Mother’s milk and BPD; Every Drop Counts

Producing milk for your newborn and perhaps even more so when you have had a very preterm infant with all the added stress is not easy.  The benefits of human milk have been documented many times over for preterm infants.  In a cochrane review from 2014 use of donor human milk instead of formula was associated with a reduction in necrotizing enterocolitis.  More recently similar reductions have been seen in retinopathy of prematurity. Interestingly with respect to the latter it would appear that any amount of breast milk leads to a reduction in ROP.  Knowing this finding we should celebrate every millilitre of milk that a mother brings to the bedside and support them when it does not flow as easily as they wish.  While it would be wonderful for all mothers to supply enough for their infant and even more so that excess could be donated for those who can’t themselves we know this not to be the case.  What we can do is minimize stress around the issue by informing parents that every drop counts and to celebrate it as such!

Why Is Breast Milk So Protective

Whether the outcome is necrotizing enterocolitis or ROP the common pathway is one of inflammation.  Mother’s own milk contains many anti-inflammatory properties and has been demonstrated to be superior to formula in that regard by Friel and no difference exists between preterm and term versions.  Aside from the anti-inflammatory protection there may be other factors at work such as constituents of milk like lactoferrin that may have a protective effect as well although a recent trial would not be supportive of this claim.

Could Mother’s Own Milk Have a Dose Response Effect in Reducing The Risk of BPD?

This is what is being proposed by a study published in early November entitled Influence of own mother’s milk on bronchopulmonary dysplasia and costs.  What is special about this study and is the reason I chose to write this post is that the study is unusual in that it didn’t look at the effect of an exclusive human milk diet but rather attempted to isolate the role of mother’s own milk as it pertains to BPD.  Patients in this trial were enrolled prospectively in a non randomized fashion with the key difference being the quantity of mothers own milk consumed in terms of a percentage of oral intake.  Although donor breast milk existed in this unit, the patients included in this particular cohort only received mother’s own milk versus formula.  All told, 254 infants were enrolled in the study. As with many studies looking at risks for BPD the usual culprits were found with male sex being a risk along with smaller and less mature babies and receipt of more fluid in the first 7 days of age.  What also came up and turned out after adjusting for other risk factors to be significant as well in terms of contribution was the percentage of mother’s own milk received in the diet.

Every ↑ of 10% = reduction in risk of BPD at 36 weeks PMA by 9.5%

That is a really big effect! Now what about a reduction in costs due to milk?  That was difficult to show an independent difference but consider this.  Each case of BPD had an additional cost in the US health care system of $41929!

What Lesson Can be Learned Here?

Donor breast milk programs are a very important addition to the toolkit in the NICU.  Minimizing the reliance on formula for our infants particularly those below 1500g has reaped many benefits as mentioned above.  The availability of such sources though should not deter us from supporting the mothers of these infants in the NICU from striving to produce as much as they can for their infants.  Every drop counts!  A mother for example who produces only 20% of the needed volume of milk from birth to 36 weeks corrected age may reduce the risk of her baby developing BPD by almost 20%.  That number is astounding in terms of effect size.  What it also means is that every drop should be celebrated and every mother congratulated for producing what they can.  We should encourage more production but rejoice in every 10% milestone.

What it also means in terms of cost is that the provision of lactation consultants in the NICU may be worth their weight in gold.  I don’t know what someone performing such services earns in different institutions but if you could avoid two cases of BPD a year in the US I would suspect that nearly $84000 in cost savings would go a long way towards paying for such extra support.

Lastly, it is worth noting that with the NICU environment being as busy as it is sometimes the question “are you planning on breastfeeding?” may be missed.  As teams we should not assume that the question was discussed on admission.  We need to ask with intention whether a mother is planning on breastfeeding and take the time if the answer is “no” to discuss why it may be worth reconsidering.  Results like these are worth the extra effort!

Breastfeeding…who says it’s not natural?!

I woke up this morning and as I do everyday, scanned the media outlets for news that would be of interest to you the reader.  Most of the time I am searching for items of interest that I hope will get people thinking about ways to improve care but once in awhile I come across something that elicits a strong emotional reaction and today was the day.

CNN released the following article today entitled

Are there unintended consequences to calling breast-feeding ‘natural’?

The premise of the article is that by reinforcing that breastfeeding is natural we may hamper initiatives to increase vaccination in many parts of the world and in particular North America I would think.  The idea here is that if we firmly entrench in women’s heads that natural is better then this will strengthen the conviction that we should not vaccinate with these “man made” unnatural vaccines.  I am sorry to be dramatic about this but I think the argument is ridiculous and in fact dangerous.

The Definition of Natural

“existing in nature and not made or caused by people : coming from nature”

From the Mirriam Webster dictionary

Breastfeeding satisfies this definition pure and simple and there is nothing that anyone should say to suggest otherwise no matter what the motive is.  The shift from formula  to breastfeeding has been predicated on this notion and a plethora of literature on the subject demonstrating reductions in such things as infections of many kinds, diarrhoea, atopic disease in the first year of life as examples.  In my world of premature infants additional reductions in NEC, bloody stools, have been seen and more recently in some cases improved neurodevelopmental outcomes.

In this case of irresponsible journalism a better approach if you were wanting to use the natural argument with respect to vaccines is to promote just that.

Vaccines are Natural

Someone will no doubt challenge me on this  point as it would be a fair comment to say that there are artificial substances added to vaccines but there is no question the organisms that we vaccinate against are natural.

Think about this for a moment.  All of the vaccines out there are meant to protect us against organisms that exists in NATURE.  These are all bacteria or viruses that have likely existed on this planet of ours for millions of years.  They are found everywhere and in many cases what we are doing when we give such vaccines are providing parts of or weakened versions of these natural organisms in order for us the human to mount a protective response.

This protective response is NATURAL.  If we didn’t vaccinate and came across the fully virulent pathogen in NATURE our bodies would do exactly what they do when a vaccine is given to us.  Our immune system would mount a response to the organism and start producing protective antibodies.  Unfortunately in many cases this will be too little too late as the bacteria or virus will cause it’s damage before we have a chance to rid ourselves of this natural organism.

