What Are the Advantages of Human Donor Breastmilk?

Patient Presentation

A 53-day-old former 32 week premature female came to clinic for her health supervision visit after discharge from the neonatal intensive care unit. She had been discharged 3 days ago and her parents reported that overall they were doing well. She had had a couple of spit-up episodes after feedings that were random and were only of breastmilk. She was bottle feeding 2 ounces every 3 hours of maternal and donor breast milk because of an insufficient maternal supply. The past medical history showed that she had been treated for hyperbilirubinemia for several days and ventilated for respiratory distress for 16 days. She had slow enteral feedings at first but once she would orally feed she had steady weight gain. She had all of her routine care including one set of immunizations prior to leaving the hospital. The family history was non-contributory.

The pertinent physical exam showed a small, well-formed infant. Her weight was 3.136 kg (50%), length was 49.5 cm (50%) and head circumference was 36.5 cm (75%) with percentiles being for gestational age. Her examination was also normal for gestational age. The diagnosis of a healthy former preterm infant was made. Routine infant cares were discussed with the family and special followup appointments were reviewed. After finishing with the patient, the medical student who was following the pediatrician had many questions about premature infants including catch-up growth, when they receive routine immunizations and breastmilk donation. The pediatrician answered the questions between seeing other patients that morning.

Discussion
Premature infants have unique needs and risks because of their prematurity. Adequate nutrition is one of those problems. In utero the fetus is basically able to “take” everything it needs from the mother already in usable form via the blood stream. In the world, the infant needs to have a neurological and oral-motor apparatus that can coordinate an adequate suck and swallow, and a gastrointestinal tract that is able to absorb the nutrients. The premature infant also needs water, protein, fat, carbohydrates, and macro- and micro-nutrients that are appropriate for its gestational age and changing needs. For example, premature infants are notoriously at risk for iron-deficiency because they are not in-utero during the 3rd trimester (or part of it) when iron is preferentially transferred to the infant. Additionally the premature infant often needs blood testing because of their ongoing medical needs, which causes iatrogenic blood loss.

Human breastmilk has been found to decrease the risk of otitis media and other upper respiratory tract infections, asthma, atopic dermatitis, gastroenteritis, celiac disease, inflammatory bowel disease, necrotizing enterocolitis, obesity, type 1 and type 2 diabetes, leukemia and sudden infant death syndrome. Exclusive maternal breastmilk is recommended for all infants < 6 months of age in the United States and internationally. The American Academy of Pediatrics and other professional societies recommend that all premature infants receive maternal human breastmilk and if it is not available, has an insufficient supply, or is contraindicated, then pasteurized donor human breastmilk that is appropriately fortified be used.

In the United States most human donor breastmilk is distributed by the Human Milk Banking Association of North America. Donor human breastmilk can be expensive because of the necessary collection, processing, storage and distribution. The cost of human donor breastmilk is approximately $4.50 per 30 milliliters. The cost of human donor breastmilk for the child above would be over $100/day. Some cost/benefit analyses show for every dollar spent on human donor breastmilk that $11 will be saved on hospital costs for prevention of necrotizing enterocolitis. Other data shows that if 90% of infants in the US were exclusively breastfed to 6 months of age, a cost savings of $13 billion/year would occur.

Learning Point
Human donor breastmilk is different than maternal breastmilk due to the differences in maternal (has a preterm infant) vs donor (usually has a full-term healthy infant) and the necessary pasteurization of the donor milk. Term maternal milk has less fat and protein than preterm maternal milk. Term maternal milk may also be lower in DHA (docosahexaenoic acid) and ARA (arachidonic acid). Pasteurization causes inactivation of white blood cells, viruses (i.e. human T-cell lymphotrophic virus) and bacteria (i.e.(E. coli, Staph. aureaus and Staph agalactiae). There are also some other protective components of the milk that are lost (such as maternal T-cells, B-cells, macrophages and neutrophils) while others are not affected (oligosaccharides).

Human donor breastmilk may be protective against necrotizing enterocolitis and may have improved developmental outcomes for premature infants. Preterm infants fed breastmilk (maternal and human donor) have slower growth than formula fed infants. However improved growth with protein supplementation of human breastmilk (maternal and human donor) has been shown.

