Best Practices: ImprovingNeonatal Outcomes through

Exclusive Human MilkJae Kim, MD, PhD

Department of PediatricsDivision of Neonatal-Perinatal Medicine

Division of Pediatric Gastroenterology, Hepatology and Nutrition

CAPH Conference, Halifax, Oct 2016

Conflict of Interest Disclosures

• Medical Advisory Board• Medela

• Speakers Bureau• Prolacta Biosciences• Nestle Nutrition• Nutricia• Abbott Nutrition• Mead Johnson Nutrition• Medela

• Shares• Pedia Solutions

• I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

Human milk is a tissue!Human Milk Blood

CELLS ENZYMES HORMONES TRANSPORTERS CYTOKINES IMMUNE MODULATORS GROWTH FACTORS

NUTRIENTS

Nutritional Components of Human Milk

MACRONUTRIENTS

LipidsTriglycerides

(167 identified)PhospholipidsSphingolipids

SterolsFatty acids

ProteinsCaseinsWhey

Amino acidsMucins

CarbohydratesLactoseGlucose

GalactoseOligosaccharides

Vitaminsvitamin Aniacinthiaminvitamin B6 panthothenic acidbiotinfolatevitamin B12vitamin Cvitamin Dvitamin Evitamin K

Mineralscalciumphosphorus ironzinccoppermanganesemagnesiumsodium potassiumchloridesulphur

MICRONUTRIENTS

Non-Nutritional Components of Human Milk

Hundreds of different compounds

Transporterslactoferrin (Fe)xanthine oxidaseglutathione peroxidasealkaline phosphatasefolate bindercobalamin binderIgF binderthyroxine bindercorticosteroid binder

Growth factors epidermal (EGF)nerve (NGF)insulininsulin-like (IGF)transforming (TGF)taurinepolyaminesgastringastric inhibitory peptide (GIP)Gastric regulatory peptide (GRP)neurotensinpeptide histidine methionine (PHM)Peptide YY (PYY)

Hormonesfeedback inhibitor of lactation (FIL) insulinprolactinthyroid hormones (T2, T3, Reverse T3)corticosteroids, ACTHoxytocincalcitoninparathyroid hormoneerythropoietinprogesteroneestrogen

Anti-inflammatorytumour necrosis factorinterleukinsinterferon-gprostaglandinsa1-antichymotrypsina1-antitrypsinplatelet-activating factor: acetyl hydrolase

Antimicrobialsecretory IgA, IgM, IgG lactoferrinlysozymecomplement C3leukocytesbifidus factorlipids and fatty acidsantiviral mucins, GAGsoligosaccharides

Digestive enzymesamylasebile acid-stimulating esterasebile acid-stimulating lipaseslipoprotein lipaseProteases

Ingredients of Infant Formula

MACRONUTRIENTS• water• nonfat milk• lactose• high oleic safflower oil, soy oil, coconut oil, C.

cohnii oil (DHA), M. alpina oil (ARA)• whey protein concentrate

MINERALS• potassium citrate, calcium carbonate, potassium

chloride, magnesium chloride, sodium chloride, ferrous sulfate, choline chloride

TRACE ELEMENTS• zinc sulfate, cupric sulfate, manganese sulfate,

sodium selenate

VITAMINS• d-alpha-tocopheryl acetate, ascorbic acid,

niacinamide, riboflavin, calcium pantothenate, vitamin A palmitate, thiamine chloride hydrochloride, phylloquinone, pyridoxine hydrochloride, beta-carotene, folic acid, cyanocobalamin, vitamin D3, biotin

EMULSIFIERS• mono- and diglycerides, soy lecithin,

carrageenan, choline bitartrate, taurine, m-inositol, L-carnitine

BIOLOGICS1. nucleotides 2. prebiotics (term formula only)3. probiotics (term formula only)

Benefits of mother’s milk to preterm infants• Cognitive development• Reduction in necrotizing enterocolitis (NEC)• Reduction in sepsis• Favorable alteration of microbiome• Reduction in retinopathy of prematurity (ROP)

• PLUS all the health benefits known for mother’ milk in term infants: reduction in infant mortality, SIDS, autism, ADHD, allergy, asthma, infection, celiac disease, cognitive outcomes, etc.

