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GLOBAL OVERVIEW AND EVIDENCE

GLOBAL OVERVIEW AND EVIDENCE. DR. MINNIE KIBORE KPA ANNUAL SCIENTIFIC CONFERENCE 2019 April 9 th 2018. Globally, will we reach SDG newborn mortality target to achieve < 12 deaths/1,000 live births by 2030?.

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GLOBAL OVERVIEW AND EVIDENCE

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  1. GLOBAL OVERVIEW AND EVIDENCE DR. MINNIE KIBORE KPA ANNUAL SCIENTIFIC CONFERENCE 2019 April 9th 2018

  2. Globally, will we reach SDG newborn mortality target to achieve <12 deaths/1,000 live births by 2030? Every region of the world experiencing increase in proportion of <5 deaths in neonatal period 22 countries with high newborn mortality rates will struggle to achieve SDG (majority in Africa)

  3. Human Milk: The Ultimate Lifesaving Medicine • Over 820,000 children’s lives could be saved annually with increased breastfeeding rates • Including 500,000 neonatal deaths annually • Nearly 13 percent reduction in all under-5 child deaths Lancet Breastfeeding Series, January 2016

  4. When mother’s own milk is not available…

  5. What does WHO recommend? • For low-birthweight or preterm, infants who do not have access to their mother’s own milk, WHO recommends donor human milk (DHM) from a human milk bank (HMB) as the best alternative2

  6. Critical lack of human milk banks in the region

  7. What is a human milk bank? • The mission of a human milk bank is to promote and supportbreastfeeding by providing to the safe, high quality donor milk to fill a gap for those who need mothers’ own milk but cannot receive it. • A human milk bank is a service established to recruit breast milk donors, collect donated milk, and then process, screen, store, and distribute the milk to meet infants’ specific needs for optimal health.

  8. The Mother-Baby Friendly Initiative Plus Model: Integrating Human Milk Banking into Newborn Care

  9. What does the evidence say?

  10. Is there risk of HIV transmission? • Orloff et al • Human milk was inoculated with HIV-1 or with HIV-1-infected cells. The inoculated milk was Holder pasteurized. • Pasteurization effectively inactivated the infectivity of both cell-free HIV-1 and HIV-1-infected cells. • No virus was recovered after the process, even after repeated subculturing • Ballard et al • Milk samples were spiked with 1 x 10 (8) copies/mL of clade C HIV-1 and treated with flash heat treatment or holder pasteurization. • HIV reverse transcriptase (RT) activity was measured before and after heating • Both methods eliminated bacteria Orloff SL, Wallingford JC, McDougal JS. Inactivation of human immunodeficiency virus type I in human milk: effects of intrinsic factors in human milk and of pasteurization. J Hum Lact. 1993;9(1):13-7 Israel-Ballard K, et al. Viral, nutritional, and bacterial safety of flash-heated and pasteurized breast milk to prevent mother-to-child transmission of HIV in resource-poor countries: a pilot study. J Acquir Immune DeficSyndr. 2005;40(2):175-81.

  11. What about transmission of other viruses and bacteria? • A systematic review of 26 articles investigating pasteurization methods and microbiological content. • Holder pasteurization and other types of human milk treatments inactivated CMV, E.Coli, Staph aureus, Listeria, Bacillus among others. Peila, Chiara et al. Human Milk Processing: A Systematic Review of Innovative Techniques to Ensure the Safety and Quality of Donor Milk Journal of Pediatric Gastroenterology and Nutrition64(3):353-361, March 2017.

  12. What about the immunological activity of donor milk after freezing and pasteurizing? • 100% activity retained for monoglycerides, free fatty acids, linoleic acid • Slightly decreased activity for IgA and sIgA, IgG, lactoferrin and lysozyme • No activity for IgM, bile salt activiated and lipoprotein lipase Douglas B. Tully, PhD, Frances Jones, RN, BScN, IBCLC, and Mary Rose Tully, MPH. Donor Milk: What’s in It and What’s Not. J Hum Lact (17)2, 2001 Lepri L, Del Bubba M, Maggini R, Donzelli GP, Galvan P. Effect of pasteurization and storage on some components of pooled human milk. J Chromatogr B Biomed Sci Appl. 1997;704:1-10.

  13. How about the nutritional content of donor milk after freezing and pasteurizing? • Vitamin content remained largely intact with the exception of Vit C and E that declined • Lactoferrin and Lysozyme concentrations also declined • Israel-Ballard K, et al. Viral, nutritional, and bacterial safety of flash-heated and pasteurized breast milk to prevent mother-to-child transmission of HIV in resource-poor countries: a pilot study. J Acquir Immune DeficSyndr. 2005;40(2):175-81.

  14. Why not just use formula? • Meta-analysis of data from six trials found a statistically significant higher incidence of NEC in the formula-fed group: typical RR 2.77 (95% CI 1.40 to 5.46); RD 0.04 (95% CI 0.02 to 0.07) • 3 trials - statistically significant higher incidence of feeding intolerance in the formula-fed group: typical RR 4.92 (95% CI 1.17 to 20.70); RD 0.10 (95% CI 0.01, 0.19) • Time to full enteral feeds mean - 9 days vs 23 RR 0.33 (0.16 to 0.66) p = 0.0007 • Reduced risk of late-onset sepsis in vulnerable, LBW infants by 19% in first 28 days compared to formula Quigley M, McGuire W. Formula versus donor breastmilk for feeding preterm or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD002971. Simmer K, Hartmann B. The knowns and unknowns of human milk banking. Early Human Development. 2009:701-704.

  15. Is it cost-effective? • Cost of providing DHM to preterm infants is mitigated by a reduced risk of complications and shorter length of stay in NICU • Estimated savings to NICU for every dollar spent on DHM: ~US$11 • In Brazil, the national HMB network has saved $540 million in health care costs annually Wight NE. Donor human milk for preterm infants. Journal of Perinatology. 2001;21:249–254. Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeeding Medicine. 2012;7(1):29–37. SchanlerRJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding human milk versus preterm formula. Pediatrics. 1999;103(6):1150–1157.

  16. Other notable effects • After opening the human milk bank, enteral feedings began 31 hrearlier (p < 0.001) • Feeds of 100 ml/kg/day were achieved 59.5 h before (p < 0.001) and 150 ml/kg/day 52 h before (p = 0.002) • There was a higher consumption of own mother’s milk during the hospital stay, and a higher rate of exclusive breastfeeding at hospital discharge (54% vs 40%). • The percentage of infants who are exclusively breastfed at discharge is 7.6% higher in NICUs with an HMB S. Vázquez-Román et al Clinical impact of opening a human milk bank in a neonatal unit. An Pediatr(Barc). 2014;81(3):155---160 Arslanoglu S, Moro GE, Bellù R, et al. Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants. Journal of Perinatal Medicine. 2013;41(2):129–131.

  17. Summary • For low-birthweight or preterm infants who do not have access to their mother’s own milk, donor human milkfrom a human milk bank is recommended as the best alternative • Pasteurization inactivates viruses and bacteria including HIV and CMV • In comparison to formula, DHM is associated with shorter time to full enteral feeds, lower incidence of feeding intolerance, lower incidence of NEC and lower risk of late onset sepsis • Processing largely retains immunological and nutritional content

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