3. • Not just a food
• Health Benefits for mother and baby
Short Term Benefits Long Term Benefits
LRTI’s OR 0.36 95% CI
0.18 to 0.74
Risk of Breast
Cancer
Risk varied 4.3%
and 28%
Obesity OR 0.78 95% CI
0.72 to 0.84
Risk of Ovarian
Cancer
OR 0.79 95% CI
0.68 to 0.91
SIDS OR 0.64 95% CI
0.51 to 0.81
Risk of Type 2
Diabetes
OR 0.63 95% CI
0.54 to 0.73
Hoddinott et al. BMJ 2008;336;881-887
5. • WHO guidance
– Provide mothers milk to all preterm infants
– Promote the use of mothers milk in neonatal units
– Support Mothers
MATERNAL MILK IS FIRST
CHOICE
Edmond K, Bahl R. Geneva WHO, 2006.
Henderson G, Anthony M, McGuire W. Cochrane Database Syst Rev 2007;(4):CD002972.
6.
7.
8. • 2250 BC – Code of
Hammurabi
• 13th
Century –
Highest paid job for
a woman
• 20th
Century –
Decline
• Today – second
choice
hmbana.org
Edmond K, Bahl R. Geneva WHO, 2006.
9. Constituents Breast Milk Davies 1977
(Term)
Lucas 1984
(Term)
Gross 1983
(Term + Preterm)
Energy (kcal) 62 71 46 66.8
Protien (g) 1.3 1.1 1.07 1.01
• UKAMB Guidelines
• Expressed Milk and Drip Milk
• Significant variation in composition
• Why women donate
Pimenteira AC et al. JHum Lact. 2008;24:69-75
10. • Holder Pasturisation
• Remove Bacterial contamination
• HIV, HTLV, CMV – Eliminated
• Little effect on LC-PUFA’s
• B and T cell destroyed
• IgA and sIgA – 20% reduction
• Human milk lipases destroyed
Tully DB, Jones F et al. J Hum Lact 2001;17(2):152-5
11. • Donor Milk vs Formula Milk for Preterm
infants
• 14 trials – 6 excluded
• Only 1 trial since 2000 – rest 1970’s and 80’s
• Formula as suppl to MBM
– Schanler et al. Lucas et al.
• Nutrient fortified DBM
– Schanler et al.
Quigley MA et al. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD002971.
15. • Schanler et al. 2005
– RCT – donor vs preterm formula as
supplement to MBM
– Fortified
– 243 infants (23-29 weeks gestation)
MM and DM had 6% incidence of NEC, PF had
an 11% incidence (p-value: 0.27)
Schanler RJ et al. Pediatrics.2005;116(2):400-6
16. • New Milk Banks opening throughout the UK
– RDE only bank in the South West
– 45 donors last 3 years
– 72 babies in the unit have benefited
• Update on the use of donor milk NICE
guidelines
www.nice.org
17. • High cost
• Has to be worth it
• Insufficient evidence
• Big study with significance
Bristol
• Not yet
• Possibility for the future
18. • Hoddinott P, Tappin D, Wright C. Breast Feeding. BMJ. 2008;336:881-887
• Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. Ch10 p153-4
• Edmond K, Bahl R. Optimal feeding of low birthweight infants, technical review
Geneva WHO, 2006
http://whqlibdoc.who.int/publications/2006/9789241595094_eng.pdf
• Henderson G, Anthony M, McGuire W. Formula milk vesus maternal breast milk
for feeding preterm or low birthweight infants. Cochrane Database Syst Rev
2007;(4):CD002972.
• Jones F 2003. http://www.hmbana.org/index.php?mode=history
• www.ukamb.org
• Thomaz ACT, Loureiro LVM, Oliveira TS, Mendonca NC, Montenegro F et al. The
Human Milk Donations experience: Motives, influencing factors, and regular
donation.J Hum Lact 2008;24:69-76
• Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor
breast milk for feeding preterm or low birth weight infants. Cochrane Database
of Systematic Reviews 2007, Issue 2. Art. No.: CD002971. DOI:
10.1002/14651858.CD002971.pub2
19. • Lucas A, Gore SM, Cole TJ, Bamford MF, Dossetor JFB, Barr I, Cork S, Lucas
PJ. Multicentre trial on feeding low birthweight infants effects of diet on
early growth. Arch Dis Child;1984;59;722-30.
