PQCNC Human Milk NCCC Track LS 1 Feeding Protocols

8/8/2019 PQCNC Human Milk NCCC Track LS 1 Feeding Protocols

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DEVELOPING FEEDING PROTOCOLS

Laurie Dunn

PQCNC Statewide meetingWinston-Salem, NC

January 13, 2011


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Action Plan:

B. Implement feedingguidelines

a. Provide early small volume feeds using moms

colostrum every chance you get as soon as you get itb. Consider using pasteurized donor milk until moms milk

is available

c. Develop unit-specific systematic feeding advancement

guidelines including but not limited to volume,fortification, use of additional protein and an algorithm

for residuals


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Provide early small volume feeds using moms

colostrum every chance you get as soon as you get it

Little evidence to support this practice, though at least

two compelling articles by Rodriguez

In Jnl Perin 2009, detailed potential benefits outlined,stressing cytokine absorption by mucosal/lymphoid

structures, but pointing to the multitude of immune

factors that could also play local and systemic roles

In Adv in Neo Care2010 a small feasibility and safety

study was presented


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Provide early small volume feeds using moms colostrum

every chance you get as soon as you get it

In sum, a safe practice, which may have major potentialbenefit

Needs further studies to see if it allows better feedingtolerance, less vent-assoc pneumonia

Could harm be seen? Aspiration?

Doubt ID risks (CMV not present in colostrum, for example)

May also send powerful message to mother re: importance offresh human milk

Note: colostrum may have protein levels as high as 3gms/100 ml


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Consider using pasteurized donor milk until

moms milk is available

Species specificity maintained

Composition: drop in some components (cells,

immunoglobulins, enzymes) with processing, but not in

nutritional value

Benefits for preterm infants

?role in establishing integrity of GI biome ***it is a safe source of human milk with respect to

potential infectious diseases


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DBM: impacton GI biome

???

Very little information

With preservation of macronutrients, andimmunomodulating factors, potential is strong thatshould prove better than formula

Potential milk components that could, for example,protect against NEC: IgA, EGF, TGF, PAF-acetyl-hydrolase


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Other benefits of DBMtothe

Premature Infant

?role in overall breast feeding support

Cohen, NeoReviews, 2007: it seems somewhat quixotic to counsel a

new mother on the importance of human milk for her preterm infantand encourage her to endure pumping while simultaneously telling

her that until her supply comes in, her baby will be fed formula

Improvement in long-term health

Lucas group in Great Britain did only long-term follow up of donormilk, and found lower blood pressure at 13-16 yrs, and amount of

human milk consumed was inversely related to BP; moreover, better

lipoprotein profiles and lower CRPs compared with formula-fed

infants


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Does Donor Milk Confer the Same

Clinical Advantages as Maternal Milk?

Benefits may be less robust for some aspects, but still

quite beneficial

Older studies did not use fortification

Strongest data is for NEC

****more research is badly needed, related to both

short and long-term outcomes, as well as effects atcellular level*****


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Donor Milk Decreases Risk of

Necrotizing Enterocolitis

*Risk of NEC is reduced significantly with donor milk, 0.35 (0.15-0.81)

DM Formula

Gross 1983 1/42 3/29

Cooper 1984 1/24 3/15

Lucas 1990 1/87 4/80

Schanler 2005 5/78 (6%) 10/88 (11%)

Overall * 8/231 (4%) 20/212 (9%)

Morales and Schanler, SeminarsinPerinatology2007


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Develop unit-specific systematic feeding guidelines

Address advances in volume, initiation and

advancement

Address fortification

Address need for additional protein

?what to do with residuals


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Difficulttask: manyissues without

clear answers

When to start?

How much to start?

Trophic feeds vs. not?

How fast to advance?


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Whento start?

Review articles on potentially best practices suggest

starting enteral feeds within first 1-4 days of life (which

also supports use of colostrum)

Few studies designed as RCT to specifically look at this

(Davey, 1994, in a study designed to look at safety of

feeding with umbilical lines in showed fewer days on TPN,

13 d vs 30 d if fed at 2 days instead of 5)

Trophic feeding studies, and some of the newer studies onfeeding from the networks, give indirect support for this


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Volume initiation and advancement:

too muchor too little?