Questions for Further Discussion
1. What are absolute and relative contraindications for use of maternal breastmilk?
2. How is human donor breastmilk processed?
3. What are hospital activities that support breastfeeding?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Breastfeeding and Premature Babies

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Academy of Pediatrics Policy Statement. Breastfeeding and the Use of Human Milk. Pediatrics. 2012:129;e827-e841.. Available from the Internet at: http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552 (cited 11/10/14).

Colaizy TT. Donor human milk for preterm infants: what it is, what it can do, and what still needs to be learned. Clin Perinatol. 2014 Jun;41(2):437-50.

Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2014 Apr 22;4:CD002971

National Association of Neonatal Nurses. Reimbursemen for Donor Human Milk for Preterm Infants. Available from the Internet at http://www.nann.org/advocacy/agenda/reimbursement-for-donor-breast-milk-for-preterm-infants.html (cited 11/4/14).

Human Milk Banking Association of North America. Available from the Internet at https://www.hmbana.org (rev. 2014, cited 11/4/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Can I Use a Space Heater?

    Patient Presentation
    A 9-month-old male came to clinic for his health supervision visit. He was developing and growing well. His mother was concerned that as winter was coming on that his room temperature was too cold. “We were thinking about buying a space heater to keep it warmer in there. What do you think?” she asked. The past medical history showed a previously full-term infant with no health issues.

    The pertinent physical exam revealed a smiley infant with growth parameters in the 50-90% and normal vital signs. He had some general dry skin on exam. The diagnosis of a healthy male with general dry skin was made. The pediatrician discussed a variety of winter safety and health issues with the family including the use of emollients for dry skin. The pediatrician told the mother that he was concerned about the space heater use because of the increased risk of fire and burns that space heaters could cause. He recommended that they use an infant sleep sack along with a sleeper for the child if they were concerned about the temperature. “Babies do just fine with one extra layer of clothing than adults. That is true when sleeping also,” he said. The pediatrician also reviewed back to sleep with the mother but acknowledged that the child by this age probably was finding his own comfortable sleep position after falling asleep.

    Discussion
    Parents have many concerns about their children’s welfare. Recommendations for children’s and other products and how they are properly used change over time with new research and the development of new or products for families. Cultural practices and individual wishes also influence the products parents use.

    Safe sleeping environment for infants are important because of the risk of sudden infant death syndrome and because infants spend an even larger proportion of the day asleep than older children and adults. Therefore sleep risks are increased. The American Academy of Pediatrics recommends that infants are always placed onto their backs when sleeping. They should be placed onto a firm surface without any additional soft materials and loose bedding such as additional bedding, bumpers, pillows etc. Room sharing of the infant with the parents is encouraged but bed sharing is not recommended. Overheating is not encouraged. One additional layer for a child than for an adult in the same environment suffices. Using sleep clothing designed to keep the infant warm without the possible hazard of head covering or entrapment is recommended. Parental smoking and drug use are discouraged and breastfeeding and use of a pacifier are encouraged.

    Learning Point
    Most infants can be kept warm enough using the recommendations above without the use of an additional space heater. Portable space heaters that use combustible fuel such as kerosene or gas have the potential problems of being flammable, producing carbon monoxide poisoning, and producing other indoor environmental air pollution. Venting must be used with combustible fuel heaters if space heaters are used. Stoves that use combustible fuel such as wood, pellets, corncobs etc. have the same problems as portable space heaters. Electric heaters are the only option for non-ventilated areas if they are used. However all types of portable space heaters and stores can cause fire and burns.

