The Innocenti Declaration (WHO/UNICEF, 1990) recognised that breastfeeding is a unique process that provides ideal nutrition for infants and contributes to their healthy growth and development. The Paediatrics and Child Health Division of the Royal Australasian College of Physicians encourages and supports the promotion of breastfeeding (see website).
Australia is signatory to the WHO International Code of Marketing of Breastmilk Substitutes (1981) which aims to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution (see website).
The many benefits of mother's own milk are well known. Breastmilk is a unique 'living' fluid. It contains
Colostrum is a high density, low-volume feed high in immunoglobulins, which evolves into mature milk between 3 and 14 days postpartum.
Breastmilk feeding for both preterm and unwell term infants assists recovery and has major health benefits.
As the unwell or preterm infant may not be able to breastfeed mothers are encouraged to provide fresh expressed milk daily; if this is not possible breastmilk can be stored in a refrigerator or freezer.
(see NHMRC Infant Feeding Guidelines for Health workers, Commonwealth Department of Health and Family Services, 1996)
Guidelines for collecting and storing breastmilk are more stringent for sick and preterm babies than for healthy babies at home.
|Freshly expressed into closed container||6 - 8 hours (260C )
If refrigeration is available store milk there
|3 - 5 days (40C)
Store in back of refrigerator where it is coldest
|2 weeks in freezer compartment inside a refrigerator
3 months in freezer section of refrigerator with separate door
6 - 12 months in deep freeze (- 180C)
|Previously frozen - thawed in refrigerator but not warmed||4 hours or less
i.e. next feeding
|Store in refrigerator 24 hours||Do not refreeze|
|Thawed outside refrigerator in warm water||For completion of feeding||Hold for 4 hours or until next feeding||Do not refreeze|
|Infant has begun feeding||Only for completion of feeding then discard||Discard||Do not refreeze
There is controversy regarding the use of sterile vs clean washed containers for storage of expressed breastmilk (EBM) intended for preterm infants. There is limited published evidence to support the use of clean containers One Level 3 nursery in Melbourne does provide sterile containers which families re-use after washing in the dishwasher and air-drying.
The long-term commitment of expressing breastmilk for a preterm infant is stressful and may result in reduced volumes of EBM. Strategies that assist in maintaining a good supply of milk include
If supply lags, technique and frequency of expression needs review before resorting to galactogues. Commencement of an oral contraceptive agent may also contribute to reduction in supply. In addition
These are substances, which stimulate the supply of breastmilk. Both pharmacological and herbal preparations are available.
Initiating breast-feeding in preterm infants does not require a demonstrated ability to breastfeed. Kangaroo care is a good introduction to mother's breasts for the preterm or unwell infant. Studies have shown that preterm infants show greater cardio-respiratory stability when breast feeding than bottle feeding. Infants exhibit sucking movements as early as 11 weeks gestation. By 32 weeks there is coordination of sucking and swallowing, but this is not sustained until closer to term.
Controversy exists over the issue of nipple confusion. Ultrasonography has shown that the sucking action used at the breast is different from that used for an artificial teat. A randomised controlled trial comparing artificial teats and cup feeding in preterm infants did not demonstrate any difference in time to achieve breastfeeding. (personal communication). If it is to be mentioned then the technique of cup feeding needs brief explanation
Similarly controversy exists between the advantages of indwelling naso-gastric feeding tubes and intermittent oro-gastric tube feeds.
Sandra Lang in her book "Breastfeeding Special Care Babies" addresses these issues in depth.
Preterm breastmilk differs from term milk, not only in nutritional composition but also in immuno-protective factors. Preterm infants given breastmilk have significantly reduced rates of sepsis and necrotising enterocolitis compared with infants fed breastmilk substitutes. Preterm infants exclusively breastfed have been found to have an IQ several points greater than infants fed breastmilk substitutes. Is this difference real world significant? Should the degree of difference be stated?
Mother's own milk may not meet the increased nutritional demands of the preterm infant whose birthweight is below 1500g. These needs persist to term postmenstrual age. There is considerable variation in the energy content of expressed breastmilk largely due to separation of the fat whilst standing. Use of hind-milk, with a two to threefold greater fat content than foremilk will provide significantly more energy for growth. The content of protein and sodium declines throughout lactation. Calcium and phosphorous content is also insufficient for the growing preterm infant.
Mother's own milk can be supplemented by combining with a commercially prepared fortifier to provide increased protein, energy and minerals.
