Ksenia Zukowsky, PhD, APRN, NNP-BC ❍ Section Editor

Beyond the Basics

Implementation of a Human Milk Management Center Diane L. Spatz, PhD, RN-BC, FAAN; Katherine J. Schmidt, MSN, RN; Sue Kinzler, RD, LDN ABSTRACT Current hospital practices surrounding the use of human milk and fortification are suboptimal. Safety of milk preparation should be a priority, as should optimization of the milk to meet the nutritional needs of hospitalized infants. This article describes the implementation of a human milk management center (HMMC) at a children’s hospital. This centralized center allows for milk to be safely prepared under aseptic technique. In addition, the HMMC staff can analyze milk composition.The widely variable nutrient composition of human milk has been well established and, therefore, should be considered when fortifying human milk. The HMMC staff have the ability to perform creamatocrits on milk, conduct human milk nutrient analysis, and make skim milk for infants. The processes for developing an HMMC are also detailed in this article. Key Words: fortification, human milk, NICU, optimization

H

uman milk is the ideal form of nutrition for all infants, and the risks of not receiving human milk are well established.1 For hospitalized infants requiring intensive care, provision of human milk is of paramount importance. Human milk provides immunological, nutritional, and developmental benefits that play a critical role in preventing associated short- and long-term morbidities often associated with these vulnerable infants.2 Infants who are fed human milk during hospitalization have a reduced risk of enteral feed intolerance, nosocomial infection, necrotizing enterocolitis

Author Affiliations: University of Pennsylvania, Philadelphia, and the Lactation Program, Children’s Hospital of Philadelphia, Pennsylvania (Dr Spatz); University of Pennsylvania, Philadelphia (Ms Schmidt), and Director of Patient and Family Services–Nutrition Services, Children’s Hospital of Philadelphia, Pennsylvania (Ms Kinzler). The authors declare no conflict of interest. Correspondence: Diane L. Spatz, PhD, RN-BC, FAAN, University of Pennsylvania, 418 Curie Blvd, Office 413, Philadelphia, PA 19104 ([email protected]). Copyright © 2014 by The National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000084

(NEC), chronic lung disease, retinopathy of prematurity, developmental and neurocognitive delays, and rehospitalization after discharge.2 Although the benefits of the use of human milk in enteral feedings for preterm and hospitalized infants are clear, some research has shown that the quantities of certain nutrients in human milk are not sufficient to meet the estimated needs of the infant for proper growth and development.3 Feeding preterm infants human milk without supplementation has been associated with delays in growth and nutritional deficits, both during hospitalization and after discharge.3 Therefore, it is recommended that human milk being fed to preterm infants be fortified to meet their nutritional requirements.3 There is evidence to support that inadequate protein intake, in particular, is the limiting factor responsible for inadequate growth and development in preterm infants and thus is the nutrient that is paid the most attention when developing fortification regimens.4 It has been suggested that, because of the increased protein needs of the very low birth-weight infant being around 3.5 to 4.5 g/kg, fortifier should be added to meet this requirement.5 Similar to the increased nutritional requirements of preterm infants to achieve optimal weight gain and brain development, it has been reported that critically ill infants who are hospitalized, possibly requiring extracorporeal membrane oxygenation, may also require fortification of

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human milk to meet their needs as well.6 Many of the complications associated with under- and overfortification of human milk for preterm infants are also concerns these critically ill hospitalized infants who may be faced with a wide range of complications, such as complex surgical anomalies.6 There are several types of human milk fortifiers (HMFs) that are commercially available and widely used in the fortification of human milk. One multicomponent HMF has been shown to provide additional nutrients to supplement human milk in the form of protein, fat, and carbohydrates, as well as minerals including calcium and phosphate.7 Traditionally, available fortifiers are made from cow’s milk, thereby containing bovine proteins, which may be a causative factor in cases of feeding intolerance in the preterm infant.8 Human milk fortifiers are available in both liquid and powder, with liquid being the preferred choice because the product is sterile. Prolacta-Plus is the only commercially available HMF that is made exclusively from human milk products and has been shown to significantly reduce the rates of NEC in preterm infants. Sullivan and colleagues8 observed significantly fewer incidences of NEC (P = .02) and surgical NEC (P = .007) in infants receiving either 40 mL/kg per day or 100 mL/kg per day of HMF than those infants receiving 100 mL/kg per day of bovine milk-based

fortifier. The amounts of the various nutrients differ slightly between fortifiers, affecting the final nutrient composition of the human milk. Table 1 presents a list of common commercially available fortifiers and the supplemental nutrients they provide. The method of fortification that is commonly used in the United States is “standard fortification,” in which a fixed concentration of fortifier is added to maternal milk to achieve a theoretical desired nutrient content.5 The challenge with this method of fortification is that it assumes that all human milk is equal. In fact, there is a wide variability in nutrient composition of human milk between mothers and the differences in nutrient composition, depending on the stage of lactation that the mother is in.9 Specifically, Bauer and Gerss9 noted that preterm milk contained higher concentrations of carbohydrates, fat, and energy than term milk (P < .05). In addition, the protein content of both preterm and term milk decreased as the stage of lactation progressed, indicating significantly higher concentration in preterm milk than in moderately preterm and term milk (P < .0001).9 Knowledge of the wide variability in human milk concentration depending on gestational age of the infant is critical when considering fortification regimens for hospitalized infants. Therefore, when fortifying human milk using standard fortification regimens, there is risk of both

TABLE 1. Composition of Commercially Available Human Milk Fortifiersa Type of Fortifier

Calories

Enfamil Human Milk Fortifierb (Amounts in 4 Vials to Be Added to 100-mL Human Milk)

Similac Human Milk Fortifierc (Amounts in 4 Packets to Be Added to 100-mL Human Milk)

30

14

Prolacta+4d Prolacta+6d (Amounts in 20 mL (Amounts in 30 mL of Liquid Fortifier of Liquid Fortifier to Be Added to to Be Added to 80-mL Human Milk) 70-mL Human Milk) 29.2

43.8

Proteins, g

2.2

1.00

1.2

1.8

Fat, g

2.3

0.36

1.8

2.7

Implementation of a human milk management center.

Current hospital practices surrounding the use of human milk and fortification are suboptimal. Safety of milk preparation should be a priority, as sho...
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