Presence of human milk bank is associated with ...

R. S. Cohen, MD DOI 10.1515/jpm-2012-0196 J. Perinat. Med. 2013; 41(2): 129–131

Recommendation and Guidelines for Perinatal Practice Sertac Arslanoglua, Guido E. Moroa,*, Roberto Bellù, Daniela Turoli, Giuseppe De Nisi, Paola Tonetto and Enrico Bertino

Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants Abstract: Human milk confers health benefits of vital importance for the sick and preterm infants in neonatal intensive care units (NICUs). Mother’s own milk is the first choice in preterm infant feeding, and every effort should be made to promote lactation. When mother’s milk is not available or is insufficient, donor human milk (DHM) is recommended. Yet, occasionally, the concern that the use of DHM might decrease breastfeeding is being raised. The present data collection planned by the Italian Association of Human Milk Banks (AIBLUD) in collaboration with the Italian Neonatal Network (INN) attempted to address this concern. A total of 4277 very low birth weight (VLBW) infants from 83 Italian NICUs were evaluated for this comparative analysis. The 83 Italian NICUs were divided into two groups: centers with a human milk bank (HMB) and centers without a HMB; the available parameters in the network – “any and exclusive breastfeeding rates” and “exclusive formula rate” at discharge – were compared. Exclusive breastfeeding rate at discharge was significantly higher in NICUs with a HMB than in NICUs without (29.6% vs. 16.0%, respectively). Any breastfeeding rate at discharge tended to be higher in the NICUs with HMB (60.4% vs. 52.8%, P = 0.09), and exclusive formula rate was lower in the NICUs with HMB (26.5% vs. 31.3%), but this difference was not significant. This report shows that the presence of a HMB and the use of DHM in NICU are associated with increased breastfeeding rate at discharge from the hospital for VLBW infants. Keywords: Donor human milk; breastfeeding; lactation; milk bank; preterm infant.

a World Association of Perinatal Medicine (WAPM), Working Group on Nutrition. *Corresponding author: Guido E. Moro, MD, Italian Association of Human Milk Banks (AIBLUD)c/o Biomedia, Via Libero Temolo No 4, 20126, Milan, Italy, Tel.: +39 3485659614, E-mail: [email protected]

Sertac Arslanoglu: Italian Association of Human Milk Banks, Milan, Italy Roberto Bellù: Italian Neonatal Network (INN), Lecco, Italy; and NICU, Manzoni Hospital, Lecco, Italy Daniela Turoli: Italian Neonatal Network (INN), Lecco, Italy Giuseppe De Nisi: Italian Association of Human Milk Banks, Milan, Italy Paola Tonetto: Italian Association of Human Milk Banks, Milan, Italy; and NICU, University of Turin, Turin, Italy Enrico Bertino: Italian Association of Human Milk Banks, Milan, Italy; and NICU, University of Turin, Turin, Italy

Recent research and systematic reviews have reinforced the conclusion that breastfeeding and human milk (HM) confer health benefits for the infant and the mother, and represent the reference normative standards for infant feeding and nutrition [1]. These benefits are of vital importance particularly for sick and preterm infants in neonatal intensive care units (NICUs). Feeding preterm infants HM decreases the rate of infection, necrotizing enterocolitis (NEC), and mortality, while improving neurocognitive and cardiovascular outcomes in the long-term [2]. Mother’s own milk (MOM) is the first choice in preterm infant feeding. When mother’s milk is not available or is insufficient, donor human milk (DHM) is recommended [1, 2] and has been considered as one of the supportive measures for the establishment of breastfeeding by some authors who applied Baby-Friendly Hospital Initiatives to NICUs [3, 4, 6]. Yet, occasionally, a concern is being raised in the health community: Does the presence of a human milk bank (HMB) and the use of DHM attenuate the efforts to promote lactation resulting in decreased breastfeeding rates in preterm infants? The present data collection has been planned by the Italian Association of Human Milk Banks (AIBLUD) in an attempt to address this concern. The data have been provided by the Italian Neonatal Network (INN) which is integrated to the well-known

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130 Arslanoglu et al., Association between human milk bank and exclusive breastfeeding

Vermont Oxford Network (VON). A total of 4277 very low birth weight (VLBW) infants admitted to the 83 Italian NICUs registered in the INN-VON program (from a total of 98 NICUs in the country) in the year 2010 were evaluated for this comparative analysis. The available parameters related to breastfeeding at the INN-VON database were as follows: rate of “exclusive breastfeeding at discharge,” “any breastfeeding at discharge,” and “exclusive formula at discharge.” Italian NICUs were divided into two groups: centers with a HMB and centers without a HMB. The distribution of the NICUs with and without HMB was similar to that of the population in the three main geographical areas of Italy: north, center, and south. In fact, the northern part of Italy in the year 2010 had a population of 28 million people, whereas the central and southern parts combined reached a population size of 31 million people [data from THE Italian National Institute of Statistics (ISTAT), 2010] (Table 1). The newborns admitted to the two groups of NICUs were similar in birth weight, gestational age at birth, and proportion of singletons or multiples (Table 2). Feeding data of the two groups at discharge from the hospital were compared by using the Mann-Whitney test. Statistical significance was set at the 5 level of probability. Statistical analyses were performed using the SPSS 17.0 software for Windows (SPSS, Inc., Chicago, IL, USA). The NICUs with and without HMB were comparable in terms of NICU characteristics and size. Feeding data at discharge are presented in Table 3 and clearly show

With HMB Without HMB

North

Center

South

Total

9 (47.4%) 31 (48.4%)

5 (26.3%) 13 (20.3%)

5 (26.3%) 20 (31.3%)

19 64

Table 1 Geographical distribution of the 83 Italian NICU.

