supplies, and lack of perceived support.
Implications for practice:
Milk technicians offer significant benefit to infants and nurses in the neonatal intensive care unit, including reducing time for infants to reach full feeds, saving nurses' time, and reducing costs.
Implications for research:
Further research is needed to identify ideal educational backgrounds for milk technicians and to directly measure the effect of milk technicians on hospital length of stay and infant growth parameters.
The use of human milk (mother's own milk and/or donor milk) in ill or medically compromised infants frequently requires some adaptation to address medical diagnoses and/or altered nutrition requirements. This tutorial describes the nutrition and immunological benefits of breast milk as well as provides evidence for the use of donor milk when mother's own milk is unavailable. Several strategies used to modify human milk to meet the medical and nutrition needs of an ill or medically compromised infant are reviewed. These strategies include (1) the standard fortification of human milk to support adequate growth, (2) the novel concept of target fortification in preterm infants, (3) instructions on how to alter maternal diet to address cow's milk protein intolerance and/or allergy in breast milk-fed infants, and (4) the removal and modification of the fat in breast milk used in infants diagnosed with chylothorax.
To outline new evidence published from 2013 to 2014 about breast milk fortification in preterm infants.
Breast milk is the feeding choice for preterm infants because of its immunoprotective properties. However, breast milk's nutrient content is not sufficient for preterm infants, and interindividual variation is high. The variation challenges standard fortification, which assumes a standard breast milk composition. Two new fortification strategies (adjustable fortification and target fortification) optimize macronutrient intake and improve growth. Adjustable fortification uses blood urea nitrogen levels to adjust fortifier strength. Target fortification analyzes breast milk and fortifies macronutrients individually to achieve targeted intake. Its feasibility is shown in clinical routine. Current breast milk analyzers used for target fortification achieve acceptable precision for protein and fat but not for lactose and energy. Evidence of benefits for postdischarge breast milk fortification is lacking. Eliminating cow's milk products and feeding exclusively breast milk may decrease the occurrence of feeding intolerance and necrotizing enterocolitis. To facilitate exclusively breast milk diets, a collaboration of prenatal, nutrition and lactation stakeholders is key. Fortification increases osmolality; however, safety cutoffs to prevent necrotizing enterocolitis are unclear. There is also new evidence that composition and structure of various macronutrients and micronutrients affect growth and development, and might play a role in future fortification concepts.
Recent research focuses on the variability of breast milk composition, its impact on postnatal growth patterns and the usefulness of target fortification. As well, diets exclusively composed of human milk are a promising approach to improve feeding tolerance. For safe fortification, osmolality cutoff levels are needed.
Preterm human milk-fed infants often experience suboptimal growth despite the use of human milk fortifier (HMF). The extra protein supplied in fortifiers may be inadequate to meet dietary protein requirements for preterm infants.
We assessed the effect of human milk fortified with a higher-protein HMF on growth in preterm infants.
This is a randomized controlled trial in 92 preterm infants born at <31 wk gestation who received maternal breast milk that was fortified with HMF containing 1.4 g protein/100 mL (higher-protein group) or 1.0 g protein/100 mL (current practice) until discharge or estimated due date, whichever came first. The HMFs used were isocaloric and differed only in the amount of protein or carbohydrate. Length, weight, and head-circumference gains were assessed over the study duration.
Length gains did not differ between the higher- and standard-protein groups (mean difference: 0.06 cm/wk; 95% CI: -0.01, 0.12 cm/wk; P = 0.08). Infants in the higher-protein group achieved a greater weight at study end (mean difference: 220 g; 95% CI: 23, 419 g; P = 0.03). Secondary analyses showed a significant reduction in the proportion of infants who were less than the 10th percentile for length at the study end in the higher-protein group (risk difference: 0.186; 95% CI: 0.370, 0.003; P = 0.047).
A higher protein intake results in less growth faltering in human milk-fed preterm infants. It is possible that a higher-protein fortifier than used in this study is needed. This trial was registered with the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/) as ACTRN12606000525583.