This is the basis of vaccination.  Allow our bodies a chance to have protection against an organism that we haven’t been exposed to yet so that when it comes we have a legion of antibodies just waiting to attach this natural organism.

CNN Didn’t Get It Right

In the article which is based on a paper entitled the Unintended Consequences of Invoking the “Natural” in Breastfeeding Promotion by Jessica Martucci &  Anne Barnhill the authors admit that the number of families that this actually would impact is small.  the question then is why publish this at all.  Steering families away from thinking that breastfeeding is natural is wrong.  Plain and simple.

If the goal is to improve vaccination rates, focus on informing the public about how NATURAL vaccinations actually are and don’t drag breastfeeding down in order to achieve such goals.

Hopefully someone out there linked to CNN will see this as this is one upset blogger at the moment…

All Things Neonatal Anniversary Edition

It is hard to believe but All Things Neonatal is a year old.  When I started this little concept I had no idea what was to come but am delighted with where it has gone.  While the Blog site itself has about 200 followers, the Facebook page is home to nearly 4200 followers with twitter accounting for over 500 more.  What began as a forum for me to get some thoughts off my chest about neonatal topics or articles of interest has morphed into a place to create change.  As I look back over the last year I thought I would update the readers of this page and other social media platforms what the outcome has been for some of the ideas that I have brought forward.  We have implemented some of these suggestions into our own unit practices, so without further ado here are the updates for some (but not all!) of the changes we have introduced.

Expanding the Circle of Influence With Neonatal Telehealth March 4, 2015

Articles pertaining to use of Telehealth in all aspects of medicine are becoming commonplace.  Locally we have seen expansion of rural sites that can connect with us and a strong desire by existing sites to connect via telehealth for a variety of reasons.  While the thrust of the program was to deliver advice to rural practitioners and support our level I and II units we have found such support leading to possibilities we had not dreamed of. Initial discussions via telehealth and in person have occurred examining whether such treatments as CPAP stabilization and NG feedings could be done in these sites.  Being able to provide such care will no doubt lead to more stable infants being transported to our site and moreover the possibility of moving the care for infants needing only gavage feeding back to their home communities.  Who knows what the future will hold for us as we also look forward to the hiring of a telehealth coordinator for NICU!

A Strategy to Minimize Blood Sampling in ventilated premature and term infants April 13, 2015 

This has been one of my favourite topics to write about.  The ability to sample CO2 from an area near the carina has been demonstrated to be accurate and to save pokes in the long run.  Since writing this piece we have tried it on several babies by using a double lumen tube and found the results to be as accurate as described in the Israeli papers.  In practice though, secretions have proved difficult to handle for longer periods of use as they can travel up the sampling lines and damage the filters in the analyzers.  A costly issue to deal with that we are currently trying to solve.  Being able to continuously sample CO2 and adjust ventilation without drawing frequent blood gases is somewhat of a dream for me and we will continue to see how we can go about making this an established practice but there is work to be done!

Is it time to ban Cow’s Milk Protein from the diet of our high risk NICU population? June 12, 2015

I think most people in Winnipeg would say the answer is yes.  On this front two major positive changes have occurred in the last year in this regard.  The first is that through a generous donation and the blessing of our health region we have been able to expand the use of donor breast milk from < 1250g for a two week period to < 1500g for a one month period.   This wonderful change came about after much effort and was celebrated in December as we not only expanded the eligibility criteria but partnered with the NorthernStar Mother’s Milk Bank to provide donor milk to Manitobans (Manitobans Now Able To Support Premature Infants Through Donor Milk Program!).  The other change which the above post also spoke of was the potential to eliminate bovine milk altogether with the use of Prolacta (Human based human milk fortifier).  While we don’t have the approval to use the product as traditionally indicated, we have used it as a “rescue” for those patients who demonstrate a clear intolerance of bovine fortifier.  Such patients would traditionally receive inadequate nutrition with no other option available but now several have received such rescue and we look forward to analyzing the results of such a strategy shortly!

Winnipeg Hospital About to Start Resuscitating Infants at 23 weeks! September 25, 2015

Without question the most talked about change was the change in threshold for recommending resuscitation from 24 to 23 weeks.  The change took almost a year to roll out and could not have been done without a massive educational rollout that so many people (a special thank you to our nurse educators!) took part in.  Looking back on the year we have now seen several infants at 23 weeks who survived with a small minority dying in the newborn period.  It is too early to look at long term outcomes but I think many of us have been surprised with just how well many of these children have done.  Moreover I believe we may be seeing a “creep effect” at work as the outcomes of infants under 29 weeks have also improved as we developed new guidelines to provide the best care possible to these vulnerable infants.  Antenatal steroid use is up, IVH down and at least from January to September of last year no infants died at HSC under 29 weeks!  I look forward to seeing our results in the future and cannot tell you how impressed I am with how our entire team came together to make this all happen!

What’s Next?

I wanted to share some of the initiatives that came forward or were chronicled on these pages over the last year to show you that this forum is not just a place for my mind to aimlessly wander.  It is a place that can create change; some good, some great and no doubt some that won’t take.  It has also been a place where ideas are laid out that have come from afar.  From readers anywhere in the world who ask a question on one of the social media sites that get me thinking!  I have enjoyed the past year and expect I will continue to enjoy what may spring forth from these pages for some time to come.  Thank you for your contributions and I hope you get a little something out of this as well!

 

Manitobans Now Able To Support Premature Infants Through Donor Milk Program!

 

What follows is a news release from today that begins a new chapter in supporting preemies here in Manitoba.  There are far too many people to thank who made this possible but to all I say THANK YOU!

New Breast Milk Drop Site at the Birth Centre  Benefits Premature and Sick Infants

DECEMBER 2, 2015 (WINNIPEG, MB) – The Winnipeg Regional Health Authority (WRHA) announced today a milk drop site is being established at the Birth Centre (603 St. Mary’s Road) in Winnipeg. Minister Blady announced the collaboration between Women’s Health Clinic and the NorthernStar Mother’s Milk Bank.

Registered donations of breast milk will be accepted by the Birth Centre in Winnipeg and transported for pasteurization at NorthernStar’s lab in Calgary. The pasteurized human milk from donors will be used to help premature and sick babies in neonatal intensive care units in hospitals, and in the community, across Canada.