2016 March of Dimes Prematurity Report Card

Impact of Neonatology to Healthcare Burden• Between 7% (CAN) to 12% (US) of live births are preterm (less than 37

weeks gestation)• NICU patients (preterm and sick newborns) represent a

disproportionate share of hospital costs• Lifelong impact to healthcare burden and costs enormous• In the US, NICU is a top generator of financial revenue to hospitals

Morbidities of the preterm infant• Growth

• Impaired growth• Altered body composition• Failure to thrive

• Brain• Intracranial hemorrhage• Loss of white and gray matter, reduced size

• Cardiovascular• Effects of patent ductus arteriosus• Long-term risk of cardiovascular disease and metabolic

syndrome

• Lung • Chronic lung disease• Asthma

• GI• Necrotizing enterocolitis• Gastroesophageal reflux• Feeding intolerance/difficulties

• Hematologic• Anemia• Neutropenia• Thrombocytosis

• Renal• Impaired kidney development

• Immune system• Skin

Goal of Feeding Preterm Infants

Provide nutrients to approximate the rate of growth and composition of weight gain for a normal fetus of the same post-conceptional age and to maintain normal concentrations of blood and tissue nutrients.

American Academy of Pediatrics Committee on Nutrition, In Pediatric Nutrition Handbook, 2013.

Matching In Utero Growth

Zeigler et al., Growth. 1976 Dec;40(4):329-41.

WEIGHT CLASS

GROWTHG/KG/DAY

~ 3 lbs per day for 70 kg adult

The Developing Gut1st Trimester 2nd Trimester 3rd Trimester

Adapted from Commare and Tappenden, 2007 Nut Clin Pract

Cytodifferentiation

Absorption

Motility

Digestion

Morphogenesis

Swallowing

0wk 14 22 28 40

ViabilityLine

STRU

CTU

REFU

NCT

ION

Preterm Risk Factors for Bowel Injury• Ischemia• Immature gut and systemic immune system• Dysmotility• Underdeveloped physical mucosal barrier (tight

junctions, mucin)• Poor acid production• Abnormal bacterial colonization

Necrotizing Enterocolitis• NEC is the most common life-

threatening gastrointestinal emergency in the newborn period

• NEC is marked by intense inflammation and acute intestinal necrosis

• Most common sites include terminal ileum, cecum and ascending colon

The Perfect Storm for NEC

PREMATURITY ISCHEMIA PATHOGENIC BACTERIA

ENTERAL FEEDING

TRANSMURAL BOWEL

INFLAMMATION

BOWEL NECROSIS

BREAKDOWN OF MUCOSAL

BARRIER/DEFENSE

NEC Pathogenesis

Hunter et al. 2008 Pediatr Res 63;2:117

Pneumatosis Intestinalis

Coagulative Necrosis

NEC Morbidity• Growth failure due to bowel injury• Intestinal obstruction and subsequent surgery• Longer hospital stay• Risk of dying• Risk for more pain and suffering• Short bowel syndrome and/or intestinal failure

• Can lead to need for long-term PN use and later bowel transplantation

• Neurodevelopmental impairment!

Necrotizing Enterocolitis

Strategies to prevent NEC

• Prevent preterm birth• Standardized feeding

protocol• Exclusive human milk

feeding• Antibiotic stewardship• Reduce anti-acid meds• Probiotics

• Blood transfusions• Patent ductus arteriosus• Congenital heart disease• Prebiotics• Minimize osmolality

NEC is the result of a biochemical reaction

WARMTH

MOISTURE

BACTERIA

SUBSTRATE(MILK OR FORMULA)

Standardized Feeding ProtocolHaving a feeding protocol is associated with reduced NEC rates

Patole, Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F147-151.