This study evaluated the cost-effectiveness of a 100% human milk-based diet composed of mother's milk fortified with a donor human milk-based human milk fortifier (HMF) versus mother's milk fortified with bovine milk-based HMF to initiate enteral nutrition among extremely premature infants in the neonatal intensive care unit (NICU).
A net expected costs calculator was developed to compare the total NICU costs among extremely premature infants who were fed either a bovine milk-based HMF-fortified diet or a 100% human milk-based diet, based on the previously observed risks of overall necrotizing enterocolitis (NEC) and surgical NEC in a randomized controlled study that compared outcomes of these two feeding strategies among 207 very low birth weight infants. The average NICU costs for an extremely premature infant without NEC and the incremental costs due to medical and surgical NEC were derived from a separate analysis of hospital discharges in the state of California in 2007. The sensitivity of cost-effectiveness results to the risks and costs of NEC and to prices of milk supplements was studied.
The adjusted incremental costs of medical NEC and surgical NEC over and above the average costs incurred for extremely premature infants without NEC, in 2011 US$, were $74,004 (95% confidence interval, $47,051-$100,957) and $198,040 (95% confidence interval, $159,261-$236,819) per infant, respectively. Extremely premature infants fed with 100% human-milk based products had lower expected NICU length of stay and total expected costs of hospitalization, resulting in net direct savings of 3.9 NICU days and $8,167.17 (95% confidence interval, $4,405-$11,930) per extremely premature infant (p < 0.0001). Costs savings from the donor HMF strategy were sensitive to price and quantity of donor HMF, percentage reduction in risk of overall NEC and surgical NEC achieved, and incremental costs of surgical NEC.
Compared with feeding extremely premature infants with mother's milk fortified with bovine milk-based supplements, a 100% human milk-based diet that includes mother's milk fortified with donor human milk-based HMF may result in potential net savings on medical care resources by preventing NEC.
A mid-infrared human milk analyzer (HMA) is designed to measure the macronutrients in human milk over a wide range of concentrations. Human milk samples (N = 30, 4 different dilutions each) were used to compare the macronutrient levels determined by the HMA to those derived from traditional laboratory methods. There was a small but statistically significant difference in the levels of fat, protein, lactose, total solids, and energy for all samples. These differences were consistent with subtle differences in the chemical principles governing the assays. For higher macronutrient levels, a trend to greater differences between the HMA and the laboratory method was seen, particularly in samples with high fat concentration. The intra-assay variation for the HMA for all macronutrients was less than 4%. It is concluded that that with appropriate sample preparation, the mid-infrared HMA can provide a practical measurement of macronutrients in human milk.
Preterm infants fed fortified human milk (HM) in standard (STD) fashion grow slower than preterm formula fed infants. Recently, low protein intake has been proven to be the primary limiting factor responsible for this growth failure. The main reason of protein undernutrition despite fortification is that STD fortification is based on the customary assumptions about the composition of HM. However, the protein concentration of preterm HM is variable and decreases with the duration of lactation. Also, the protein concentration of banked donor milk, which is most often provided by mothers of term infants, is likely to be lower. Hence, most of the HM fed to preterm infants during the fortification period is likely to have an inadequately low protein concentration. This hypothesis has been confirmed very recently by comparing the assumed and actual protein intakes in preterm infants fed fortified HM. Novel fortification models have been devised to deal with the problem of ongoing protein undernutrition. Individualized fortification is the recommended method to optimize HM fortification. There are two models of individualization: "adjustable fortification" and "targeted fortification". Both ways are feasible and effective in improving protein intakes and growth. Adjustable fortification has the advantage of being practical and avoids excessive protein intakes.