“There can be a number of reasons why a mother may not be able to provide breast milk for her baby,” said Health Minister Sharon Blady. “This new Milk Drop site will help families ensure premature and sick babies get the best possible start in life by providing pasteurized donor human milk an infant needs to not only survive, but thrive.”

The minister noted that establishing a human milk drop supports recommendations made in the Manitoba Breastfeeding Strategy, released in 2013.

The WRHA purchased a freezer for the milk drop with funds provided by the Winnipeg-based Siobhan Richardson Foundation. The Birth Centre will house the freezer and ensure the safe handling and storage of donated human milk before it is shipped to Calgary for processing.

“My thanks and appreciation goes out to the Siobhan Richardson Foundation for supporting new moms as well as our tiniest patients,” said Dana Erickson, Chief Operating Officer, Health Sciences Centre and WRHA executive responsible for child health and women’s health.  “This milk drop initiative in Manitoba is a reality because of their vision and generosity along with the commitment and hard work of our excellent health care team.”

Studies have shown premature infants who receive the nutrients of pasteurized human milk from donors, when their mother’s own milk is not available, have fewer long-term health needs. The use of pasteurized donor human milk instead of formula can reduce the risk of serious health complications in pre-term infants. Having a dedicated milk supply for these babies can save lives.

“Several health outcomes for preterm infants are improved when pasteurized donor human milk, rather than formula, is used in these high risk infants,” said Dr. Michael Narvey, section head of neonatology for the Winnipeg Regional Health Authority. “Pasteurized donor human milk has been proven to reduce the chances of an infant developing a serious condition of the bowel which can lead to lifelong and serious health consequences.  Babies weighing less than 1500 grams are significantly less likely to develop this serious condition when they are given pasteurized human milk from donors as opposed to formula.”

Starting January 4, 2016, the Birth Centre will accept breast milk from donors approved by NorthernStar Mothers Milk Bank (formerly the Calgary Mothers Milk Bank). Women must first contact the NorthernStar Mothers Milk Bank to be screened prior to dropping off their donation at the Birth Centre. Women will then need to have further screening including blood tests by their primary care provider to confirm if they qualify as a donor. These donations will be sent to the milk bank’s lab in Calgary where the donor milk is tested, pasteurized, and then prioritized for premature and sick infants.

“We are excited to see Manitoba’s first Milk Drop opening in Winnipeg,” said Janette Festival, Executive Director, NorthernStar Mothers Milk Bank. “This Milk Drop is a testament to cooperation of multiple groups who believe in the medical power of donor human milk for babies in need. We hope this new ‘drop’ will encourage women in the Winnipeg area to consider becoming a milk donor.”

Women’s Health Clinic operates the Birth Centre facility and community programming, and will be collecting the donations and shipping them to the milk bank for testing and pasteurizing.

“Women and families come to the Birth Centre every day for a range of maternal health and wellness services, making it an ideal location for the new Milk Drop site,” said Joan Dawkins, Executive Director of Women’s Health Clinic. “Women who are interested in donating can get the process underway now by contacting NorthernStar Mothers Milk Bank.”

To donate, mothers can contact the milk bank at 1-403-475-6455 or visit NorthernStarmilkbank.ca.

For more information contact:

Melissa Hoft

Winnipeg Regional Health Authority

P: (204) 926-7180 C: (204) 299-0152 E: mhoft@wrha.mb.ca

 

Amy Tuckett

Women’s Health Clinic (Birth Centre)

P: (204) 947-2422 ext. 147 C: (204) 996-6289 E: atuckett@womenshealthclinic.org

 

Janette Festival

NorthernStar Mothers Milk Bank

P: (403) 475-6455 E: director@northernstarmilkbank.ca

 

Halloween Edition: 5 Spooky Thoughts About Neonatology in 2015

The 10th Annual Bowman Symposium did not disappoint!  World class presenters gathered to provide a top to bottom update on a variety of topics spanning from the nervous system to Genetics.  After a day and a half of presentations though I was left with some concerning (scary) thoughts and it seemed Halloween was the perfect time to share them with you!

How Much Oxygen is Just Right?

Dr. Ola Saugstad provided a wonderful history of the use of oxygen in Neonatology.  After his talk it was clear that oxygen is most definitely a drug with its most concerning side effect being the production of oxygen free radicals in the body.  If we are too restrictive aiming for saturations of 85 – 89% we spare our infants ROP but put them at greater risk of death.  Too high at 91 – 95% and they may survive but with more ROP (BOOST  and SUPPORT).  If we resuscitate with 100% oxygen that is associated with worse outcomes but so too is 21% in our newborns < 28 weeks.  The NRP would advise us to use 21 – 30% to start in this group for resuscitating but he recommends 30%.  Certainly the recent publication by Jack Rabi out of Calgary suggests room air may in fact be harmful in this group as a starting point! After 50 years of research we still don’t know what to give newborns to help them start their life outside the womb.  Scary.

It’s All In The Name

Next up is Dr. Aviva Goldberg who raised a very important point that I had not considered before.  In every researchers quest to come up with a catchy name for their study that people will remember, the connotation is equally important.  The SUPPORT study came under heavy fire (commentary here) after a surprising increase in mortality was found in the arm randomized to 85 – 89% saturations.  Families sued the investigators and in their complaints they were angry about being misled.  How could a study that was named the SUPPORT study do anything other than help their children?  The title in and of itself they argued misled them as they never would have thought increased mortality could be a risk.  Researchers make sure you test out your clever names with parents before finalizing your studies.  The decision otherwise could come back to haunt you…

Jury Still Out on Bevicizumab (Avastin) for ROP

Dr. Ian Clark provided an overvue of the current state of thinking on treating ROP.  For central disease in Zone 1 Avastin is preferred but for more peripheral disease laser seems to still be recommended due to its decisiveness in eliminating the disease without affecting future vision.  Concerns continue though with respect to potential systemic effects of putting an anti-VEGF medication in the eye.  Can it leak out and cause disruption to angiogenesis in other organs and in particular the brain? A recent poster at the CPS meeting in Toronto entitled  Neurodevelopmental outcomes of extremely preterm infants treated with bevacizumab for severe retinopathy of prematurity indicates that there may be greater impairment in those receiving injections.  There are several flaws in this paper though including greater numbers of males (we always do worse), more sepsis and worse SNAP-II scores in the injection group but the results have been making it into discussions leaving Ophthalmologists wondering if they are doing the right thing…very scary.