Key Elements of a Great Feeding Protocol• Established consensus from

medical faculty• Visible, nurse-driven advancement• Linear advancement• Trophic feeding for extremely

preterm infants• Incorporate timing of fortification

and vitamins

10% of very preterm babies developed NEC

30-50% NEED SURGERY

25-50% DIE!

Human milk can reduce NEC (medical and surgical) by at least 50%

Most very preterm infants are fed formula!!

Fractional Human Milk Feeding Reduces Chances of NEC

Fraction ofHuman MilkFeeding

Meinzen-Derr et al. NICHD Network, J Perinatol 2008:1-6

Lactation support• Ideally mothers should initiate

pumping or breastfeeding within 2h after vaginal delivery and 4h after cesarean section

• Peak lactation volumes may be influenced by very early pumping/expressing milk within the first hour of life

Parker et al. Breastfeed Med. 2015 Mar;10(2):84-91.

<1h and ≤6h>6h

Human Milk

Human Milk

Bovine(intact or

hydrolyzed) HMF

HumanHMF

CurrentStandard

EmergingStandard

Preterm Formula

Past

Progress in Human Milk Fortification

Exclusive Human Milk vs Preterm Formula: RCT in Extremely Preterm

HM PF p

Birth weight (g) 996 ± 152 983 ± 207 NS

Gestational age (wks) 27.7 ± 1.5 27.5 ± 2.4 NS

Study duration (d) 50 ± 20 50 ± 23 NS

Preterm <1250 gPlanned for Infant Formula

Preterm Formula (PF)n=23

Exclusive Human Milk (HM) and Fortiifier

n=29

Cristafalo et al. J Pediatr. 2013 Dec;163(6):1592-1595.e1.

Results

• First randomized double-blind trial in infants of exclusive diets of HM vs PF

• The significantly shorter duration of TPN and lower rate of surgical NEC further support an exclusively human milk diet

HM PF p

n 29 23

Duration of TPN (d) 27 36 0.04

NEC 1 (3.6%) 5 (21.7%) 0.08

Surgical NEC 0 4 0.04

Cumulative morbidity 0.7 ± 0.5 1.2 ± 1.0 0.03

Length increment (cm/d) 0.12 ± 0.03 0.16 ± 0.04 0.006

Cristafalo et al. J Pediatr. 2013 Dec;163(6):1592-1595.e1.

Exclusive human milk reduces overall NEC and surgical NEC

Sullivan et al (2010) J Pediatr. 2010;156:562-7

Protocol violations:received bovine product

Impact of choosing bovine products

No NEC Medical NEC Surgical NECMortality 10.6% 20.9% 23.2%

Double the risk of death!

Sullivan et al (2010) J Pediatr. 2010;156:562-7 Ganapathy et al. 2011 Breastfeeding Medicine

NEC continues to add to long-term costs within the first three years of life

• Texas Medicaid healthcare utilization database• Jan 2012 to Dec 2013• 253 survivors of NEC (73 surgical NEC)• 2909 matched controls• Medical NEC incurred higher costs than controls between 6 and 12

months• Surgical NEC incurred higher costs than controls up to 36 months

• Costs tapered down from ~ 18K to 8K per survivor

Ganapathy et al. BMC Pediatr. 2013 Aug 20;13:127.

An exclusive human milk (EHM) diet reduces TPN need

Ghandehari et al. BMC Res Notes. 2012 Apr 25;5:188.