All human milk fortifiers contain similar amounts of protein, energy, calcium and phosphorous. The differences relate to the type of protein and the amounts of lactose, sodium and vitamins. Dr K Simmer has prepared comparative tables indicating the composition of breastmilk and fortifiers available in Australia.
In general infants with a birthweight less than 1500g and less than 30 weeks gestation will benefit from addition of fortifier, which should continue to discharge, when the infant is not breastfeeding. In practice fortification of breastmilk is best delayed until the infant demonstrates tolerance of a reasonable volume of enteral feeds (150 mls/kg/day). Breastmilk fortification is often commenced at half strength for 2 days and if tolerated full strength supplementation is introduced. However, there are a number of potential complications with fortification. These include:
As the fortifier is usually cow's milk based there is a theoretical advantage in using a product in which the protein has been hydrolysed. Infants fed fortified human milk receive less volume, but greater intakes of protein and minerals and experience greater weight gain and incremental linear growth than infants fed unfortified milk. The growth of infants fed fortified breastmilk is still less than infants fed on preterm formula. However the quality of the milk and its many advantages far outweigh any growth disadvantage. In general, fortifier can be discontinued once the infant reaches a corrected age of term and prior to discharge from hospital.
When there is insufficient breastmilk available for an infant tolerating enteral feeds parents should give consent for the use of formula. If the intention is to primarily breastfeed then use of a protein hydrolysed or semi-elemental formula may be appropriate. If the infant is not tolerating full volume feeds then the formula should be standard 67 kcal per 100 mls. Most preterm formulae are 85 kcal per 100mls and are fed once the infant is tolerating volumes of 150mls/kg/day as they provide better nutrition. Dr K Simmer has prepared comparative tables indicating the composition of preterm formulae available in Australia. Donor human milk is not an option as there are no human milk banks in Victoria.
In general, preterm formulas can be discontinued once the infant reaches a corrected age of term and prior to discharge from hospital.
Most psychoactive medications are now generally considered safe, although dosage needs to be considered. Infants should always be carefully monitored for effects of sedation when their mother's are using psychoactive drugs.
Be aware that drug companies are very cautious in their recommendation of safety for the breastfed infant. Preferably consult specific reference texts or drug advisory services experienced in lactation.
Methadone passes in small quantities into breastmilk and generally the benefits of breastmilk overcome the disadvantages. In situations of very high maternal dosage (eg 90mg daily) the infant is at risk of sedation.
Buprenorphine is a long acting narcotic agonist and antagonist used to replace methadone in opiate addicts. Little information is available regarding the pharmacology of this drug in lactation. Sedative effects are of concern.
Marijuana passes into breastmilk and the relative dose is concentrated. Infants are at risk of sedation, feeding difficulties and poor weight gain.
Scientific data is limited. Given the variability in standards of preparation of herbal supplements it is recommended that breastfeeding mothers avoid such products.
Increased rates of initiating breastfeeding have resulted in an increased incidence of jaundice. There is an inverse correlation between the number of breastfeeds per day and level of jaundice. Increasing the number of breastfeeds per day from 6 to 12 per day for each of the first 3 days of life results in significantly lower serum bilirubin on day 3. Increased number of feeds is associated with significantly greater daily milk intake, better elimination of meconium and thereby reduced entero-hepatic circulation.
Commencement of phototherapy should be seen as an opportunity to review breastfeeding frequency and technique. It is not carte blanche to introduce supplemental formula feeds. Preferably mothers will be encouraged to express after feeding and top-up their babies with their own milk rather than formula. Excessive use of formula runs the risk of reducing milk supply, as the infant is less stimulated to empty the breast.
ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 Use of psychiatric medications during pregnancy and lactation. Obstetrics & Gynecology. 111(4):1001-20, 2008 Apr.
Drugs in Pregnancy and Lactation. Briggs G et al. 6th edition 2002. Lippincott Williams and Wilkins.
Medications and Mother's Milk. T Hale. 10th edition, 2002. Pharmasoft publishing, Texas.
Royal Women's Drug Information. Tel. 9344 2000
Mental Health Research Institute Psychotropic Drug Information Service. Tel: 9388 1633
Breastfeeding Online - Dr Jack Newman Dr Jack Newman (Toronto paediatrician who established the first hospital based breastfeeding clinic in Canada) provides informative parent hand-outs in addition to practical advice for clinicians
Text: Lawrence R. Breastfeeding: a guide for the Medical Profession. 5th edition available through Breastfeeding.com - Dr Ruth Lawrence
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