Cow’s Milk Human Milk Fortifier Is Safe For Premature Infants… Or is it?

Next up was Dr. Bill Diehl Jones who presented in vitro data on the effect of these supplements with respect to their contribution to oxidative stress.  Such stress has been associated with BPD, NEC and ROP to name a few disorders in preemies.  A paper published this week in which intestinal cells were exposed to human milk with HMF experienced significantly increased intracellular oxidation, cell damage, and cell death compared to those exposed to just breast milk.  A paper from 2013 indicates that premature infants fed HMF experience increasing levels of urinary isoprostanes (a measure of oxidative stress). We know that infants receiving these products experience better growth and bone density than those without exposure but is there a cost?  Will further research in this area drive us towards exclusive human milk based diets?  The seed that has been planted in my head now questioning the safety of this product I use every day…a little frightening.

Curtailing Antibiotic Use And The Coming Black Swan

John Baier spoke about practice variation between Neonatologists in terms of the decision to prolong antibiotics or not in the face of negative cultures.  While we do have variation, the good news is that we overall have cut down our tendency to prolong past 48 hours in the face of negative cultures.  If we practice long enough though, the Black Swan will eventually rear its ugly head.  The Black Swan is an exceptionally unusual event but one that has dramatic impact.  How will we respond when a patient becomes septic after 48 hours and the antibiotics were stopped?  Will we panic and change our practice entirely to avoid the internal pain again of feeling like we made a mistake or remember that we have saved countless infants from the long-term effects of indiscriminate use such as NEC, atopic disease and obesity in childhood just to name a few.  It is this nagging doubt I have about how we will react that gives me cause to worry!

Finishing With a Miracle

It doesn’t seem right to end on a down note so I thought it would be worth celebrating that a cure has been found for something very scary.  Hypophosphatasia is a rare disorder of the bone which was previously lethal in many cases.  Thanks to research that our own Dr. Cheryl Greenberg led here in Canada we are able to successfully treat these children now.  The Bowman symposium showed us incredible videos of such treated children and to end this post I found this video from Youtube of Gideon who was one of these patients treated with FDA Okays Asfotase Alfa (Strensiq).  If you would like to leave this post with a smile on your face until next Halloween have a look at the video!

Reducing length of stay for preterm infants. Ask them, don’t tell them when to feed!

Will that be q2h, q3h or q4h feeding?  When I started my residency in Pediatrics that was the question I needed to ask before writing an order to start oral feeding in a preterm infant.  At the time it seemed perfectly reasonable but I have to admit the question for me was “What if they aren’t ready?”.  Does a baby who won’t take the breast or bottle at the 3 hour mark clearly show they aren’t able to feed or that they really are just not ready to feed?  We commonly say that children are not small adults.  Hospitalized adults commonly will utter the words “I’m not hungry” when their food tray is brought to them.  This may be a reflection of what has been put before them rather than whether hunger exists or not but they seem to be able to be ready to eat so why not children and by extension preterm infants in the NICU.

My approach to feeding premature infants was fairly consistent until about 10 years ago when nurses in Edmonton, Alberta (in a level II unit) introduced me to “semi-demand” feeding.  What I find interesting about this, is the paucity of evidence that existed on the subject.  At the time, the evidence really centred around one paper but the impact of the approach was undeniable.  In 2001 McCain et al published the randomized controlled trial involving 81 infants A feeding protocol for healthy preterm infants shortens time to oral feeding.  The concept of semi-demand feeding was to assess each infant (once preterms reached 32-34 weeks CGA) before a feed for signs “of feeding readiness”.  This was accomplished through offering non-nutritive sucking every three hours before a scheduled feed.  If the infant was found to be in a wakeful state, the oral feeding was commenced but otherwise the infant was left for 30 minutes with NNS attempted again.  If the infant was still not ready then a gavage would be given.  The key here is that the infants were monitored for signs of feeding readiness rather than insisting upon an arbitrary time for their next feed.  The study findings were a halving of the time it took to reach full feeds (10 days in control vs. 5 days in semi-demand) with no difference in weight gain observed between groups.  The latter point is worth emphasizing, as the concern with semi-demand has been from some that in a worst case scenario where feeds took place every 3.5 hours a baby would miss one feed compared to another infant on a q3h schedule.  This fear though does not bear out in the study.

The experience in the centre I currently work at has been so positive that it is hard to find a patient that is not fed in such a way whether a physician orders the approach or not!  What is truly fascinating to me is how effective the approach seemingly is and has been adopted again with very little evidence compared to that traditionally needed to change a practice in the neonatal world.  Interestingly, although we can’t say for sure we have noticed year over year declines in length of stay for infants born with a birthweight of 1500 – 2000g since the introduction of semi-demand feeding.  This could be a coincidence as this has not been the only practice change in our units but it certainly is interesting.

I was delighted to see a paper published this week on the topic by Wellington and Perlman.  This was a Quality Improvement project entitled Infant Driven Feeding in Premature Infants: A Quality Improvement Project.  This study compared three periods.  The first was one in which physicians set the feeding schedule (PDF), the second a training period for a new system and the last the infant driven period (IDP).  In the PDF phase, the physicians would order one oral feed a day, then two, three and so on when the full feed was attained at each prescribed level.  In the IDF period an assessment sheet for feeding readiness would be completed before each attempt and the decision to offer an oral feed based on the perceived ability to feed at that time.

While this study was not an RCT it is a much larger group of patients than the study by McCain.  This comparison was between 153 PDF vs 101 IDF patients.  Feeding readiness assessments would start at 32 weeks CGA but feedings would not be offered by either approach until 33 weeks CGA similar to our own approach to feeding for the most part.  The use of IDF made no difference to timing of first attempt at nipple feeding.  The time to attain full nipple feeding was where significant differences in approach became apparent.