11-14% Reduction in TPN useGreater when looking at TPN after initial use

Increased likelihood if HMF started earlier

EHM

Balance of effects in developing NEC

Benefit of

Human Milk

Detriment of

Formula

Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet• Retrospective study including preterm infants 28 weeks and/or VLBW ⩽

( 1500 g)⩽• Single center (The Herman & Walter Samuelson Children’s Hospital at Sinai,

Baltimore, MD, USA)• March 2009 until March 2014

• (2012-2014)• group H (exclusive human milk or EHM)

• (2009-2012)• group B (bovine-based fortifier and maternal milk)• group M (mixed combination of maternal milk, bovine-based fortifier and formula)• group F (formula fed infants)

• N = 293 infants between 23 to 34 weeks gestation and birth weights between 490 and 1700 g

Assad et al. J Perinatol. 2016 Mar;36(3):216-20.

Less feeding intolerance (P<0.0001)Lower number of days to full feeds by 9-10 days (P<0.001)Lower incidence of NEC (P<0.011)Shorter length of stay by 4 to 22 days for EHM groupSimilar average weight gain per among the four groups (18.5 to 20.6 g per day)

Assad et al. J Perinatol. 2016 Mar;36(3):216-20.

Lower total hospitalization costs by up to $106,968 per infant (P<0.004) in those fed an EHM diet

Assad et al. J Perinatol. 2016 Mar;36(3):216-20.

Beyond Necrotizing Enterocolitis Prevention: Improving Outcomes with an Exclusive Human Milk-Based Diet

• Retrospective cohort study• 4 centers, N =1,587 infants (Texas, Illinois, Florida, and California)• Lower NEC (16.7% versus 6.9%, p < 0.00001)• Reduced mortality (17.2% versus 13.6%, p = 0.04)• Reduced late-onset sepsis (30.3% versus 19.0%, p < 0.00001)• Reduced ROP (9% versus 5.2%, p = 0.003)• Reduced BPD (56.3% versus 47.7%, p = 0.0015)

Hair et al. Breastfeed Med. 2016 Mar;11:70-4.

Continuum of Health Benefits from Human Milk

Newborn SeniorChild

NEC Neurodevelopment

ROP Visual performance

BPD Asthma, Lung Disease, Neurodevelopment

Adult

Sepsis Neurodevelopment

Containing Health Care Costs• What motivates reduction in health care costs?

• Public model of cost-bundled that limit spending per patient (Medicaid)• Fee for service• Payer that pay out for sicker patients staying longer in hospital

• Performance or outcomes based incentives• Value based models• Perspective matters

• Cost to the patient and family• Cost to the hospital• Cost to the healthcare system• Cost to society

Economic Costs of NEC• One case of medical NEC is almost $75,000 USD• One case of surgical NEC is almost $200,000 USD

• NEC costs the health care system $5 billion USD annually (assume 10% incidence of NEC and 30% mortality)

• NEC constitutes 19% of the total costs for initial care for all newborns in the US

Bisquera J et al. Pediatrics 2002;109:423-428Ganapathy et al. Breastfeed Med. 2012 Feb;7(1):29-37

Balancing the cost of an exclusive human diet

Feeding of 160 mL/kg/dayPowder HMF: 1 packet per 25 mL of milk =$0.06/mL = 100X costs

Ganapathy et al. Breastfeed Med. 2012 Feb;7(1):29-37

Cost equation• Costs CAN 12,500 per patient• Protocol to 34 weeks according • Net savings of CAN 10,208 per patient given EHM diet

• If human milk was a drug, would we act differently?

Ganapathy et al. Breastfeed Med. 2012 Feb;7(1):29-37

History of Donor Milk

• 1909: the first milk bank was established in Vienna, Austria

• 1910: milk bank in Boston• North American history in milk banking is 100 years

old• 1974: Canada’s first milk bank in Vancouver• By early 1980’s 23 banks in Canada and 30

in US• 1981: HIV identified as a pathogen; North

America reduced to 8 banks• 1985: Human Milk Banking Association of North

America (HMBANA) established • 2000: Vancouver Milk Bank almost closes

http://en.wikipedia.org/wiki/File:HIV-budding-Color.jpg

Images from Toronto SickKids Archives

HIV

Modern Human Milk Banking• HMBANA• International Human Milk Banking Association• Organizations in other countries