• Davies DP. Adequacy of expressed breast milk for early growth of preterm
infants. Arch Dis Child;1977;52;296-301
• Gross SJ. Growth and biochemical response of preterm infants fed human
milk or modified infant formula. NEJM;1983;308;5;237-241.
• Tully DB, Jones F, Tully MR. Donor Milk: What’s in it and What’s not. J Hum
Lact.2001;17(2):152-5
• Schanler RJ, Lau C, Hurst NM, O’Brian Smith E.Randomised trial of donor
human milk versus preterm formula as substitutes for mothers’ own milk
in the feeding of extremely premature infants. Pediatrics.2005;116(2):400-
6
• www.Nice.org.uk
The question I wish to answer is does bristol need a donor milk bank?
Understanding of the Importance of Breast milk
Review the needs of the Preterm Infant
Discuss the role of Donor Breast milk
Critically Appraise the Evidence
Aims for the Future
Contains antibodies, enzymes, and hormones, all of which have health benefits
Use reflects the whim of fashion
Here are some of the short and long term benefits which have been described in various papers and put together into meta analyses
A preterm infant has various additional needs when compared to a term baby
The most noticeable difference is the additional protein requirement. 2.2g/kg/day for a term and 3-3.6g/kg/day for a preterm <1kg
There are various reasons for this ….
The preterm also shows rapid growth trebling weight
It has been long established that breast milk is best for preterm infants
More important as these baby’s are immunocompromised and have immature digestive systems so require the immune components of breast milk
However some mothers are not able to provide milk for their baby
Medical and psychological reasons
Being apart from the baby with lack of stimulation and anxiety
Too ill to provide
There are then two options
Donor milk or formula milk
Inherent qualities from Wet Nurse
knowledge of infection
maternal milk unavailable from the WHO guidelines
Specific guidelines relating to the health of the mothers
Screened for serology and with a lifesyle questionnaires
Expressed or milk from a breast pump is preferred as there is increased fat and energy content as the donor milk accesses the hindmilk
Women donate for various reasons. Personal experiences with the NICU or premature infants have a significant factor. Many of the mums who donate do so as they have too much milk to provide for their infant who is on the NICU
Holder pasturisation is required by the united kingdom association of milk banking
– 62.5°C for 30 minutes
– precusors for DHA and Arachidonic acid
PUFAS – DHA essential for retinal and brain development
AA- precursor for prostaglandins and leukotriens
IgA is essential as it is not transferred across the placenta and these babies have a very low immune reserve.
How similar to MBM
5/6 excluded studies because of non randomisation of the feeding groups
1/6 excluded because infants were given maternal breast milk instead of formula milk
4 –Term formula vs donor breast milk
4 – Preterm formula vs donor breast milk
The first variable I looked at was change in weight
Found to grow better when taking formula milk – describe results
Is this a sign that they are getting superior nutrition?
Absorbing more and laying down more tissue than the breast fed group
NEC was the second variable I chose to look at
morbidity and mortality around 20%
Sequaele strictures and malapsorption
More important than rate of growth as these babies may die!
Arguably the most important variable
How likely is this child to lead a normal life?
Not just a baby in an incubator, they do become adults
Most recent paper included in the review
Used fortified donor breast milk as a supplement to maternal breast milk
6% incidence of NEC in MM and DM
11% incidence of NEC in PF
Shame the p-value was 0.27- lower incidence of NEC than they anticipated overall therefore sample size was too small
However added weight to the cochrane analysis
Satellite milk bank set up 3 years ago.
Main processing occurs in princess anne maternity hospital southampton
170 L
Sister…said that they have been getting more and more people donating
Pasturisation, screening, couselling, venue overheads staff
Can the decreased incidence in nec and possible better neurological sequele make up for the costs of running a milk bank?
The decrease in incidence of NEC makes the possibilty of donor milk that little bit closer
More evidence Ideally
Fortification of milk – this has only been done in one study to date
Don’t think Bristol is ready just at this moment
More evidence would back up the weight ideally neurological data
The NEC result is promising