Time to reach full nipple feeding by gestational age at birth:

<28 weeks: IDF versus PDF group reached full NF 17 days sooner (374/7 vs 40 weeks; p=0.03)

28–316/7: IDF versus PDF group reached full NF 11 days sooner (35 4/7 vs 37 1/7 weeks; p<0.001)

≥32 weeks: IDF versus PDF group reached full NF 3 days sooner (354/7 vs 351/7 weeks; p=0.04).

Affect on discharge

<28 weeks GA, no difference between the IDF versus PDF group (41 3/7 vs 39 4/7 weeks; p=0.10).

28–316/7 weeks GA, IDF group were discharged 9 days earlier (366/7 vs 381/7 weeks; p<0.001).

≥32 weeks GA, the IDF group were discharged 3 days earlier (36 weeks vs 363/7 weeks;

p=0.048)

Although the findings are clear there does need to be the usual acknowledgement that this is not the gold standard RCT but the practice change in the unit was done pretty carefully.  The concept is one that makes a great deal of sense regardless.  The lack of difference in discharge for the smallest infants makes some sense as it may well be apnea of prematurity that is the last to resolve.  There is no disputing however the benefit in earlier discharge for the 28 – 31 6/7 week group.  They achieve feeding earlier and go home faster.  From a family centred approach this is the best of both worlds.  One should not write off the use of this technique in the smallest infants either as they will have their care normalized much earlier with the NG tube being removed and the parents getting to participate and practice feeding much earlier in their course. Although not measured in this study, it would be intriguing to look at the number of patients who were admitted to hospital post discharge with failure to thrive.

Imagine the impact as well on hospital length of stay data if you multiple the reductions in length of stay by the total number of patients seen in these gestational age categories each year.  This almost certainly can represent over a year of patient days for many hospitals.

As I see it the direction is clear.  We should not force our premature infants to follow a schedule that works for us.  Rather use the cues that only they can provide to tell us when and how much milk they desire.  Both the parents, infants and our hospitals will benefit.

Shouldn’t the newborns of same-sex male partners be entitled to breast milk too?

There is the potential for a very significant issue to arise in the NICU environment in the coming years.  As I was preparing the last blog piece following the decision by SCOTUS to allow same-sex marriage in all 50 states I began to think about the so-called ripple effect.  In other words, now that the law has been changed, what impacts could this have that might have been unforeseen.  The first thought that crept into my mind was that as male same-sex parents they would read the same literature that promotes breast milk feeding in the NICU and no doubt want the best for their infant in the NICU or for that matter any baby.  In many NICUs however there are weight or gestational age restrictions indicating who will receive donor breast milk if the mother is not able or not willing to produce her own.  In our unit for example we given DBM to all babies currently under 1250g and those recovering from NEC or other bowel surgery.  Might men in a same-sex marriage who have adopted a child or used a surrogate who is not willing to breastfeed demand the same?

In looking into this I came across a very strange story from 2013 in which a nurse in the UK offered to “rent her breasts” to gay parents. The story at the time caused a fairly big stir as it raised a number of questions as to safety and the morality of it all.  In some ways it was ahead of its time as there have been a number of articles recently addressing the very issue of safety of milk (will be addressed further in the article obtained outside of HMBANA approved breast milk banks.

As same-sex couples increase and many then choose to have children of their own to raise what demands will be made of access to breast milk?  There is no question “breast is best” and I have either written or posted to Facebook many articles suggesting decreased incidence of allergy, necrotizing enterocolitis, improvements in the microbiome and many other benefits as well.  What do we do in the situation of the same-sex family who declares that they want to provide breast milk to their infant in hospital as it is the best source of nutrition for their infant.  If we say for example that their 2 kg, 34 week infant is too big to qualify for DBM is this fair given that they have no option for producing their own milk in the setting of male same-sex partners?  Could we as health care providers be labelled as discriminating?

One option is to allow such parents to bring in their own milk but then where do they source it from?  Milk purchased online or from the community may be contaminated with bacteria, viruses or contain some cow’s milk as some recent publications have demonstrated. Can we knowingly allow families to bring such milk into the hospital to feed their infant?  Perhaps, but only if we have medical legal safeguards in place that protect the hospital from knowingly allowing patients to bring in milk which could be contaminated.  Waivers of liability would need to be in place in each hospital permitting such sourcing of milk.  If however we strongly discourage such practice will we direct them to the milk bank supplying our local hospital.  Herein lies the challenge though.  If availability of volume was not an issue, we could provide to all infants in the unit but the reality is there is simply not enough to go around.  Furthermore, the larger the infant, the more donor milk they utilize and the more depleted the supply becomes for those of our smallest infants who are most in need of avoiding formula.  Finally, who should pay for this milk if the family cannot produce any as in this situation.  This is not a case of a mother who could produce but chooses not to but rather a family who is desperate to use what they have read is best but physically is incapable of producing.  The same of course could be said for those women who try and cannot or due to prior surgery are unable to produce milk.  I believe this is an issue that will come up across the US and Canada and I will be interested to see how it plays out and what role Bioethics may play in helping to resolve some of these questions.

This will be a slippery slope.  If male same-sex parents are provided with free access to donor milk I don’t see how donor milk will not be made available to all families who cannot provide their own.  Why would the male parents who biologically be unable to provide milk be given this “liquid gold” while other mothers who are pumping round the clock, taking domperidone and seeing a lactation consultant and getting only drops be denied as their newborn is 1600g and above the weight cutoff.  I hope you can see the issue of equity popping up in this discussion.

Finally why not allow those parents who are male same-sex partners to simply pay for the milk they need if they don’t qualify for “free” milk under a unit’s program?  Sadly the issue then becomes one of equity again.  Do we want to care for infants in an environment where the wealthy who can afford to pay for the donor milk from an HMBANA milk bank get it and the poor are only offered formula?  I have to admit I realize there are health care systems where this is the case but in Canada where we have a socialized medical system this kind of two tiered system would cause many to become nauseated.

I fear that this issue will come up as the number of people marrying and choosing to have children in same-sex relationships increases.  If it leads to a 100% human milk diet for infants in the NICU I would say that is a good thing but I think the road like Winnipeg will be paved with many potholes that we will have to do our best to navigate around.

Are Pediatricians really saying that children raised by heterosexual couples are healthier than from same-sex parents?

