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.
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.
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?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Age: Premature Newborn
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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
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.
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.
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.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital