Promoting Mother’s Milk Use in the NICU

1. Promoting Mother’s Milk Use in the NICU Jan Schriefer DrPH Assistant Professor Kristen Brown NNP Neonatal Nurse Practitioner Golisano Children’s Hospital at University of Rochester Medical Center

2. Objectives for our session: • Understand the relationship between human milk and the rates of necrotizing enterocolitis infections • Identify the elements that promote the use of human milk in the Neonatal Intensive Care Unit • Practice motivational interviewing skills used for supporting health behavior changes

3. Why should premature infants be fed their mother’s milk? • Because they derive the same benefits that term infants derive • Because, in addition, premature infants derive special, strong benefits

4. Health benefits (all infants) associated with mother’s milk use Long term • Asthma • Obesity • Diabetes type 1 and 2 • Childhood leukemia • CV risk factors (cholesterol, blood pressure) • Intelligence Ip et al. 2007

5. Why should premature infants be fed mother’s milk? Short term • Acute otitis media • Gastroenteritis • Severe lower respiratory tract infection • Atopic dermatitis • SIDS Ip et al. 2007

6. Mother’s milk and the infant’s immune system Breast milk complements and stimulates the immature immune system of the infant, and protects the infant while the immune system is getting up to speed The premature infant’s immune system is particularly immature (hence the high susceptibility to infection) and strong protection human milk provides for the premature infant

7. Mother’s milk & the premature infant Sepsis El-Mohandes et al., 1997 Hylander et al., 1998 Furman et al., 2003 Schanler et al., 2005 (not for donor milk) Sepsis + NEC Schanler et al., 1999 Meinzen-Derr et al., 2008

8. Meinzen-Derr et al. for NRNJ Perinatology 2009;29:57-62 • The likelihood of NEC or death after 14 days was decreased by a factor of 0.83 (CI 0.72-0.96) for each 10% increase in the proportion of total intake as human milk

9. HOW MUCH DOES NEC COST? • Hospital charges for a NEC infection are estimated at $200,000 per survivor Bisquera, JA et al PEDIATRICS Vol. 109 No. 3 March 2002, pp. 423-428. • WOW….one case of NEC is expensive not to mention painful for the baby!!!!!!!

10. Human milk is better “tolerated” than formula Faster gastric emptying =shorter gastric half- emptying time Cavell et al., 1981 HM 48 min vs Form 78 min Ewer et al., 1994: HM 36 min vs Form 72 min Van den Driessche et al.,1999: HM 47 min vs Form 65 min “Full feeds more quickly” (Simmer et al., 1997) Less GE reflux with HM than formula (Peter et al., 2002)

11. NICU Targets Recommended by Vermont Oxford Network Aims • 100% of VLBW infants should receive their mother’s milk for at least the first two weeks of life. • Have moms pumping within 6 hours of delivery Measures • The proportion of premature infants receiving > 50% of the volume of their feedings from their mother’s milk at 2 weeks of life. • The proportion of mothers who are providing breast milk at 2 weeks.

12. NICU Strategies • Educational programs for parents and staff stressing the benefits of human milk • Incorporate an experienced lactation consultant into the NICU setting • Identify procedures for human milk collection, storage, and handling • Encourage provision of maternal contact (skin-to-skin) to stable infants • Include lactation support and breast milk pumping counseling in admission orders • Provide or facilitate access for mothers to an appropriate breast pump in home and hospital setting • Encourage and support breast feeding prior to introduction of bottle/nipple feeding when developmentally appropriate

13. NICU Strategies • Create uniform policies regarding human milk fortification and supplementation with appropriate vitamins and minerals as indicated • Monitor maternal milk supply as a "vital sign" with a pumping log • Track feeding tolerance and selected outcomes including duration of human milk use, days to full feeds, days of TPN use, incidence of feeding intolerance, incidence of NEC, use of human milk fortifiers, and successful establishment of breast feeding • Facilitate communication with obstetricians and primary care providers around issues of lactation initiation and benefits of human milk • Encourage obstetric providers to actively support breast feeding and breast pumping, before the infant is delivered

14. Potential Barriers to Change • Maternal perception that small initial milk volumes are inadequate • Desire to initiate feeds regardless of breast milk availability • Perception of difficulty in collection, labeling, and safe storage of breast milk • Lack of appreciation that mother's milk is a priority in the care of a premature infant • Perception that infants fed human milk grow more poorly than infants fed preterm formula • Lack of knowledge, policy, or available resources regarding fortification of human breast milk

15. NICU Project to Increase Mother’s Milk Use in VLBW Infants and Reduce NEC

16. A New Outcome Measure for NICUs • Percent of NICU Moms with premature infants who are providing Milk: 44%

17. Motivational Interviewing (MI) • Ask permission to discuss breastfeeding and the importance of mother’s milk • STOP GIVING ADVICE about it • Giving advice on health behaviors can backfire and cause people to resist your advice

19. Readiness Ruler 10 • On a scale of 0-10 • How ready are you • To provide breast milk? • To try pumping? • Consider breastfeeding? • 0 = Not ready • 10= Very ready 0

20. MI is like a dance between the care team and parent…follow their lead

21. BRAVO! Breastfeeding An Education Performance

22. Thank you for helping us promote mother’s milk!!