Nice summaries showing 20-25 ml/kg/d is safe, >50-60ml/kg/d is unsafe

best practice summaries suggest 10-20 ml/kg/d as standardprotocol

Newer small articles looking at 30-35 ml/kg/d are interesting

Tyson and Kennedy (Seminars in Perinatology 2007) suggest

we still really dont know, but to design a study would require~3800 babies!


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Fortification improves growth and bony density

Fortified vs Unfortified Human Milk

y > 600 infants; randomized*

y Growth Weighted Mean Difference

Weight gain (g/kg/d) + 3.6 [2.7; 4.6]Length (cm/wk) + 0.12 [0.07; 0.18] Head circumference (cm/wk) + 0.12 [0.07; 0.16]

y Bone mineral content (mg/cm) + 8.3 [3.8; 12.8]

y Nitrogen balance (mg/kg/d) + 66 [35; 97]

y BUN (mg/dL) +16 [8; 24]

y

Relative Risk Relative Risk Feeding intolerance 2.9 [0.6; 13] NS Necrotizing enterocolitis 1.3 [0.7; 2.5] NS Death 1.5 [0.7; 3.3] NS

Kuschel CA & Harding JE 2005 The Cochrane Library*Some comparisons with partial supplements


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Added proteinimproves growth as well

Requirement for growth estimated (Ziegler) to be 4.3 gm/kg/d for the


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Feeding Protocol Should Improve Feeding

Practices, Safety and and Consistency

from VO Got Milk group: Kuzma-OReilly

Peds 2003,Potentially Better Practices in Neo

Int Care Nutrition

Feeding practice Baseline Implementation

Use of HM as first feed 47% 62%

Day feeds started 9 5

Day to reach 120kcal/kg/d from enteralfeeds

39 +/-26 28 +/- 15

Rates of NEC (3institutions)

16%/6%/5% 6%/4%/6%

And significantly dropped avg length of stay


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Patole. Impactof standardised feeding regimens onincidence of

NEC: a systematic review and meta-analysis of observational

studies. Arch Dis Child Fetal Neo Ed 2005;90:F147-F151

Very nice summary of 6 studies evaluating impact ofstandardized feeding protocols on NEC rates in LBW orVLBW infants in 6 different units; total of ~4000 babies(pre-protocols) and nearly 5000 post-protocols

Different decisions re: start of feeds, advancement,reasons to withhold feeds, but consistency of approach

seemed most important meta-analysis showed reduction of NEC from 4.6% to

2.2%, or a relative risk reduction of 87%


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C. Safetyinthe use of expressed milk

2. Use of donor milk

a. Use only screened pasteurized milk

b. Consider strategies to optimize growth inbabies receiving donor milk

c. Track batch number of milk given to infant


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Consider establishing multidisciplinarycommittee for

nutritional supportinthe ICN: suggested goals

1. Promote exclusive feeding of human milk Consistent message by all staff

Includes mothers milk and donor milk

2. Foster and implement a collaborative feeding plan Plan is family-guided with professional input

Plan solicited from all families

3. Promote optimal growth Modifications of human milk considered first

Growth parameters in context of range and body mass index at birth4. Promote best practice through education of staff and parents

Information provided to families

Education provided for staff


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Consider establishing multidisciplinarycommittee for

nutritional supportinthe ICN: suggested guiding principles

Mothers milk is preferred, donor milk is second choice, for all babies


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Former 27 wk 865 gm infant,

fed all 24 cal MBM plus PP


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former 30 wk 1230 gm infant, fed

all 24 cal DBM plus PP


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Former 25 and 6/7 wk 709 gm

Twin B, fed 24 cal MBM with PP


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Former 25 and 6/7 wk 760 gm Twin A,

fed unfortified MBM until ~3/25

PQCNC Human Milk NCCC Track LS 1 Feeding Protocols

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