• UKAMB & other European countries• South America – Brazil & Venezuela• South Africa• Other countries – India, Japan, China

• National Milk Bank (est. 2005)• Prolacta Bioscience (est. 2005)• Medolac (est. 2013)

Donor Milk Banking in North America

hmbana.org

Existing Milk Banks Cities Served by Milk Banks

Donor human milk

PROS• Human specific• Bridges gap when

mother’s milk supply insufficient to meet infant’s requirements

CONS• Lower quality milk compared to fresh

milk• No cellular components or probiotics• Less protein due to maturity of milk• No lipase activity that may alter

digestion• Reduced bioactive components due

to processing• Reduced salts and vitamins

Screening(Questionnaire and Blood)

Expression of milk

Freezing, storage, andtransport

Thawing and Bacterial culture

Batching

Pasteurization

Culture of batch

Freezing

Processing of Donor Human Milk

Thawed for use

Mothers’ Own Milk Bank of Austin, Texas

HMBANANONPROFITMILK BANKING

COMMERCIAL MILK BANKING

Major Concerns For Use of Donor Human Milk

• Nutrition• Loss of bioactivity (immunologic protection)• Infectious risk• Tampering• Cost• Supply• Legal

Level of Quality of Human Milk

• Breastfeeding

• Fresh human milk

• Refrigerated human milk

• Really frozen human milk (-80ºC)

• Frozen human milk (-20ºC)

• Donor human milk

TRIAGE• Colostrum > Fresh mature >

Refrigerated > Frozen

Recommendations for Donor Human Milk Banking

AAP Committee on Nutrition Statement (in press)CPS Committee of Nutrition (Kim and Unger) 2012• Donor human milk is an acceptable alternative to mother’s own milk for preterm infants

when it is not available• HMBANA or commercial donor banks are suitable sources• AAP

• The use of donor human milk in appropriate high-risk infants should not be limited by an individual’s ability to pay.

• Policies are needed to provide high-risk infants access to donor human milk on the basis of documented medical necessity, not financial status.

• Avoid unpasteurized milk sharing off Internet

• CPS• Recognized functions of the human milk bank should include the promotion of breastfeeding and

ongoing human milk research.• Pasteurized human donor breast milk should only be prescribed following written informed

consent from a parent or guardian.

Canadian Milk Banking

California Milk Banking

MMB of San Diego 2017

• All of California is currently served by one milk bank

• UC San Diego is developing a milk bank in San Diego for Southern California

Benefits of Donor Human Milk to Preterm Infants

• DOMINO Study (Canada)• Recently completed• Saw reduction in NEC• Long-term followup data pending

• NICHD (Donor milk trial)• Ongoing recruitment• Slowing recruitment due to loss of equipoise

• Optimom study (Canada)• Donor milk derived fortifier study• Closed but not reported

Oral Colostrum CareOropharyngeal administration involves placing small amounts of a liquid directly onto the oral mucosa with expectation that the liquid, or any of its components, is absorbed by the mucous membranes.

Rodriguez, N.A., et al., Oropharyngeal administration of colostrum to extremely low birth weight infants: theoretical perspectives. J Perinatol, 2009. 29(1): p. 1-7.

Colostrum Breast MilkTotal Protein (g/100mL) 3.7 1.3

IL-6 (pg/mL) 978.8 86.92

Fat (g/100mL) 2.9 4.2

Lactose (g/100mL) 57 7.4

IgM (mg/g protein) 30 4

IgA (mg/g protein) 175 20

IgG (mg/g protein) 3 2

Colostrum• Produced when the tight junctions in the mammary epithelium are

open• Paracellular transport of immunologically derived protective components

from mother’s circulation into milk

• Contain various immunomodulatory agents • Secretory immunoglobulin A [sIgA]• Growth factors• Lactoferrin• Anti-inflammatory cytokines

