Breastfeeding the premature and the sick baby

1. Breastfeeding the premature and the sick baby Jack Newman, MD, FRCPC

2. In retrospect, it has become obvious that incubator care is a large factor in the difficulty establishing breastfeeding in premature and sick babies

3. So we need to ask the question… • Is incubator care the only way, or even the best way, to take care of premature and sick babies?

4. Early skin to skin care vs. incubator care • Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200-2199 gram newborns. ActaPaediatr2004;93:779-785

5. Two groups • All babies were put skin to skin with the mother after birth • After the five minute Apgar, if the baby was stable (monitored continuously), the baby was randomly assigned to • Skin to skin care (SCC) for 6 hours • Transferred to incubator and “usual” care

6. Protocol • All babies had an IV line placed with glucose running at 4.17 mg/kg/min • All had an orogastric tube placed • All were started on theophylline by orogastric tube • Oxygen given if required • If the baby was well, breastfeeding attempted at 50 min, 3 hours and 5 hours • After 6 hours, all babies given routine care

7. Parameters • All babies were continuously monitored • The following situations were considered “exceeding parameters” (see later slide) • Skin temperature below 35.5°C for two consecutive recordings • Heart rate <100 or >180 for two consecutive recordings • Apnea >20 seconds • O2 saturation <87% despite support • Blood glucose <2.6 mmol/l confirmed by lab

8. SCRIP score

12. Kangaroo Mother Care

13. Kangaroo Mother Care • If medical condition allows: • Infant, wearing a diaper only, is placed between mother’s breasts, with head in “sniffing position” • Maintains baby’s physiological functions at least as well as, and often better than incubator care • Facilitates breastfeeding

14. Kangaroo Mother Care • Fewer apneas and bradycardias • Less frequent and less severe desaturation • Oxygenation improved (even if not desaturated, allowing lower concentrations of inspired oxygen) • Body temperature maintained • Earlier discharge from hospital • Improved arousal regulation and stress reactivity

15. Kangaroo Mother Care • Infants cry less and cry is not of distress type • Provides analgesic effects during painful procedures • Less stress in baby (shown by decreased ß endorphin and cortisol release) • Positive effects seem to be maintained after contact ended • Better parent-child relationship • Greater likelihood of full breastfeeding in hospital and at discharge

17. Gas exchange • Föhe K, Kropf S, Avenarius S. Skin to skin contact improves gas exchange in premature infants. J Perinatology2000;5:311-15 • 53 preterm infants <1800 g in a prospective study, during incubator care (60 min), skin to skin contact (90 min) • All babies on oxygen, 5 still being ventilated

19. More References • Cattaneo A, Davanzo R, Worku B, et al. Kangaroo Mother Care for low birthweight infants: A randomized control trial in different settings. Acta Pædiatr 1998;87:976-85 • Törnhage C-J, Sturge E, Lindberg T, Serenius F. First week Kangaroo Care in sick very preterm infants. Acta Pædiatr 1999;88:1402-4 • Johnston CC, Stevens B, Pinelli J et al. Kangaroo Care is effective in diminishing pain response in preterm neonates. Arch Pediatr Adolesc Med 2003;157:1084-8

20. More References • Feldman R, Weller A, Sirota L, Edelman AI. Skin-to-skin contact (Kangaroo Care) promotes self-regulation in premature nfants: sleep-wake cyclicity, arousal modulation and sustained exploration. Develop Psychol 2002;38:194-7 • Charpak N, Ruiz-Peláez JG, et al. A randomized controlled trial of Kangaroo Mother Care: Results of followup to 1 year corrected age. Pediatrics 2001;108:1072-9

21. More References • Ohgi S, Fukuda M, Moriuchi H, et al. comparison of kangaroo care and standard care: Behvioral organization, development and temperament in healthy low birth weight infants through 1 year. J Perinatology 2002;22:374-9 • Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics 2002;109(4) www.pediatrics.org/cgi/content/full/109/4/e57

22. WHO document on KMC (2003) • http://whqlibdoc.who.int/publications/2003/9241590351.pdf • All the references you could want • Includes practical information for implementation of Kangaroo Mother Care

23. Breastmilk and breastfeeding

24. Breastmilk and breastfeeding • “We are dealing with a question of life and death • “You should be happy your baby is surviving; breastfeeding is a minor issue” saving the baby’s life and helping the mother with breastfeeding are not mutually exclusive • Nor should they be

25. The premature baby • The word “premature” covers a lot of ground • What may be true about the 26 week gestation baby, weighing 600 grams, being ventilated for weeks, may not be true of the 33 week gestation baby, weighing 1600 grams, who is otherwise well • The latter has more in common with a full term baby than he does with that 26 week gestation premature baby

26. They both need breastmilk • But the methods of feeding them, the need for fortification, the approaches are very different • Each baby needs to be treated as an individual • The “one size fits all” approach to feeding premature babies is inappropriate

27. Generalizing from the NICU • Unfortunately, much of how we approach feeding the premature comes from NICU’s, neonatologists and pædiatric nutritionists who deal with that 26 week gestation premature baby, but never see a healthy 33 week gestation baby • In fact, most premature babies fall into the latter group • they are relatively mature and larger, often have only minor medical problems, and are in hospital essentially for “nutritional support”