With HMB Without HMB

that the presence of a HMB in a NICU is associated with increased breastfeeding rate at discharge from the hospital for VLBW infancts. This positive impact is more pronounced for exclusive breastfeeding. Our results represent the first national survey on the positive effects of the availability of DHM on breastfeeding rate of VLBW infants at discharge, confirming the existing data from Australia [7], USA [5], and Spain [8] which already indicate that the presence of a HMB does not decrease the breastfeeding rate of VLBW infants, but is supportive for breastfeeding promotion. The report from Australia indicates that the opening of a HMB did not reduce the rate of breastfeeding, but increased the breastfeeding rate at discharge [7]. In Utah, USA, a program designed to improve HM availability for preterm infants and consisting of using exclusively HM (MOM and/ or DHM) was implemented in a NICU: the BEST program (“Breast Milk Early Saves Trouble”). Its implementation for 12 months increased HM and DHM use in NICU, and breastfeeding rate at discharge tended to increase compared to the situation prior to the implementation period [5]. The Spanish study from Madrid evaluated the impact of the establishment of a HMB in a NICU on the rate of exclusive breastfeeding at discharge and formula use in NICUs. The researchers concluded that the presence of a HMB in a neonatal unit did not reduce the rate of exclusive breastfeeding at discharge, but did reduce the use of infant formula during the first 4 weeks of life. Also, having DHM available enabled earlier initiation of enteral feeding [8]. Our study shows a great variability in breastfeeding rate among NICUs; this observation demonstrates the need to further improve uniform breastfeeding promotion and support in Italian NICUs. Our confirmative data pointing at a positive impact of DHM use on breastfeeding rate suggest that human milk banking is not only about

Median birth weight (g)

Birth weight range (g)

Gestational age (weeks)

Gestational age range (weeks)

Number of singletons

Number of multiples

Total number of infants

1080 1086

320–1890 290–2080

28 29

21–38 21–38

649 (68%) 2280 (67%)

305 (32%) 1116 (33%)

954 3396

Table 2 Birth weight, gestational age, and proportion of singletons or multiples in the infants admitted to the 83 NICUs.

Any breastfeeding (%) Exclusive breastfeeding (%) Exclusive formula (%)

Italian NICUs without a HMB (n = 64)

Range (%)

Italian NICUs with a HMB (n = 19)

Range (%)

P-value

52.8 16.0 31.3

4.0–85.1 0.0–57.9 1.6–62.71

60.4 29.6 26.5

29.7–84.1 0–77.8 0–51.4

0.087 0.007 0.188

Table 3 Feeding data for VLBW infants at discharge from the hospital.


Arslanoglu et al., Association between human milk bank and exclusive breastfeeding 131

collecting, storing, processing, testing, and distributing milk, but also about the extension of the culture of breastfeeding and use of HM in NICUs, and may serve also as a tool for promotion of lactation. Besides, having access to DHM when MOM is insufficient might attenuate the possible feeling of guilt and inadequacy among mothers and might be encouraging. We acknowledge that the promotion of breastfeeding and the use of MOM come first in NICUs. Regular maternal

support to establish and maintain lactation and transition to breastfeeding has the highest priority. The purpose of HM banking is to provide HM supply for infants (mainly preterm). When MOM is not available or is insufficient, donor milk is the best alternative and is associated with elevated rate of exclusive breastfeeding. Received August 17, 2012. Accepted October 16, 2012. Previously published online November 15, 2012.

References [1] American Academy of Pediatrics. Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–41. [2] Arslanoglu S, Ziegler EE, Moro GE. Donor human milk in preterm infant feeding: evidence and recommendations. J Perinat Med. 2010;38:347–51. [3] do Nascimento MB, Issler H. Breastfeeding the premature infant: experience of a baby-friendly hospital in Brazil. J Hum Lact. 2005;21:47–52. [4] Maastrup R, Bojesen SN, Kronborg H, Hallstrom I. Breastfeeding support in neonatal intensive care: a national survey. J Hum Lact. 2012;28:370–9. [5] Montgomery D, Schmutz N, Baer VL, Rogerson R, Wheeler R, Rowley AM, et al. Effects of instituting the “BEST Program”

(Breast Milk Early Saves Trouble) in a level III NICU. J Hum Lact. 2008;24:248–51. [6] Nyqvist KH, Kylberg E. Application of the Baby Friendly Hospital Initiative to neonatal care: suggestions by Swedish mothers of very preterm infants. J Hum Lact. 2008;24:252–62. [7] Simmer K, Hartmann B. The knowns and unknowns of human milk banking. Early Hum Dev. 2009;85:701–4. [8] Utrera Torres MI, Medina Lopes C, Vazquez Roman S, Alonso Diaz C, Cruz-Rojo J, Fernandez Cooke E, et al. Does opening a milk bank in a neonatal unit change infant feeding practices? A before and after study. Int Breastfeed J. 2010;5:4. The authors stated that there are no conflicts of interest regarding the publication of this article.
