Nurse-Driven Initiative to Increase Exclusive Human Milk Feeding by Using Pasteurized Donor Human Milk to Treat Hypoglycemic Term Neonates

Facilitators and Barriers of Human Milk Donation

PURPOSE

The purpose of this study is to examine perceptions and experiences of women who donate human milk and highlight various aspects of the breast milk donation process.

STUDY DESIGN

A cross-sectional descriptive study.

METHODS

An online survey was conducted with a convenience sample of women who donated milk at several milk banks in the United States. A questionnaire of 36 closed and open-ended items were developed and validated by the research team. Descriptive statistics and content analysis were used. Semantic content analysis involved three procedures: coding, categorizing text units, and refining the identified themes.

RESULTS

A total of 236 women who donated breast milk completed the questionnaire. Mean age of participants was 32.7±4.27 and 89.40% were non-Hispanic White women with a bachelor's degree (32.20%) or graduate degree (54.70%). Most participants were women who actively donated breast milk, ranging from one to four times. Two themes, facilitators and barriers of milk donation, were identified. Facilitators to milk donation included attitudes toward milk donation, commitment for donating, motivation in donating, and support. Barriers included personal factors, environment, milk donor process, and psychosocial factors.

CLINICAL IMPLICATIONS

Nurses, health care providers, and lactation professionals should educate women about milk donation resources and opportunities. Strategies to increase awareness about milk donation among underrepresented groups such as women of color are highly recommended. Future research is needed to further explore specific factors that increase milk donation awareness and minimize barriers to potential donors.

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records

Introduction

The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs).

Materials and Methods

A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery.

Results

Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers.

Conclusions

Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

The Association Between Type of Supplementation in the Newborn Nursery and Breastfeeding Outcomes at 2 and 6 Months of Age

BACKGROUND

Supplementation in the newborn nursery has been associated with shorter breastfeeding duration. However, supplementation may at times be necessary.

RESEARCH AIM

To determine the association between type of supplementation in the newborn nursery (mother's own milk, formula, donor human milk) and breastfeeding outcomes at 2 and 6 months of age.

METHODS

This was a prospective, longitudinal, observational multi-group cohort study. In total, 2,343 surveys were sent to parents who, prior to delivery, indicated intent to exclusively breastfeed. Participants were grouped by type of nursery supplementation. Surveys asked about breastfeeding outcomes when infants were 2 and 6 months old. Our final analytic sample included data from 1,111 healthy newborns ≥ 35 weeks. We used multiple logistic regression to compare future breastfeeding outcomes for infants who were exclusively directly breastfed or who received supplementation during their birth hospitalization.

RESULTS

Both the donor human milk and formula groups had decreased breastfeeding at 2 and 6 months compared to the exclusively directly breastfed group. Notably, for infants who received formula compared to donor human milk, the odds of breastfeeding at 2 and 6 months were 74% and 58% lower, respectively (OR = 0.26, 95% CI [0.12, 0.56] at 2 months; OR = 0.42, 95% CI [0.19, 0.94] at 6 months). The donor human milk group had lower odds of breastfeeding at both follow up times compared to the mother's own milk group.

CONCLUSION

Among those who intend to breastfeed, supplementation with donor human milk instead of formula in the newborn nursery may support longer breastfeeding.

Improving donor human milk collection in a hospital without a human milk bank: a quality improvement initiative at an urban tertiary-care teaching hospital

Feed intolerance and necrotising enterocolitis (NEC) are challenges while treating sick neonates. These can be reduced by giving human milk, but adequate availability of mother’s own milk or pasteurised donor human milk (PDHM) is a challenge in neonatal setups, like ours, without an attached human milk bank. Hence, this quality improvement initiative was taken to improve donor human milk collection in our urban tertiary-care teaching hospital, to at least 500 mL per week in 4 weeks. After analysing the problem, our quality improvement team identified a shortage of human milk donation that was due to low awareness among the stakeholders and lack of a system to collect and store human milk and transport it to a milk bank. The team first established a system of supplies needed for milk collection, storage and transportation. It then tested change idea of information, education and counselling to increase milk donation. The team carried out a few plan-do-study-act cycles (individual and group counsellings, and usage of videos and information leaflets) to test the change ideas and adapted a few and abandoned some. During this journey, the milk collection increased to above the target amount. Various challenges were addressed, and there was a need for constant motivation of the stakeholders, especially the mothers, and now there is sustained milk donation in the setup. This is incorporated in the standard operating procedure and as a quality indicator of the unit for sustaining the changes in the unit. Our initiative can be replicated in other setups for increasing collection of donor human milk. Greater PDHM availability for sick neonates will, in effect, reduce NEC and feeding intolerance rates, leading to reduced hospital stay, morbidity, mortality and economic burden.