28. Let’s not generalize • We cannot take what may be appropriate for that 26 week gestation baby in a NICU as a basis for the nutrition of the bigger premature babies found in nurseries in most community hospitals • For example, if the mother is pumping enough milk, most babies of 33 or more weeks gestation do not need “fortification” • Different approaches are necessary for this group

29. Confession • I did 6 months in a tertiary NICU as part of my training • But most of my experience in feeding premature babies comes from my experience with prematures in Africa • babies who did not make it on oxygen alone, didn’t make it • this is a different situation from NICU

30. Still, this allows some perspective on the question of feeding premature babies

31. Why breastmilk for the premature? • Breastmilk provides: • Protection against infection • Protection against NEC • Appropriate lipid profile (PUFA’s) • Better cognitive development • Better visual development • A role for the mother in the care of her baby • this is very important

32. Breastfeeding and sepsis • Rønnestad A, et al. Late onset septicemia in a Norwegian national cohort of extremely premature babies receiving very early full human milk feedings. Pediatrics 2005;215:e262-e268

33. Cumulative proportions of infants initiated on enteral feeding (black bars) and established on FEF with human milk (gray bars), according to age, among extremely premature infants in Norway, 1999-2000 Ronnestad, A. et al. Pediatrics 2005;115:e269-e276

34. Survival free from LOS according to week of establishment of FEF with human milk among extremely premature infants in Norway, 1999-2000

35. RR of future LOS if FEF with human milk is not established within a given age (in days) among extremely premature infants in Norway, 1999-2000

36. Why breastmilk for the premature? • And, for the same reasons that breastmilk is best for the full term baby • Premature babies don’t need breastmilk less they need it more!

37. Alternatives to breastmilk? • There is lack of evidence for safety, superiority or even equality of the alternatives (preterm formulas and fortifiers) in the long term • Unlike drugs, the formula companies do not have to prove they are safe, never mind useful • We should be careful about using them routinely • They should be used as drugs, if necessary, but not if not necessary

38. Apparent deficiencies of breastmilk • Not enough protein to support the growth of the premature baby • Most of the protein in breastmilk is not even absorbed (don’t tell anyone) • Insufficient calcium, phosphorus and vitamin D for bone mineralization • Insufficient calories for intrauterine growth rate • Intolerance of some tiny premature babies to lactose

39. Intrauterine growth rate • Besides being intellectually satisfying, is there any proof that a baby is better off growing at intrauterine growth rates? • How did we establish this “standard”? • The physiologic situation is completely different for a baby outside the uterus • Are there suggestions that more is not necessarily better? • Yes • There are advantages to exclusive breastfeeding (or breastmilk feeding) that go beyond growth rate • A balance which is best for the baby needs to be struck

40. Advantages to exclusive breastmilk feeding? • Lipid profile in adolescents • Singhal A, Cole TJ, Lucas A. Breastmilk feeding and lipoprotein profile in adolescents born preterm: follow-up of a prospective randomised study. Lancet 2004;363:1571-8

41. Results • “The ratio of LDL to HDL cholesterol was significantly lower in adolescents who had been randomised to bank breastmilk compared with those who received preterm formula” • “CRP concentration was also significantly lower in adolescents randomised to banked breastmilk compared with preterm formula” • CRP=C reactive protein, a marker for atherosclerosis • “As expected, early weight gain was significantly greater in infants randomised to nutrient-enriched preterm formula than in those randomised to banked breastmilk”

42. Is more weight gain necessarily better? • “As expected, early weight gain was significantly greater in infants randomised to nutrient-enriched preterm formula than in those randomised to banked breastmilk”

43. The more breastmilk a baby got, the lower his LDL to HDL ratio (better profile)

44. Different study, same cohort • Effects on blood pressure • Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. Lancet 2001;357:413-9

46. And there’s more • Singhal A, Cole TJ, Fewtrell M, et al. Is slower early growth beneficial for long term cardiovascular health? Circulation 2004;109:1108-13 • Singhal A, Fewtrell M, Cole TJ, Lucas A. Low nutrient intake and early growth for later insulin resistance in adolescents born preterm. The Lancet 2003;361 (March 29):1089-97 • Singhal A, Farooqi IS, O’Rahilly S et al. Early nutrition and leptin cencentrations in later life. Am J Clin Nutr 2002;75: 993-9

47. Osteopænia, fractures etc. • Bone demineralization is often cited as a reason to use fortifiers • And there does appear to be a benefit to giving extra calcium and phosphorus to prevent osteopænia in very small premature babies • But of course, it is not necessary to give cow’s milk (from which fortifiers are made) in order to give extra calcium and phosphorus • Calcium and phosphorus can be added to breastmilk without using fortifiers, based on individual evaluation of biochemical factors

48. One long term study • Bishop NJ, Dahlenburg SL, Fewtrell MS, et al. Early diet of preterm infants and bone mineralization at age five years. Acta Pædiatr 1996;85:230-6 • Compared banked donor milk vs preterm formula as a supplement to mother’s breast milk in 54 children aged five years • “Increasing human milk intake was strongly positively associated with later bone mineral content.”

49. Implications? • “…a period of mineral deprivation in the newborn period is good for long term bone mineralization! This would represent another example of programming. It could represent the action of other factors within breastmilk, such as growth factors”¹ • ¹Ryan S. Bone mineralization in Preterm Infants. Nutrition. 1998;14:745-747

50. Let’s look at how feeding of the premature baby is often undertaken