• More highly concentrated in mother’s of preterm infants

Evidence that oral colostrum care benefits preterm babies

• Seigel 2013• Retrospective cohort study of 369 inborn ELBW infants, 5 day treatment• Mortality, surgical NEC, SIP rates unchanged• Higher weight at 36 weeks (1666g vs. 1380g p<0.001)

• Lee 2015• Double blind, placebo-controlled trial of 45 infants <28 weeks gestation in South Korea• Increased urine levels of immunoglobulin A and lactoferrin• Significant decrease in clinical sepsis

• Sohn 2016• Impact of buccal administration of human colostrum on the oral microbiota of 12 VLBW

infants• OCC altered the colonization of the oral cavity with effects lasting after the intervention

ELBW = birth weight less than 1000 grams; VLBW = birth weight less than 1500 grams

Human milk derivatives: value of a cream supplement

• HM-derived cream supplement if energy density of HM <20 kcal/oz using a near infrared HM analyzer

• Treated until 36 weeks PMA

• HM-derived cream should be considered an adjunctive supplement to an exclusive HM-based diet to improve growth rates in premature infants

Human Milk

HumanHMF

Exclusively Human

Human milk

cream

Velocity Cream supplemented(n=39)

No cream(n=39)

p

Weight (g/kg/d) 14.0 +/- 2.5 12.4 +/- 3.0 0.03

Length (cm/wk) 1.03 +/- 0.33 0.83 +/- 0.41 0.02

Terminology

MicrobiotaThe collection of microbes in a

particular environment

MicrobiomeThe catalog of microbes and their genes in a particular environment

MetagenomicsThe collection of genes and genomes from microbiota

Terminology

PROBIOTICS POSTBIOTICSPREBIOTICS

SYNBIOTICS

Human Milk is the Original Synbiotic

The human gastrointestinal microbiota

• First inoculation during birth with passage through birth canal

• Influenced by prebiotics and probiotics• Adult microflora by 2 years of age• Over 500 bacterial species• 1010 organisms (at least ten fold higher than

human cells)• Symbiosis between man and bacteria• 5-10 lbs of bacteria, about 60% of fecal mass• The “forgotten organ”

We need microbes!

N Engl J Med. 2002 Sep 19;347(12):911-20.

FALL OF INFECTION RISE OF AUTOIMMUNITY AND IMMUNE DYSFUNCTION

Dysbiosis

• sick ecosystem• low diversity of species• Imbalance• lack of functional redundancy• susceptibility to disease

Type of birth

Vaginal birth C-section• Sterile environment• Frequent use of antibiotics• Preterm infants born ~70% by C/S• Exposure to nosocomial microbes• Long-term risk of food allergy

• Papathoma et al. 2016

• Long-term risk of immune dysfunction• Asthma, laryngitis, gastroenteritis, ulcerative

colitis, rheumatoid arthritis, celiac disease• Kristensen et al. J Allergy Clin Immunol. 2016

Feb;137(2):587-90.

• Delivery through birth canal• Direct contact to and ingestion

of vaginal flora• Vaginal flora a mix of maternal

vaginal and colonic flora

Risk of the preterm infant

• Often not delivered from birth canal

• Frequent use of broad spectrum antibiotics

• Delay in enteral feedings• Sterilization of infant formulas• Nosocomial bacterial

colonization

Impaired Colonization of the Preterm Gut

• Delay in establishment of gut flora

• Reduction in the number of bacteria

• Reduction in the diversity of bacteria

Dietary differences and predominant organisms

BifidobacteriaLactobacilli

E. coliBacteroides

Clostridia

Harmsen et al., J Pediatr Gastroenterol Nutr. 2000;30(1):61-67.Gronlund et al. Clin Exp Allergy. 2007 Dec;37(12):1764-72.