This is a lengthier piece than normal but the message at the end is critical to disseminate so I would encourage you to share this if you wish with others to prevent misinformation from being propagated in the media by the sensationalism of a claim by a group of Pediatricians. 

My Facebook page became awash in rainbow overlaid posts on Friday.  Very quickly I realized as did most of the developed world, that the US Supreme Court ruled in favour of same-sex marriage and just so no one thinks that this will turn into a homophobic piece, I celebrated the change along with many friends and fellow Social Media colleagues.

After the initial excitement began to wane I came across a press release that I found a little shocking given that I belong to the group of people (as a Pediatrician not a member of the organization) that released the statement shown below.  The statement is from the American College of Pediatricians

Tragic Day for America’s Children

by ADMIN3 on JUNE 27, 2015 in PRESS RELEASE

Dr. Michelle Cretella, President of the American College of Pediatricians in response to the SCOTUS decision today stated, “[T]his is a tragic day for America’s children. The SCOTUS has just undermined the single greatest pro-child institution in the history of mankind: the natural family. Just as it did in the joint Roe v Wade and Doe v Bolton decisions, the SCOTUS has elevated and enshrined the wants of adults over the needs of children.“

Although it is disappointing only 4 of the 9 justices heeded the scientific findings in the College Brief, the College will continue to proclaim the important unique contributions of both mothers and fathers to the optimal nurturing of all children.

As I went to their website and read about this organization it became clear that this group is mixing Church and State so to speak.  Their mission statement states:

Mission of the College

The Mission of the American College of Pediatricians is to enable all children to reach their optimal physical and emotional health and well-being. To this end, we recognize the basic father-mother family unit, within the context of marriage, to be the optimal setting for childhood development, but pledge our support to all children, regardless of their circumstances.

Who are these people and why are they speaking out in such contrast to the American Academy of Pediatrics who in 2013 published their technical report in support of same-sex couple raising children.  The AAP which has about 64000 members dwarfs the membership of possibly 200 Pediatricians that comprise the American College of Pediatricians.  The smaller group was formed when a group of Pediatricians became upset in 2002 of the AAPs position that endorsed same-sex couples adopting children.   The trouble of course with an organization such as this is that their name implies some degree of credibility but in looking at their track record on this issue they have little to none.  They are a group that seems to ignore the literature discussed below in favour of quasi-scientific religious literature suggesting harm from such family units.  The support of the AAP, the dominant organization in the field was made clear June 26th with this statement.  I particularly like the quote from the president of the AAP.

“Every child needs stable, nurturing relationships to thrive, and marriage is one way to support and recognize those relationships,” said Sandra G. Hassink, MD, FAAP, AAP president. “Today’s historic decision by the U.S. Supreme Court supports children in families with same-gender parents. If a child has two loving and capable parents who choose to create a permanent bond, it’s in the best interest of their children that legal institutions allow them to do so.”

Putting aside my natural suspicion of the American College of Pediatricians, it did lead me to ask an important question.  Are kids truly better off being raised in a heterosexual marriage?  Perhaps there is evidence to show that indeed this is something that we as Pediatricians should be promoting.  Looking at the evidence though would suggest otherwise or at least that there is no difference.  In 2014 the largest study to date was published by Australian researcher Crouch et al involving 315 parents representing 500 children from same-sex marriages (complete study here).  The study involved a questionnaire that would then be compared against population data to see if differences exist between parental units.  A little over two-thirds of the parental units were Lesbian.  The results demonstrated that in virtually all measures of child health the parental units were equivalent.  Curiously, sense of stronger family cohesion was present with the same-sex groups.  Possible reasons for this may be related to the way in which children are brought into this world in the two parental unit types.  Given that people of the same-sex must plan (there are exceptions no doubt) to procreate there is little chance of the unexpected pregnancy occurring.  These are almost all “wanted or chosen” children as opposed to the situation encountered in many pregnancies that are not planned.  That is not to say that these children can’t or won’t be loved but the likelihood seems much lower in a LGBT parenting situation due to the planning that is generally required.  While the research did not go on to elaborate on why the cohesion might be enhanced this is just my speculation.

Adding to this piece of evidence that these children are likely to have equivalent health to the traditional family rearing model is a well-timed report that surfaced the same week as the Supreme Court Ruling.  The report from the Huffington Post challenges that after reviewing 19000 studies on same-sex parenting there can be no conclusion that the children of such families are worse off in any measure of health. Where the above group derives their mission statement from then is certainly not based on science but rather perception.

Back to the American College of Pediatricians (ACOP).  I mentioned earlier that I was suspicious of the ACOP and what they portray as advocating for a child’s best health.  As a writer of a blog I firmly believe that the buck stops at me with respect to content.  If I have a guest writer I am responsible for their content as well as my own.  I took the liberty of reviewing a recent piece from their blog and what I saw both shocked me and left me with the certainty that this group is not so much advocating for the health of children as condemning those lifestyles that they do not believe fit the mother-father mold.  On June 5th the group released the following piece entitled “P” is for Pedophile.  Please click on the link if you have the stomach for it but to give you a taste of what they are talking about here is the quote from the first line of the entry.

“Driving in this morning I began to wonder. Why isn’t the movement of LGBT not the PGBT movement: “P” for pedophile?”

If this group had any credibility by having a professional sounding name, my hope is that this post will spread wide and far to help discredit this organization.  The evidence suggests that members of the LGBT community raise just as healthy kids as any of us and any attempts to smear people simply for who they happen to bond with for life amounts to hate and there should be no room in Pediatrics or any other field of medicine for that.

Is it time to ban Cow’s Milk Protein from the diet of our high risk NICU population?

The picture looks ridiculous.  Why does this seem so unnatural yet we feed babies this same product around the world.  Granted they don’t drink it from the source as this man is but the liquid is in essence the same.  As the saying goes, “Cow’s milk is for baby cows”.  When you put it that way it helps put in context the question posed as the title of this post.  Should we be surprised that the consumption of a milk meant for another species might have some side effects at a population level if fed to enough infants; especially those with fragile bowel due to prematurity or other high risk condition compromising blood flow to the gut.