    If used, space heaters should:

    • Be safety-certified. This can be checked at the Occupational Safety and Health Administration here.
    • Have an on-off switch that automatically turns the unit off at a certain temperature and if tipped over.
    • Placement
      • Have at least 3 feet or more of clear space around the unit – this includes curtains, wallhangings, rugs, papers, bedding, etc.
      • Placed on a non-combustible, level surface
      • Placed away from any foot traffic
    • Cord
      • The cord should be placed directly into the electrical socket with no extension cord used
      • The cord should not be placed under objects such as rugs
    • Use
      • Never used in a bathroom
      • Never used near a water source
      • Never used while sleeping or otherwise unattended
      • Use only when an adult is awake and can monitor the unit
    • Maintenance
      • Regularly checked for any damage to the unit, cord and electrical outlet
      • Regularly checking the space around the unit

    Safety equipment should always be easily available such as fire and carbon monoxide detectors and fire extinguishers.

    Questions for Further Discussion
    1. When can older children have soft or loose items in their sleeping environment?
    2. How often should smoke detectors and fire extinguishers be replaced?
    3. What are some recommendations for winter safety for parents? See here for recommendations.

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Sudden Infant Death Syndrome, Infant and Newborn Care and Winter Weather Emergencies.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    National Environmental Education & Training Foundation (NEETF). Environmental management of pediatric asthma. Guidelines for health care providers. Washington (DC): National Environmental Education & Training Foundation (NEETF); 2005 Aug. 56 p. Available from the Internet at http://www.guideline.gov/content.aspx?id=10019&search=space+heaters (cited 10/28/14).

    Consumer Product Safety Commission. Reducing Fire Hazards for Portable Electric Heaters Available from the Internet at http://www.cpsc.gov/Global/Safety%20Education/Home-Appliances-Maintenance-Structure/098.pdf (cited 10/28/14).

    American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Policy Statement. Pediatrics. 2011, October 17. Available from the Internet at http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284.full.pdf+html (rev10/17/11, cited 10/28/12).

    Korioth, T. Prevent burns, fires when using space heaters. American Academy of Pediatrics News. Available from the Internet at http://aapnews.aappublications.org/content/33/12/32.6.full
    (rev. 2012, cited 10/28/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Types of Patients Can Be Referred for Palliative Care Services?

    Patient Presentation
    A 26-year-old male came to the inpatient unit for increasing respiratory distress. He had cystic fibrosis and over the past year had had frequent hospitalizations for respiratory distress, pneumonia and “tune-ups” and his pulmonary function was diminishing rapidly over the time. Over the past week he had been more tired and somnolent. He had an increased oxygen requirement with increased coughing and secretions. The coughing and oxygen make it difficult for him to communicate and he had told his mother that he wanted to come to the hospital now. He was well known to the hospital staff and his parents were always very attentive to him during his hospitalizations. The social history was that he was an only child. His mother was a homemaker and his father was a businessman.

    The pertinent physical exam showed a very thin male in moderate respiratory distress. He was breathing deeply 24 times/minute with frequent coughing. His saturation was only 88% on 2 liters of oxygen/minute by nasal cannula and only increased to 90% with 5 liters/minute. A 100% non-rebreather was used increasing his oxygen saturation to 92-94%. He was somnolent but would waken and be appropriate with the staff. He was barrel-chested. His lungs had crackles with diminished breath sounds throughout. His nail-beds were blue with marked clubbing.

    The diagnosis of marked respiratory distress in a patient with cystic fibrosis whose pulmonary status had been diminishing was made. His parents asked to talk with the staff outside his room. “He’s dying and we know it. He does too. He didn’t want to come to the hospital until now otherwise we would have been here earlier. The coughing is really bothering him because he wants to talk when he is awake. We’ve never specifically talked about what to do when the time comes, but it’s here. What more can we do?” they asked. The staff and parents discussed options and then went back into the room to discuss them with the patient. He indicated that he wanted help with the secretions and didn’t like the non-rebreather. He also didn’t want any antibiotics started and just wanted to be with his family and the hospital staff. When asked about resuscitation he said, “Ask my mom.” She shook her head to indicate no as did his father. So the team used medication to help with the secretions along with some pulmonary toilet techniques. A nasal cannula was again tried but he then indicated that he wanted the re-breather back. He denied much pain but his mother thought that the coughing was hurting him, so small doses of oral morphine were given. After that he seemed more comfortable and slept well. Over the next 18 hours, he would drift in and out of sleep and would talk briefly. At one point he asked for the nasal cannula back because it was more comfortable. He went to sleep and over time his respiratory rate began to slow and he died peacefully with his family and staff members around him.