Postnatal growth failure in preterm infants is due to interactions between genetic and environmental factors, which are not fully understood. We assessed dietary supply of nutrients in very-low-birth-weight (VLBW, < 1500 g) infants fed fortified human milk, and examined the association between nutrient intake, medical factors and growth during hospitalisation lasting on average 70 d. We studied 127 VLBW infants during the early neonatal period. Data were obtained from medical records on nutrient intake, growth and growth-related factors. Extra-uterine growth restriction was defined as body weight < 10th percentile of the predicted value at discharge. Using logistic regression, we evaluated nutrient intake and other relevant factors associated with extra-uterine growth restriction in the subgroup of VLBW infants with adequate weight for gestational age at birth. The proportion of growth restriction was 33 % at birth and increased to 58 % at discharge from hospital. Recommended values for energy intake (>500 kJ/kg per d) and intra-uterine growth rate (15 g/kg per d) were not met, neither in the period from birth to 28 weeks post-conceptional age (PCA), nor from 37 weeks PCA to discharge. Factors negatively associated with growth restriction were energy intake (Ptrend = 0.002), non-Caucasian ethnicity (P = 0.04) and weight/predicted birth weight at birth (Ptrend = 0.004). Extra-uterine growth restriction is common in VLBW infants fed primarily fortified human milk. Currently recommended energy and nutrient intake for growing preterm infants was not achieved. Reduced energy supply and non-Caucasian ethnicity were risk factors for growth restriction at discharge from hospital.
Inadequate nutrition leading to growth failure is common among premature infants. Although fortified breast milk (breast milk plus commercially prepared fortifier) is the preferred feeding, nutrient intakes achieved with fortified breast milk fall short of meeting nutrient needs. This is mainly due to inadequate protein content of fortifiers and variability in composition of expressed breast milk.
A new adjustable fortification regimen has been designed to ensure that protein needs of premature infants are met at all times. The new regimen encompasses increasing the amount of fortifier and adding extra protein to breast milk guided by periodic determinations of blood urea nitrogen (BUN). The study tested the hypothesis that infants fed according to the new regimen have higher protein intakes and improved weight gain compared to infants fed according to standard fortification regimen.
In a prospective, controlled trial, preterm infants with birth weights of 600-1750 g and gestational ages between 26 and 34 weeks were fed their own mother's milk or banked donor milk or both. Infants were randomly assigned before 21 days of age to either the new adjustable fortification regimen or the standard regimen. The study period began when feeding volume reached 150 ml/kg/day and ended when infants reached a weight of 2000 g. Standard fortification (STD) consisted in the use of the recommended amount of fortifier. Adjustable fortification (ADJ) consisted in the use, in addition to standard fortification, of extra fortifier and supplemental protein guided by twice-weekly BUN determinations. The primary outcome was weight gain, with serum biochemical indicators and nutrient intakes as secondary outcomes.
Thirty-two infants completed the study as planned (16 ADJ, 16 STD). Infants receiving the ADJ regimen had mean protein intakes of 2.9, 3.2 and 3.4 g/kg/day, respectively, in weeks 1, 2 and 3, whereas infants receiving the STD regimen had intakes of 2.9, 2.9, 2.8 g/kg/day, respectively. Infants on the ADJ regimen showed significantly greater gain in weight (17.5+/-3.0 vs 14.4+/-3.0 g/kg/day, P<0.01) and greater gain in head circumference (1.4+/-0.3 vs 1.0+/-0.3; P<0.05) than infants on the STD regimen. Weight and head circumference gain were significantly (P<0.05) correlated with protein intake. No significant correlations were found between growth parameters and intake of fat and energy. There were no significant differences between groups in BUN and other serum chemical values. In the ADJ group, BUN concentrations increased significantly (P<0.001) over time but were not significantly higher than in the STD group.
Premature infants managed with the new adjustable fortification regimen had significantly higher weight and head circumference gains than infants managed with standard fortification. Higher protein intake appears to have been primarily responsible for the improved growth with the adjustable regimen. The new fortification method could be a solution to the problem of protein undernutrition among premature infants fed human milk.
To validate near-infrared reflectance analysis (NIRA) as a fast, reliable and suitable method for routine evaluation of human milk's nitrogen and fat content.
One neonatal intensive care unit.
124 samples of expressed human milk (55 from preterm mothers and 69 from term mothers).
Measurement of nitrogen and fat content by NIRA and traditional methods (Gerber method for fat and Kjeldahl method for nitrogen).