Supplementation-based hypoglycemia guidelines including donor breast milk reduce NICU admission

OBJECTIVE

To study the effects of a supplementation-based hypoglycemia guideline including donor (DM) on NICU admission, exclusive breastfeeding, and blood glucose concentrations in infants at-risk for neonatal hypoglycemia (NH).

PROJECT DESIGN

We integrated DM, feeding supplementation, and reduced frequency of blood glucose testing into an NH bundle for term and late-preterm newborns. We then examined NICU admission rates and rates of exclusive breastfeeding at discharge.

RESULTS

NICU admission rates were reduced to 6% (-10%). Exclusive breastfeeding rates increased to 55% (+22%). Median cost of DM utilization was $13.73 per patient with an average volume of 50.8 ml/infant. DM supplementation resulted in similar times to last hypoglycemic episode and greater increases in blood glucose compared to expressed breast milk or breastfeeding alone (+9.6 mg/dL, p < 0.05).

CONCLUSIONS

A supplementation-based hypoglycemia guideline including donor milk may be an effective way to reduce NICU admissions for asymptomatic hypoglycemia and support mothers in achieving breastfeeding goals.

ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical conditions that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Use of donor human milk in nonhospitalized infants: An infant growth study

When mother's own milk (MOM) is unavailable or insufficient, donor human milk (DHM) is recommended as the next best alternative for low birthweight infants. DHM use for healthy, term infants is increasing, but evidence for growth and tolerability is limited. This retrospective study evaluated growth in term infants in the community who received DHM from a UK milk bank. Mothers of infants receiving DHM between 2017 and 2019 were contacted (n = 49), and 31 (63.2%) agreed to participate. Fourteen infants received DHM as a supplement to other feeds (MOM and/or infant formula) and 17 were exclusively fed DHM where breastfeeding was impossible (range: 3–6 weeks). Growth was assessed by deriving z‐scores using the WHO standard for infant growth and compared with 200 exclusively breastfed infants. Multivariate regression analysis revealed no feeding method‐specific association between z‐score and age, nor between weight and age, suggesting that z‐scores and growth velocity were not affected by feeding exclusive MOM, supplemental DHM or exclusive DHM. DHM was well‐tolerated with no adverse events that led to early cessation. After receiving supplemental DHM group, 63% of infants whose mothers had no physical barrier to breastfeeding (5/8 infants) were exclusively breastfed. This novel study reports adequate growth outcomes of healthy nonhospitalized infants receiving DHM, either as the sole milk source or supplement. Prospective studies are needed to confirm whether DHM is a suitable feeding alternative for term infants in the community, optimal durations, as well as the impact of DHM availability on breastfeeding rates and maternal mental health.

DHM recipients were compared with the who infant growth standard (World Health Organization, 2020) by deriving z‐scores. The WHO Anthro Macro (World Health Organization, 2011 ) was used to calculate weight‐for‐age, length‐for‐age and head circumference‐for‐age z‐scores; z‐scores are the standard deviation of an infant's anthropometric measurements when compared with the WHO standard for infant growth and are gender and age specific.