    Discussion
    Pediatric pallative care (PPC) is care for patients who have life-threatening conditions or need end of life care. The main stakeholders receiving PPC are the patients and all members of the family which may include siblings, grandparents and other members. Other stakeholders are the medical care team including ancillary staff at the hospital and other venues where the patient receives care. PPC is provided by an interdisciplinary team including physicians, nurses, social workers, pharmacists, psychologists, chaplains/faith workers and others who assist families in four main areas: “…relieve suffering, improve quality of life, facilitate informed decision-making and assist in care coordination between clinicians and across sites of care.”

    PPC providers can help provide treatment to relieve suffering including management of pain, nausea and emesis, pruritis, agitation, anxiety, depression, delirium, seizures, constipation, sleep disturbances, and dyspnea. Providers can also improve quality of life through frank and open discussions among stakeholders to provide support, relieve family conflict and distress and streamline care that supports the decisions made in a culturally sensitive manner. PPC providers facilitate informed decision-making through frank and compassionate communication regarding treatment options, goals of care, advanced planning, and education of end of life trajectory. Assisting with communication among stakeholders is often key. The providers also assist with care coordination between clinicians and across sites of care, obtaining and coordinating resources so patients have care provided in the most appropriate settings for them. “Often the most therapeutic intervention by the PPC teams is impartial listening”

    In a recent paper on barriers to PPC for children the most common barriers included uncertain prognosis (55%), family is not ready to acknowledge the incurable condition (51%), language barriers (47%) and time restraints (47%). Other barriers in the literature include lack of resources for PPC, communication problems, inappropriate eligibility criteria, fragmented care, lack of training and expertise, communication problems, false-hope for cure and inappropriate continuation of life-saving technology. Many families who are offered PPC say that they wish that they had had end of life discussions earlier in the course of the illness. The patient above died in the early 1990’s before many newer treatments were available for cystic fibrosis and many years before PPC became established as a specialty in 2006.

    Learning Point
    Patients and families have better outcomes when PPC is integrated into the care early as a part of ongoing care particularly as children often receive concurrent disease-directed and palliative care therapy. Two main questions arise frequently: who to refer to PPC and when to refer to PPC. Patients can/should be referred who have life-threatening illnesses but the trajectories of the disease/illness may be different:

      1. “Life-threatening conditions for which treatment is available but may fail” – irreversible kidney failure or cancer
      2. “Conditions where premature death is inevitable but treatment may prolong life” – Duchenne muscular dystrophy or cystic fibrosis
      3. “Progressive conditions without curative treatment options” – mucopolysaccaridoses
      4. “Irreversible but non-progressive conditions causing severe disability, health complications and risk of premature death” – cerebral palsy or some brain injuries

    When to refer patients includes evidence of disease progression, an increase in frequency or duration of hospitalizations or extensive intensive care unit hospitalizations, symptoms that are progressing and not readily managed, and at decision making times about adopting or discontinuing technology.

    Questions for Further Discussion
    1. What palliative care services are available in your local area?
    2. What are the similarities and differences of palliative care consultations and ethics consultations?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Cystic Fibrosis, Palliative Care, Hospice Care and End of Life Issues.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Feudtner C, Womer J, Augustin R, Remke S, Wolfe J, Friebert S, Weissman D. Pediatric palliative care programs in children’s hospitals: a cross-sectional national survey. Pediatrics. 2013 Dec;132(6):1063-70.

    Section on Hospice and Palliative Medicine and Committee on Hospital Care. Pediatric Palliative Care and Hospice Care Commitments, Guidelines, and Recommendations. American Academy of Pediatrics. Pediatrics. 2013:132(5);966-972.

    Levine D, Lam CG, Cunningham MJ, Remke S, Chrastek J, Klick J, Macauley R, Baker JN. Best practices for pediatric palliative cancer care: a primer for clinical providers. J Support Oncol. 2013 Sep;11(3):114-25.

    Moore D, Sheetz J. Pediatric palliative care consultation. Pediatr Clin North Am. 2014 Aug;61(4):735-47.