Agreement between NIRA and traditional methods. Variability in fat and nitrogen content of human milk.
A strong agreement was found between the results of traditional methods and NIRA for both fat and nitrogen content (expressed as g/100 g of milk) in term (mean fat content: NIRA = 2.76; Gerber = 2.76; mean nitrogen content: NIRA = 1.88; Kjeldahl = 1.92) and preterm (mean fat content: NIRA = 3.56; Gerber = 3.52; mean nitrogen content: NIRA = 1.91; Kjeldahl = 1.89) mothers' milk. Nitrogen content of the milk samples, measured by NIRA, ranged from 1.18 g/100 g to 2.71 g/100 g of milk in preterm milk and from 1.48 g/100 g to 2.47 g/100 g in term milk; fat content ranged from 1.27 g/100 g to 6.23 g/100 g of milk in preterm milk and from 1.01 g/100 g to 6.01 g/100 g of milk in term milk.
NIRA can be used as a quick and reliable tool for routine monitoring of macronutrient content of human milk and for devising individualised human milk fortification regimens in the feeding of very premature infants.
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.
During the last few decades, neonatal survival rates for preterm infants have markedly been improved. The American Academy of Pediatrics recommended that preterm neonates should receive sufficient nutrients to enable them to grow at a rate similar to that of fetuses of the same gestational age. Although human milk is the recommended nutritional source for newborn infants for at least the first six months of postnatal life, unfortified human breast milk may not meet the recommended nutritional needs of growing preterm infants. Human milk must therefore be supplemented (fortified) with the nutrients in short supply. The fortification of human milk can be implemented in two different forms: standard and individualized. The new concepts and recommendations for optimization of human milk fortification is the "individualized fortification". Actually, two methods have been proposed for individualization: the "targeted/tailored fortification" and the "adjustable fortification". In summary, the use of fortified human milk produces adequate growth in premature infants and satisfies the specific nutritional requirements of these infants. The use of individualized fortification is recommended.
To demonstrate that the real-time nutritional analysis of human milk carbohydrate, fat and protein with near-infrared (NIR) spectrophotometric methods is accurate.
A prospective study of the measurement of the macronutrient content of human milk. Milk was first analyzed on the SpectraStar 2400 Near Infrared Analyzer (Unity Scientific, Columbia, MD, USA), and then sent for primary chemical analysis for fat, protein and carbohydrate. Forty-two samples were used to create a calibration file. Ten samples were then used to validate the machine.
After logistic regression analysis, the validation set had a correlation (r (2)) of 0.91 for carbohydrates, 0.95 for fat and 0.95 for protein.
This study demonstrates the feasibility of the use of NIR for nutrient analysis of human milk. NIR offers the potential for analysis and adjustable fortification of human milk to optimize nutrient intake for the high-risk neonate.
The primary objective of this study was to investigate the composition of breast milk of mothers with extremely preterm infants (<28 weeks) for their nutrient content over the first 8 weeks of lactation, and to compare premature to term milk.
Breast milk from 102 mothers who had delivered preterm infants and from 10 mothers who had delivered term infants were collected longitudinally. Fat, protein, carbohydrate, minerals and energy content were estimated weekly in each participant. Milk samples were representative of complete 24-h cycles.
Carbohydrate, fat and energy concentrations were significantly higher in preterm than in term milk (p < 0.05). Protein content of both preterm and term milk decreased with the progress of lactation demonstrating significantly higher values in extremely preterm milk (<28 weeks) than in moderately preterm and term milk (p < 0.0001). The sodium levels of preterm milk were significantly elevated (p < 0.05) only in the first week. Other changes in mineral content were detected neither in preterm nor term milk.
Our data provide new information on the macronutrient content of milk in mothers of extremely preterm infants with possible implications for the nutrition of this population.
Protein content of preterm human milk (HM) is relatively low and extremely variable among mothers: thus, recommended protein intake is rarely met.