The following piece was written by Kari Bonnar with contributions from Sharla Fast both Registered Dieticians in our NICUs.  It has been recognized for some time now that the use of donor milk in our highest risk premature infants is associated with less NEC and based on a previous review of the evidence we have been using DBM for the past several years.  What this post explores though is the potential for further benefit by taking the next step.  That is to ask the question; what additional benefit may be gained by replacing all sources of Cow’s Milk protein in this population.  I am delighted to present their review of the literature here as I am sure you will find it as informative and thought provoking as I have.

The health benefits of human milk for all infants, including those born extremely premature, have been increasingly recognized and published.¹ The American Academy of Pediatrics policy statement on breastfeeding and the use of human milk recommends that all preterm infants receive human milk including donor human milk if mother’s own milk is unavailable.² When compared with a diet of preterm formula, premature infants have improved feeding tolerance and a lower incidence of late onset sepsis and necrotizing enterocolitis (NEC) when fed their mothers’ own milk.³  For mothers of extremely premature infants, providing sufficient milk to meet their infant’s needs is a common challenge. Pasteurized donor human milk has been made available to this population in WRHA since 2011 as it has been found to be well tolerated and is also associated with a significantly lower incidence of NEC.⁴

However, as the sole nutritive substance, human milk does not meet the macronutrient and micronutrient requirements of preterm infants. Multi-nutrient fortifiers are required to provide additional protein, minerals and vitamins to ensure optimal nutrient intake and neurodevelopmental growth.⁵  Prolacta Bioscience has recently launched in Canada with their human milk-based fortifiers, which are gaining popularity due to the ongoing research and success with these products in the United States, Austria, and now Canada.⁶ It is a new and novel approach that is proving to be most beneficial in reducing neonatal morbidity and mortality rates.⁷

In infants fed an exclusive human milk diet, Sullivan et al. found a reduction in medical NEC of 50% and surgical NEC of almost 90% compared to a diet containing cow’s milk-based products.⁷ To date, there is no other intervention that has had such a marked effect on the incidence of NEC.⁸ Abrams et al. found that for every 10% increase in intake of anything other than an exclusive human milk diet, the risk of NEC increases by 11.8% and the risk of surgical NEC increases by 21%, both with a 95% confidence interval.⁹

 Patel et al. found that for every dose increase of 10ml/kg/day of human milk over the first 28 days post birth, the odds of sepsis decreased by 19%.¹⁰ Further to this, they found that overall NICU costs were lowest in very low birth weight (VLBW) infants who received the highest daily dose of human milk. Similarly, Abrams et al. reported that for each 10% increase in the intake of other than exclusive human milk diet, there was an 18% increase in risk for sepsis.⁹ In addition to predisposing the infant to other morbidities in the preterm population, and subsequent neurodevelopmental disability, sepsis significantly increases NICU costs by 31%. This translates into higher societal and educational costs for VLBW infants who survive sepsis with neurodevelopmental disability.^{10 ,11}

A reduction in the number of days on total parenteral nutrition (TPN) was found by Cristofalo at al. with the use of an exclusive human milk based diet, in addition to reduction in sepsis and NEC.¹² These same findings have been documented by Ghandehari et al. which reflect that an exclusive human milk diet leads to improved feeding tolerance and therefore, a decrease in total TPN days.¹³ Given that TPN is often the cause of late onset sepsis, the reduction of TPN days is imperative and almost always translates into decreased length of stay.¹⁴ Abrams et al. found that duration of TPN was 8 days less in infants receiving a diet containing <10% cow’s milk-based protein versus ≥ 10%, another recognizable dose related finding.⁹

It is well documented that increased growth leads to a decreased incidence of cerebral palsy and poor neurodevelopmental scores at 18-22 months corrected age, therefore adequate growth (weight, head circumference and length) is crucial in this population.¹⁵ The study by Hair et al. followed a standardized feeding protocol with early and rapid advancement of fortification with donor human milk derived fortifier and found that growth standards were being met and resulted in a marked decrease in extrauterine growth restriction.¹⁴  Cristofalo et al. study also compared growth rates, which were found to be slightly slower in the human milk fortified versus cow’s milk fortified arm of this study. However, it was mentioned that the small differences could be prevented with further adjustments in fortifier to improve rates of growth, as shown by Hair et al.^{12, 14} Abrams et al. confirms in their findings that growth rates were similar among human milk-based and cow’s milk-based fortification.⁹ This is a popular area of ongoing research with many abstracts also showing adequate growth rates with use of human milk-based fortifiers.

In closing, the review of current evidence clearly indicates that a diet of exclusive human milk is associated with lower mortality and morbidity in extremely premature infants without compromising growth and should be considered as an approach to nutritional care for these infants. Further research is needed to fully capture the extent to which using exclusive human milk diets actually reduce overall healthcare costs via improving the short and long term outcomes of extremely premature infants. Research to date only explores the financial impact for the first few years of life; therefore the true costs of these major morbidities are vastly underestimated and underreported. There are many unpublished trials and abstracts that are currently in process that will only strengthen the shift toward exclusive human milk-based diets, ideally making this common practice among Canadian centres in the very near future.

1 American Academy of Pediatrics. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005; 115:496-506

2 American Academy of Pediatrics. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:3;e827-41

3 Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: Beneficial outcomes of feeding fortified human milk vs preterm formula. Pediatrics 1999;103:1150-7

4 Boyd CA, Quigley MA, Brocklehurst P, Donor Breast milk versus infant formula for preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2007;92:F169-75

5 Agostini C et al. Enteral nutrition supply for preterm infants: commentary from the European society for pediatric gastroenterology, hepatology, and nutrition committee on nutrition. JPGN 2010;50:1:85-91

6 Prolacta Bioscience, Industry, California: product description. http://www.prolacta.com/human-milk-fortifier

7 Sillivan S, et al. An Exclusively Human Milk-Based Diet is Associated with a Lower Rate of necrotizing Enterocolitis than a Diet of Human Milk and Bovine Milk-Based Products. J Pediatr 2010:156;562-7

8 Bell EF. Preventing necrotizing enterocolitis: what works and how safe? Pediatrics 2005:115;173-4

9 Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater Mortality and Morbidity in Extremely Preterm Infants fed a diet containing cow milk protein products. Breastfeed Med. 2014:9;1-8