    Schwantes S, O’Brien HW. Pediatric palliative care for children with complex chronic medical conditions. Pediatr Clin North Am. 2014 Aug;61(4):797-821.

    Johnson LM, Snaman JM, Cupit MC, Baker JN. End-of-life care for hospitalized children. Pediatr Clin North Am. 2014 Aug;61(4):797-821.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • “I’m Just In the Band”

    Patient Presentation
    A 13-year-old female came to clinic for her health supervision visit. She had no concerns except for a dry red rash on her chin. She said that she had it off and on but it had worsened in the past two weeks. She denied any new soaps, lotions, or cosmetics. The past medical history was non-contributory. The social history showed that she was doing well academically in 8th grade. She played the clarinet and was in a church-organization that performed community service.

    The pertinent physical exam revealed a healthy female with growth parameters in the 10-25%. Her skin examination showed some dry irritated skin about 2 cm wide that extended linerally from her lip to her chin. It did not appear infected. Her left index finger and right thumb also showed some irritated skin. She denied any changes in skin sensation or pain.

    The diagnosis of a healthy female with dermatitis was made. The physician asked more questions about her skin and the girl offered that she had been practicing her clarinet more because of some upcoming performances plus a high-stakes audition. She also offered that her hands and shoulders had been hurting her somewhat for the past two weeks since she had significantly increased her practice time. She denied any lip-licking or changing any equipment including her clarinet reeds. The physician explained that although she understood the need to practice more that the girl was overdoing it. “We can deal with rash on your chin from all the saliva, but you are rubbing your fingers on your clarinet and your hands and shoulders are sore. You might be able to do well in the audition, but how are you going to play after that?” she asked. She continued, “You are a performer just like any other well-trained athlete, and…” “But I’m just in the band,” the girl interrupted. “You are an athlete just like any other athlete who has to practice to perform their best. If an athlete suddenly increases their training, they often can get hurt. You need to increase your training or practicing just like an athlete does for your performances and audition. You have to work up to it and take care of your body,” the pediatrician advised. The mother didn’t know about the hand and shoulder pain and agreed that this needed to be addressed and they would talk with the music teacher. The pediatrician recommended to split her practices into two times a day for shorter amounts of time, and to change positions often between sitting and standing. She also recommended if possible using a mirror to check her positioning from time to time while practicing. “Athletes don’t do the same thing all the time and you shouldn’t too. Your music teacher probably will have other suggestions for positioning and increasing your practice time in a smart way.” In the meantime, the pediatrician recommended using emollients on her chin and hands to help with the dermatitis, and not holding her clarinet so tightly.

    Discussion
    Instrumental music, either as an avocation or profession, provides great pleasure for those performing and listening. Unfortunately it can also cause health problems. Many of the problems are musculoskeletal or neurological in etiology due to overuse and the musician may experience pain. Prelude to pain can include stiffness or tingling or other skin sensations. Musicians may experience weakness, loss of function, control (accuracy) and ability (speed) as well as problems with tone.

    “The most prevent problems involve overuse of muscles resulting from repetitive movements of playing, often in combination with prolonged weight bearing in an awkward positions.” String players have the highest prevalence of musculoskeletal problems. Musculoskeletal strain can also be caused by transporting large or awkward instruments and equipment inappropriately. Other common health problems of instrumental musicians include peripheral neuropathies, dermatitis and other otolaryngological problems.

    In prevalence studies of school-age children (7-17 years) learning and performing instrumental music, 67% reported at least one time during their lifetime an instrument-related musculoskeletal problem, 56% had an experience in the past month, and 30% reported being unable to play their instrument at least once because of the problem. Of those reporting a problem, within the past month, 5% had taken medication for the problem and 4% had sought medical attention for the issue. Females and musicians who were older reported more problems. Older musicians and those playing more instruments have increased risks of problems because of the increased exposure and use.

    Musicians young and old need to be taught proper technique and reminded of proper technique to mitigate potential problems. Musicians need conditioning to strengthen the primary and secondary body areas for the instruments and to acclimate the performer to the performance levels needed. This is the same as any other well-trained athlete or performer.

