PQCNC Human Milk NCCC Track LS 1 Feeding Protocols
Transcript of 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