Breastfed Formula fed

Mai et al 2011 PLoS One. 2011; 6(6): e20647.

MICROBIOTA BEFORE NEC OCCURS

Maternal infant microbiome

There are no sterile environments. Not uterus, not fetus.

Vinturache et al 2016 Sem Fetal Med 1-6

Human Milk Microbiome

• Human milk has its own microbiota

• Phyla include Firmicutes, Proteobacteria and Actinobacteria

• Each mother’s microbiota is unique

• Donor human milk is pasteurized and therefore microbe-free

Hunt et al. PLoS One. 2011;6(6):e21313.

BIFIDOBACTERIA LACTOBACILLI

• B. infantis• B. breve• B. adolescentis• B. longum• B. bifidus• B. catenulatum• B. animalis• B. suis• B. globosum

• L. reuterii• L. fermentum• L. rhamnosus• L. salivarius• L. gasseri• L. caseii• L. planarum

infant

adult

Bold found in human milk

Human Milk Oligosaccharides (HMO)

• Third largest component in human milk!

• Small chain sugars (>150 variations)• Resist digestion• Substrate for beneficial intestinal

microflora• Support favorable bacteria population

in infant colon (“BIFIDOGENIC”)• Beneficial microflora stimulate the

developing immune system

Bode, J Nutr 2006;136:2127-30.Boehm J Nutr 2007;137(3 Suppl 2):847S-9S.

BacteriaFungal

Viral HIVIntestinal development

Intestinal immune functionNEC

Multitude of effects of HMO

Intestinal epithelial health

HMO

Diffusion of Innovation

Rogers EM, 1962 Law of Diffusion of Innovation

Trend in feeding in last decade

Human milk based fortifiers

Preterm formula

Mother’s milk

Donor milk

Hydrolyzed bovineOral colostrum care

S Curve

Mother pumps

Milk in bottle

Milk in storage container

Milk in home freezer

Milk in cooler for transport

Milk in NICU freezer

Milk thawed

Milk measured

Milk fortified

Milk drawn into syringes

Milk in tubing

Milk in baby (finally!)

MILK “TRAFFIC” CHAIN

Changing the clinical practice towards a dominant mother’s

milk culture in hospitals is very challenging but cost effective in promoting a

healthier long term outlook for premature infants

The future…

Exclusively Human

Human Milk

HumanHMF

Donor milk derived

additives

• Maternal lactation support• Donor human milk banking• Lacto-engineering science

• Addition of cream• Addition of protein• Human milk derivative bioactive additives

• Refinement of processing of human milk for preservation of function

• Increased cost benefit analysis for other long-term morbidities

Priorities1. Maternal lactation2. Donor human milk3. Human milk fortifiers4. Human milk derivatives

The SPIN Program Ten Steps

1. Have a NICU nutrition/human milk policy2. Educate all mother/baby staff in SPIN 10-steps3. Educate NICU families about optimal premature

infant nutrition4. Prevent extra-uterine growth restriction5. Standardize enteral feeding procedures6. Target 100% human milk nutrition 7. Maximize mothers’ milk production8. Optimize milk quality and safety9. Encourage skin-to-skin care and breastfeeding10. Plan a nutritional discharge from NICU

NUTRITION LACTATION

THE SPIN TEAM

• Medical director• Lactation director• NICU F/U Neo• NICU CNS• Lactation• OT• NICU Dietician• Research RN• NICU Staff RN

spinprogram.ucsd.edu

Take home points• Human milk is the single most powerful

intervention to optimize the best health outcomes in all babies

• In the absence of maternal milk, donor human milk is a superior substitute to formula

• Donor milk derivatives now support the provision of an exclusively human milk diet

• Initiating and maintaining a balanced gut microbiota begins with maternal milk

• Moving towards an exclusively human milk diet will show increasing cost savings and long-term healthcare benefits to preterm infants

It takes a village to care for our babies!

Parent Advocacy against NEC

www.necsociety.org