To evaluate in a NICU setting if HM protein content after standard fortification meets the recommended intake, and also to check the effect of fortification on the osmolality of HM, as an index of feeding intolerance.
Protein content of 34 preterm HM samples was evaluated by a bedside technique (Near-Infrared-Reflectance-Analysis - NIRA); osmolality was also checked. Seventeen samples were fortified with Aptamil BMF, Milupa (Group A) and 17 with FM85, Nestlé (Group B). Fortification was performed as recommended by the manufacturer ("full fortification [FF]") and also with a lower amount of fortifier ("low-dose fortification [LF]"). After fortification, actual protein content was calculated and compared to that needed to meet recommended intake (2.33-3g/dl), and osmolality was measured.
After FF, protein content was above 3g/dl in none of the samples, and below 2.33 g/dl in 16/34 samples (11 in Group A, 5 in Group B). After LF, protein content was above 3g/dl in none of the samples and below 2.33 g/dl in 32/34 samples (15 in Group A, 17 in Group B). Osmolality exceeded 400 mOsm/kg in 19 samples after FF (10 in Group A, 9 in Group B) and in 2/34 samples after LF (1 in each group).
HM protein content after standard fortification fails to meet the recommended intake for preterm infants in approximately half of the cases.
The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.
To evaluate the health benefits of an exclusively human milk-based diet compared with a diet of both human milk and bovine milk-based products in extremely premature infants.
Infants fed their own mothers' milk were randomized to 1 of 3 study groups. Groups HM100 and HM40 received pasteurized donor human milk-based human milk fortifier when the enteral intake was 100 and 40 mL/kg/d, respectively, and both groups received pasteurized donor human milk if no mother's milk was available. Group BOV received bovine milk-based human milk fortifier when the enteral intake was 100 mL/kg/d and preterm formula if no mother's milk was available. Outcomes included duration of parenteral nutrition, morbidity, and growth.
The 3 groups (total n = 207 infants) had similar baseline demographic variables, duration of parenteral nutrition, rates of late-onset sepsis, and growth. The groups receiving an exclusively human milk diet had significantly lower rates of necrotizing enterocolitis (NEC; P = .02) and NEC requiring surgical intervention (P = .007).
For extremely premature infants, an exclusively human milk-based diet is associated with significantly lower rates of NEC and surgical NEC when compared with a mother's milk-based diet that also includes bovine milk-based products.
Mother's milk is optimum for preterm infants, but human milk fortifier is required at times, because some nutrients are sometimes insufficient for infant growth. It is important to measure the nutrients in breast milk at bedside so that the amount of nutrients that need to be supplemented can be determined. A human milk analyser (HMA, Miris) is currently available. We examined if the macronutrient values measured by human milk analyser are comparable with those measured by conventional methods. We also sought to discover whether we could dilute the milk sample used for the human milk analyser measurement if the amount of milk available for testing was insufficient.
First, the results of protein, fat and lactose content in breast milk samples obtained using the human milk analyser and conventional methods were compared. Second, we measured diluted samples and compared the values with nondiluted samples.
When comparing the human milk analyser and conventional methods, all three nutrients exhibited a significantly positive correlation (p < 0.001); lactose content was reliable on the condition that it is 6-7 g/dL. The lactose content measured by the HPLC method was obtained by 3.05 x human milk analyser value - 13.4. When comparing diluted and nondiluted samples, fat and protein had expected values after dilution whereas lactose did not.
The human milk analyser can inform us about the amount of major nutrients in breast milk: fat, protein and lactose. However, when human milk is diluted, the lactose content measured by the human milk analyser is overestimated.
To improve the nutritional management of pre-term infants, a new individualized human milk fortification system based on presupplementation milk protein analyses was evaluated.
In an open, prospective, randomized multicenter study, 32 healthy preterm infants (birth weights, 920-1750 g) were enrolled at a mean of 21 days of age (range, 9-36 days) when tolerating exclusive enteral feedings of 150 ml/kg per day. All infants were fed human milk and were randomly allocated to fortification with a bovine whey protein fortifier (n = 16) or ultrafiltrated human milk protein (n = 16). All human milk was analyzed for protein content before fortification with the goal of a daily protein intake of 3.5 g/kg. During the study period (mean, 24 days) daily aliquots of the fortified milk were obtained for subsequent analyses of the protein content.