Donor Human Milk Use in Populations Other than the Preterm Infant: A Systematic Scoping Review

Introduction: Exclusive breastfeeding is recommended for an infant's first 6 months of life. If unable to breastfeed, expressed breast milk, including donor human milk (DHM), is recommended for optimal nutrition. Benefits of DHM in preterm infants have been established by extensive research. However, less is known about DHM use in other populations. Objective: To conduct a scoping review of the literature regarding DHM use in populations other than preterm infants. Materials and Methods: PubMed and Clinicaltrials.gov were used to search for articles and clinical trials published between January 1, 2000 and February 29, 2020. In total, 182 articles and reports were identified and screened by 2 independent reviewers. Results: Twenty-six articles met inclusion criteria and were reviewed. Studies were mostly observational in design and included infants born >35 weeks gestational age with health risks (9/26) and healthy infants (14/26). Most studies in infants with health risks (7/9) investigated clinical outcomes, with small, observational studies suggesting potential improvements in feeding tolerance and gastrointestinal health. Regarding healthy infants, no studies addressed growth, only one study measured clinical outcomes, and findings related to breastfeeding outcomes were conflicting. Over half of the studies reviewed (15/26) were not designed to establish a potential relationship between DHM use and relevant health-related outcomes. Conclusion: The current evidence of DHM use in populations other than preterm infants is limited by lack of direct health measures and infrequent use of randomized trials. More research is warranted to investigate clinical, growth, and breastfeeding outcomes.

National Prevalence of Donor Milk Use Among Level 1 Nurseries

BACKGROUND AND OBJECTIVES

Donor milk use has increased among very preterm infants because of mounting evidence of health benefits; however, the extent that donor milk is used among healthy term infants in level 1 nurseries is unclear. We aimed to determine (1) national prevalence of and (2) hospital factors associated with donor milk use in level 1 nurseries.

METHODS

Among 3040 US birthing hospitals, we randomly selected hospitals from each of 4 US regions (119 in northeast, 120 in Midwest, 116 in west, and 103 in south) for a total of 458 hospitals. We surveyed the nursing leaders of these hospitals from October to December 2017 regarding routine use of donor milk in the level 1 nursery (yes or no). To estimate national prevalence, we weighted responses according to the number of birthing hospitals within each region. We examined relationships between routine donor milk use in the level 1 nursery and hospital characteristics using multivariable logistic regression.

RESULTS

In total, 214 of 458 (47%) nursing leaders responded. The national prevalence of routine donor milk use in level 1 nurseries was 17.6%. Eighty-five percent of donor milk programs were ≤5 years old. Donor milk use occurred more often in hospitals with ≥1500 annual births (41.7%), compared to ≤500 annual births (6.3%) (adjusted odds ratio 7.8; 95% confidence interval 1.8-34.4), and in the west (30.9%), compared to the northeast (10.5%) (adjusted odds ratio 4.1; 95% confidence interval [1.1-14.9]).

CONCLUSIONS

Although there is limited evidence to support donor milk for healthy infants in the nursery, nearly one-fifth of level 1 US nurseries routinely used donor milk in 2017.

Clinical and Sociodemographic Factors Associated With Human Donor Milk Supplementation in Term Newborns

OBJECTIVES

To identify differences between healthy term newborns supplemented with human donor milk (HDM) and those supplemented with infant formula. We hypothesized that sociodemographic and clinical distinctions exist between newborns receiving different milk types.

METHODS

This retrospective study included term newborns admitted to the postpartum unit between March 2017 and April 2019 with ≥1 supplemental feeding with HDM or formula for indications other than hypoglycemia. Maternal and newborn data were abstracted from the electronic medical record.

RESULTS

Five hundred eighty-four dyads met inclusion criteria. More newborns received supplementation with formula than with HDM (57.7% vs 42.3%; P < .001). Infants undergoing phototherapy who required supplementation were more likely to receive HDM (P < .001). Newborns born to white and non-Hispanic mothers were more likely to receive HDM than those born to African American (adjusted odds ratio [aOR] 5.6; P = .007), Hispanic (aOR 3.0; P = .001), or Asian American mothers (aOR 2.7; P = .007). Newborns born to primiparous women (aOR 1.6; P = .03), those born to women with private insurance (aOR 3.7; P < .001), and those born via cesarean delivery (aOR 2.0; P < .001) were more likely to receive HDM. HDM use was more likely in primary English- or Spanish-speaking households (aOR 8.5; P = .009). Newborns receiving their first supplemental feeding during the day (aOR 1.9; P = .001) were more likely to be supplemented with HDM.

CONCLUSIONS

There are clinical and sociodemographic differences between healthy term newborns supplemented with HDM and formula. These findings reveal that there are disparities in current supplementation practices for healthy newborns.