10 Patel AL, Johnson TJ, Engstrom JL, Fogg LF, Jegier BJ et al. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatology 2013:33:514-19

11 Ganapathy V, Hay JW, Kim JH. Cost of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med. 2012:7;29-37

12 Cristofalo EA, Schanler RJ, Blanco CL, Sullivan S, Trawoeger R, et al. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. J Pediatr. 2013;1-4

13 Ghandehari H, Lee ML, Rechtman DJ. An exclusive human milk based diet in extremely premature infants reduces the probability of remaining on total parenteral nutrition: a reanalysis of the data. BMC. 2012:5;188

14 Hair AB, Hawthorne KM, Chetta KE, Abrams, SA. Human milk feeding supports adequate growth in infants ≤1250 grams birth weight. BMC. 2013:6;459

15 Ehrankranz RA, Dusiuk AM, Vohr BR, Wright LL, Wrage LA, et al. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics. 2006.117:4; 1253-61

Bressure, Lactavists and Brelfies

Nineteen seventy two was notable for many things aside from the year of my birth.  Canada defeated the Soviets in the summer series, the Watergate scandal took down a Presidency, The GodFather was released and for the purposes of this post breastfeeding rates in the US reached an all time low of 22%.  For an excellent review of the history of breastfeeding the article by AL Wright is excellent.

Rates of breastfeeding began a steady decline in the 1960s as more and more women entered the workforce and seemingly had to choose between employment and breastfeeding.  This was a time when it was not seen as being acceptable to breastfeed in public (although that is not the case in many places still to this day) and the workplace was not as conducive to supporting women as in current times (think onsite daycares).  Add to this that the 1970s also saw a backlash of sorts in the appeal of breastfeeding due to science “perfecting” a better source of nutrition in formula and we had the low rates that we did.  In fact through discussions with parents from that generation, mother’s who chose to breastfeed may have been viewed by some as being silly for not using something like formula that could let the whole family in on the experience.  Mom, Dad, kids and grandparents could all take part in the wonderful act of feeding.  Why be so selfish?

Following this period as research began to demonstrate improved outcomes with breastfeeding including reductions in atopic disease, less hospital admissions and more recently positive impacts on intelligence and your microbiome the trend reversed. In fact, as the above graph demonstrates, rates approximating 70% were reached by the late 1990s.  Since that time the CDC has shown that initiation rates have continued to rise and currently are at the highest documented levels in history.

Looking at the CDC data though reveals some very important information.  While the rates of any breastfeeding reach 80%, the rates at 6 months hover around 50%.   This means that a significant portion of US women are using some formula when they come home and from the graph on the right about 35% by three months are exclusively breastfeeding. This number is far short of the goal the WHO has set to encourage exclusive breastfeeding for the first 6 months however it is a remarkable achievement for infant health.

http://www.who.int/topics/breastfeeding/en/

A recent trend on social media and print media has been the Brelfie.  As you may know, this involves taking a picture of yourself breastfeeding your baby and posting it in one forum or another.  This has been popularized by many celebrities and made it’s way onto the cover of Elle magazine this month.

So called Lactavists have been overjoyed to see such public acceptance and promotion of breastfeeding.  As a Neonatologist I am delighted to see such high rates of breastfeeding and with it the beneficial effects that it brings.

Curiously, though all of this attention and promotion of breastfeeding has created a culture that is now being called bressure.  This is defined as pressure to breastfeed and was the subject of a recent survey by Channel Mum in the UK.  The highlights of the survey that went out to  2,075 mums showed:

–  16 per cent of bottle-feeding mums have been on the receiving end of cruel comments from other mothers they know

 – one in 20 being attacked on social media

 – 69 per cent of bottle-feeding mums said they had been judged negatively

–  41 per cent made to feel they have ‘failed as a mum and failed their child’ by not breastfeeding

–  15 per cent of mums have even lied to cover up their bottle-feeding and appear to be ‘better’ mums.

This so called bressure has led to a public campaign to increase awareness of the harassment that some mothers feel which involves taking selfies with cards having one word describing what breastfeeding meant for them.  A video from Channel Mum can be seen here

Channel Mum Video Response to Brelfies

While I am all for breastfeeding, I find it peculiar that the experience that breastfeeding mothers (all 22% of them) had in 1972 is now being felt by a larger percentage in 2015 who are bottle feeding.  It is unfortunate that assumptions are being made of many of these women who put a bottle in the mouths of their infants.  How many times does one conclude that the mother simply chose not to breastfeed because they were worried about the way their breasts would be affected cosmetically or that they simply chose to go back to work and breastfeeding would just get in the way.  I suspect in most cases the truth is much different.  Many of these mothers have tried to breastfeed but couldn’t produce enough.  Others may have suffered from cracked nipples, mastitis, abscesses or due to prior surgery were unable to produce milk.  Many such mothers have agonized over their “failure” to do something that they hear “everyone can do”.  While they are told it takes some work for many that is a huge understatement.  Is it not bad enough that these women have suffered the feeling of failure?  To be looked at or spoken to in a disapproving way does nothing to support them.  Add to this that by 3 months of age at least in the US 65% of mothers are providing some formula and it seems silly to take the “high and mighty” approach in the first couple of months and assume the worst of these women. Many of the “breastfeeders” will soon enough join the ranks of those using some formula.

Maybe the better option is to try and help.  Many of the above problems whether it be producing enough quantity or pain related to breastfeeding can be addressed through tips on technique.  While I am not an expert in this, hospitals would do well to increase staffing of on site lactation consultants to help mothers who wish to breastfeed get off on the right foot so to speak.  A larger working force of midwives in North America in particular could certainly provide help in this regard.  What I can say is that if a woman suffers a bad experience with breastfeeding in their first pregnancy the likelihood they will try again the next time is lower especially if we as a society make them feel like a failure.

Yes we need to promote breastfeeding and we should do what we can to follow the WHO recommendations and minimize the use of formula when possible.  While bressure may have been intended to yield something good we need to be sensitive.  Perhaps a better strategy next time a friend says they are going to use formula is to ask if they are having trouble with breastfeeding and if they need some help. Not having the discussion will ensure that nothing changes and a chance to do something will be lost due to misdirected bressure.