Both fortifiers were well tolerated, and growth gain in weight, length, and head circumference, as well as final preprandial concentrations of serum urea, transthyretin, transferrin, and albumin were similar in both groups. The ultimate estimated protein intake was equivalent in both groups (mean 3.1+/-0.1 g/kg per day). Serum amino acid profiles were similar in both feeding groups, except for threonine (significantly higher in the bovine fortifier group) and proline and ornithine (significantly higher in the human milk protein group).
Protein analyses of the milk before individual fortification provides a new tool for an individualized feeding system of the preterm infant. The bovine whey protein fortifier attained biochemical and growth results similar to those found in infants fed human milk protein exclusively with the corresponding protein intakes.
For term infants, human milk provides adequate nutrition to facilitate growth, as well as potential beneficial effects on immunity and the maternal-infant emotional state. However, the role of human milk in premature infants is less well defined as it contains insufficient quantities of some nutrients to meet the estimated needs of the infant. Observational studies have suggested that infants fed formula have a higher rate of growth than infants who are breast fed. However, there are potential short term and long term benefits from human milk. Commercially-produced multicomponent fortifiers provide additional nutrients to supplement human milk (in the form of protein, calcium, phosphate, and carbohydrate, as well as vitamins and trace minerals).
The main objective was to determine if addition of multicomponent nutritional supplements to human milk leads to improved growth, bone metabolism and neurodevelopmental outcomes without significant adverse effects in premature infants.
Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 3003), MEDLINE (searched August 29, 2003), previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language.
All trials utilising random or quasi-random allocation to supplementation of human milk with multiple nutrients or no supplementation in premature infants within a nursery setting were eligible.
Data were extracted using the standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk and weighted mean difference.
Supplementation of human milk with multicomponent fortifiers is associated with short term increases in weight gain, linear and head growth. There is no effect on serum alkaline phosphatase levels; it is not clear if there is an effect on bone mineral content. Nitrogen retention and blood urea levels appear to be increased. There are insufficient data to evaluate long term neurodevelopmental and growth outcomes, although there appears to be no effect on growth beyond one year of life. Use of multicomponent fortifiers does not appear to be associated with adverse effects, although the total number of infants studied and the large amount of missing data reduces confidence in this conclusion. Blood urea levels are increased and blood pH levels minimally decreased, but the clinical significance of this is uncertain.
Multicomponent fortification of human milk is associated with short-term improvements in weight gain, linear and head growth. Despite the absence of evidence of long-term benefit and insufficient evidence to be reassured that there are no deleterious effects, it is unlikely that further studies evaluating fortification of human milk versus no supplementation will be performed. Further research should be directed toward comparisons between different proprietary preparations and evaluating both short-term and long-term outcomes in search of the "optimal" composition of fortifiers.
The purpose of this study is to describe the processing of human milk to remove its fat content and its use in seven infants with chylothorax.
The mother's milk was centrifuged at 3000 r.p.m. for 15 min at 2 degrees C. After centrifugation, the milk separated into a solidified-fat top layer and a lower liquid portion. The fat-free liquid portion was then poured into collection cups and frozen for the patient's use at a later date. A sample of the mother's milk before and after processing was stored and analyzed for fat, sodium, potassium, calcium and zinc.
The mean fat removed was 5+/-1 g/dl (mean+/-s.d.), which was the same as the pre-fat content of the mother's milk. Seven infants with chylous pleural effusions used the fat-free human milk. All infants started on the fat-free milk after a month of age for an average of 16 days duration (7 to 34 days range). There was no reaccumulation of the chylous pleural effusions with the use of the fat-free mother's milk. Mother's milk electrolytes were similar before and after processing.
Fat-free human milk may be an important additional dietary therapy for infants with chylothorax and may add the immunologic properties of human milk that other feedings cannot provide.
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