    The main treatment for musculoskeletal problems is rest. Other options include analgesics and anti-inflammatory medications, muscle relaxants, acupuncture, physical therapy including heat/cold, ultrasound, and electrical stimulation treatment. Also rehabilitation therapies including splinting, stretching and stabilization of various musculature, and surgeries (nerve entrapment or compression, muscular incompetence may be needed. Psychological, dermatological, dental, audiology and speech therapy professionals may also offer other help for musicians.

    Learning Point
    Health problems due to instrumental music performance include:

    • Musculoskeletal
      • Strain
      • Tenosynovitis
      • Musculature incompetence due to overuse and pressure – examples include due to velopharyngeal muscles, orbicular oris muscle or “Satchmo mouth” named for trumpeter Louis Armstrong, or oral muscular incompetence or “Gillespie Cheeks” named for trumpeter Dizzy Gillespie.
      • Hypermobility syndrome
      • Arthritis
      • Joint nodes – Heberden’s and Bouchard’s
      • Temporomandibular joint pain – especially in upper string and brass players
    • Neurological
      • Compressive neuropathies
      • Nerve entrapments
      • Focal dystonia – involuntary, localized motor movement that interferes with the playing ability
      • Sensory loss to specific areas of pressure
      • Visual field loss – due to high intraoral pressures in woodwind and brass musicians
      • Neuromas
    • Dermatological
      • Dermatitis – acute or chronic, due to contact of various parts of the body with the instrument or other substances. Improperly fitted instruments, friction and hygiene also add to the problem. Fiddler’s neck, cellist’s chest, flautists’s chin, guitar nipple are all examples of dermatitis.
      • Allergens – “The most frequently reported culprit substances were: colophony [rosin], exotic woods, nickel sulphate, varnishes, and propolis (bee glue).”
      • Calluses
      • Subungual hematomas and onycholysis
    • Otolaryngological
      • Hearing loss
      • Laryngocoele – due to increased air pressure
    • Dental
      • Increased tooth calculus – especially in single reed instrumentalists
      • Bruxism – especially in brass players
      • Malocclusion – i.e. cross-bite in violinists
    • Infectious Disease
      • Herpes simplex infections
      • Impetigo
    • Psychological
      • General stress
      • Performance anxiety
    • Cardiac
      • Unmasking of underlying cardiac anomalies such as patent foramen ovale due to valsalva maneuvers
      • Potential arrhythmias such as AV block

    Questions for Further Discussion
    1. What are some health problems in other performing arts such as dance or vocal music?
    2. What health related problems are seen in the visual arts?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: http://www.nlm.nih.gov/medlineplus/rashes.html, http://www.nlm.nih.gov/medlineplus/ergonomics.html, http://www.nlm.nih.gov/medlineplus/sportsfitness.html and http://www.nlm.nih.gov/medlineplus/exerciseandphysicalfitness.html.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Liu S, Hayden GF. Maladies in musicians. South Med J. 2002 Jul;95(7):727-34.

    Lombardi C, Bottello M, Caruso A, Gargioni S, Passalacqua G. Allergy and skin diseases in musicians. Eur Ann Allergy Clin Immunol. 2003 Feb;35(2):52-5.

    Ranelli S, Straker L, Smith A. Prevalence of playing-related musculoekeltal symptoms and disorders in children learning instrumental music. Med Probl Perform Arts. 2008;23:178-185.

    Ranelli S, Straker L, Smith A. Playing-related musculoskeletal problems in children learning instrumental music: the association between problem location and gender, age, and music exposure factors. Med Probl Perform Art. 2011 Sep;26(3):123-39.

    Rodriguez-Lozano FJ, Saez-Yuguero MR, Bermejo-Fenoll A. Orofacial problems in musicians: a review of the literature. Med Probl Perform Art. 2011 Sep;26(3):150-6.

    Lee HS, Park HY, Yoon JO, Kim JS, Chun JM, Aminata IW, Cho WJ, Jeon IH. Musicians’ medicine: musculoskeletal problems in string players. Clin Orthop Surg. 2013 Sep;5(3):155-60.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital