This document discusses the benefits of breast milk and breastfeeding for infants in the NICU. It begins by outlining the objectives of increasing awareness of the importance of breast milk for preterm infants in the NICU and educating about its benefits. It then covers several key areas in less than 3 sentences each: the positive impact of breast milk on the gastrointestinal tract, lipid and fatty acid composition, anti-microbial components, short and long-term health benefits, limitations for preterm infants, and methods for fortification to meet their nutritional needs.

1. Presented by: Sirag Elsabea
MD Alexandria - DCHI – Dublin
MRCPCH – UK , NRP - Instructor
Consultant Neonatologist
Breast Milk and
Breast Feeding for
NICU Infants
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6. WHAT DO YOU FEEL AS A NEONATOLOGIST??!!
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Sorry I think
Time is over
And let us eat

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Breast Milk
and
Breast Feeding

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OBJECTIVES
 To increase awareness about
breast milk for NICUs babies
especially prematures.
 To educate about the benefits of
breast milk and feeding

18. AAP Policy Statement
 Breastfeeding is the normal way
to feed a baby.
 Breastfeed exclusively for the first
6 months.
 Continue for at least 1 year, and
as long thereafter “as is mutually
desired”
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*The World Health
Organization (WHO)
recommends 2 years.

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Gastrointestinal Tract

20.  stimulate gastrointestinal growth and
motility.
 protective and decrease the risk of
NEC and other infections.
 intestinal colonization by the beneficial
microbes of the Bifidobacteria and
Lactobacilli species rather than
pathogenic bacteria. 20

21. The rate of gastric emptying.
The intestinal Lactase activity in
premature infants.
the intestinal permeability early
in life in premature infants
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 Early feeding increases intestinal lactase
activity in preterm infants.
 Lactase activity is a marker of intestinal
maturity

24. Lipids in human milk
 Complex organization of the fat globule.
 Pattern of fatty acids.
 Bile salt-stimulated lipase .
These factors promote the digestion and
absorption of lipid.
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25. Hopeless Trial!
 Premature formulas are modified to
increase the MCFA content to 40 percent of
lipids.
 Human milk contains 12 percent of MCFA.
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26.  Studies have failed to identify a benefit of
MCFA compared to polysaturated fatty acids.
 Substituting MCFA for long chain fatty
acids (LCFA) in formula did not improve
weight gain or absorption of lipid or
minerals
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27. Long-chain polyunsaturated fatty
acids:
As arachidonic and docosahexaenoic
acids(DHA), derived from linoleic and
linolenic acids.
Brain
Retina
RBC membrane 27

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29. Necrotizing Enterocolitis in
Premature Infants (UK)
In-Hospital Diet All Cases Confirmed Cases
Formula Only (n=236) 24 (10%) 17(7%)
Mother's Milk
+ Formula (n=437) 16 (4%) 11 (2%)
+ Donor HM (n=253) 11 (4%) 3 (1%)
MM = mother`s milk, HM = pasteurized donor milk
Lucas, Lancet 1990;336;1519

30. Anti-microbial components
Protein
Lactoferrin
(One study found that supplementing the diet of premature infants
with bovine lactoferrin, which has 77 percent homology with
human lactoferrin, was associated with a significant reduction in
late-onset sepsis and NEC)
 Lysozyme
 Serum immunoglobulin A (sIgA)
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31. Lipids–cont.antimicrob.
Products of lipid hydrolysis:
 free fatty acids
 monoglycerides
have a detergent-like property that
lyses viruses, bacteria, and protozoa,
such as Giardia
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32. CHO –cont.antimicrob
 Oligosaccharides found in carbohydrate
polymers and glycoproteins can change
the intestinal bacterial flora by facilitating
the growth of bifidobacteria and
Lactobacillus species
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33. CHO –cont.antimicrob
Urinary oligosaccharides mimic bacterial
epithelial receptors, thereby reducing
bacterial adhesion to urinary epithelial
cells
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34. WBC–cont.antimicrob
Human milk contains white blood cells,
90 percent of which are neutrophils and
macrophages.
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35. WBC–cont.
The lymphocytes in human milk
may contribute to cytokine production
(T-cells) or IgA production (B-cells)
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36. In developing countries
 Morbidity and mortality is lower in
breast-fed versus formula-fed infants.
Incidence of gastroenteritis and
respiratory disease is lower in breast-
fed infants
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Prevention of illnesses while
breastfeeding

37. In developed countries
The attack rate of acute illnesses is lower
among breast-fed infants compared to
formula fed infants
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38. Gastroenteritis
Breastfeeding compared to formula
feeding lowered the incidence of
gastroenteritis during the first 13 weeks
of life. (3.0 versus 15.7 percent)
Howie PW, Forsyth JS, Ogston SA, et al. Protective effect of breast
feeding against infection. BMJ 1990
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39. Infants with mothers who had a high
educational level, infants who were
breastfed had fewer days of diarrhea
than those who were formula-fed during
the first 12 months of life (2.6 versus 6.3
days).
Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity
between breast-fed and formula-fed infants. J Pediatr 1995
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40. In a population-based survey of the
United Kingdom, the risk of
hospitalization for diarrhea was reduced
in infants exclusively breast-fed
compared to infants who never breast-
fed (adjusted OR 0.37, 95% CI 0.18 to
0.78)
Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for
diarrheal and respiratory infection in the United Kingdom Millennium
Cohort Study. Pediatrics 2007
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41. There was a trend in reduced
hospitalization in infants who were
partially breastfed compared to those
who never breast-fed (adjusted OR 0.63,
95% CI 0.32 to 1.25).
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42. The protective effect of human milk
appears to be due to the presence of
maternal antibodies
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43. In infants exclusively breastfed for over
two weeks, a reduced rate of
enterovirus was associated with high
maternal enterovirus antibody levels in
the breast milk.
Sadeharju K, Knip M, Virtanen SM, et al. Maternal antibodies in
breast milk protect the child from enterovirus infections. Pediatrics
2007
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44. Respiratory disease
Respiratory illnesses are reduced in
frequency and/or duration in breast-fed
compared to formula-fed infants
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46. Human Milk and Infections in
VLBW Infants
Human Milk Formula
Total infection (% infants) 29% 47%
Multiple infections 3.3% 8.0%
Sepsis/ Meningitis 20% 33%
Birth weight in 1 kg, gestational age 28 wk
Hylander, Pediatrics 1998 – 102
Georgetown University
Medical Center

48. LONG-TERM BENEFITS
 There are reported associations
between the duration of breastfeeding
and a reduction in incidence of
obesity, cancer, adult coronary heart
disease, certain allergic conditions,
type 1 diabetes mellitus, and
inflammatory bowel disease 48

49. The study of young adults (mean age
27.2 years), there was a positive
association between the duration of
breastfeeding and scores from two
cognitive tests
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Cognitive development

50. Wechsler Adult Intelligence Scale
(IQ) according to duration of
breastfeeding were as follows:
Breastfed ≤1 month: 99.4
Breastfed ≥1 to 3 months: 101.7
Breastfed 4 to 6 months: 102.3
Breastfed 7 to 9 months: 106.0
Mortensen EL, Michaelsen KF, Sanders SA, Reinisch JM. The
association between duration of breastfeeding and adult
intelligence. JAMA 2002; 287:2365 50

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52. Human Milk and Subsequent Intellectual
Performance in Premature Infants at 8 yr
Significant factors affecting IQ
Social Class - 3.5/class
Mother's Education + 2.0/group
Female Gender + 4.2
Mechanical Ventilation - 2.6 /week
Receipt of Human Milk + 8.3 IQ points
Lucas, Lancet 1992; 339:261
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53. United Kingdom
Breastfeeding is associated with
improved child cognitive development:
a population-based cohort study.
Quigley MA, Hockley C, Carson C, et al. J Pediatr 2012
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54. average increases in the scores in the
British Ability Scales tests between 2
and 6 points when performed at five
years of age for children who were
breast-fed compared with those who
were never breast-fed
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55. British Ability Scales II (BAS 2)
School Age
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56. The School Age BAS2 is made up of a
series of tasks measure a number of
basic abilities and mental processes that
are significant for learning and
educational performance in children.
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57. Impact of breast milk on IQ, brain
size and white matter development
Pediatr Res. 2010 April; Elizabeth Isaacs PhD Nutrition Unit
UCL Institute of Child Health London – UK
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58. This study showed a dose response
relationship between early breast milk
intake and later IQ and, uniquely, with
whole brain volume at adolescence.
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59. May be this is one of the reasons
Infants fed human milk had the lowest
concentrations of Methionine, Phenylalanine,
and Tyrosine.
 High levels of these amino acids may interfere
with brain development.
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60.  Human milk contains cysteine and
taurine, two amino acids that are
deficient in premature infants.
 Cysteine is needed to synthesize the
antioxidant glutathione.
 Taurine is needed for bile conjugation
and brain development.
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61. Visual function
Several studies have indicated that
human milk-fed term and premature
infants have improved visual function
compared to formula-fed infants.
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62. Stress reduction
There appears to be an analgesic effect
of breastfeeding, which may be due to
the enhanced maternal-infant bonding.
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64. Breast Milk And Ptreterm
Newborn
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65. Too Little ??
Insufficient ??
Very Important ??
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66. LIMITATIONS OF HUMAN MILK
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67. Premature infants have greater
nutritional needs to achieve optimal
growth in the neonatal period than
at any other time of their life.
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Fortification of human milk is required to
meet the increased nutritional needs of the
preterm infant.

69. Requirements
Protein
A healthy premature infant requires a
protein intake of approximately 3.5 to 4.0
g/kg per day with an energy requirement
of 120 kcal/kg per day.
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70. A meta-analysis of low birth weight
infants (birth weight <2500 gm)
compared protein intake of ≥3 g/kg per
day (but <4 g/kg per day) to a lower
intake <3 g/kg per day in five
randomized studies
Cochrane Database Syst Rev 2006; :CD003959.
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71. Two additional studies
published after the
meta-analysis
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72. Pediatr Res 2006; 59:265.
J Perinatol 2010; 30:517.
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73. Neither human milk nor preterm
formula meet the protein
requirements for premature infants.
SO, WHAT CAN I DO NOW ???!!73

74. HMF
Contain lyophilized protein that can
be human or bovine.
However, the protein source may
affect plasma amino acid patterns.
Plasma conc. of Cystine, Taurine, and
Proline are greater when lyophilized
human milk protein is added
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77. Studies have shown that the addition of
human milk fortifier is associated with short-
term improvements in weight, length, and
head circumference growth.
Other studies suggest human milk fortifier
may improve bone mineralization and
neurologic outcome.

78. LIPID
Hindmilk (milk at end of expression) may
be 1.5 to 3 times more than that of foremilk
Delivery of lipid
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79. Fat absorption may be augmented
by newer human milk fortifiers
that contain fat.
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80. DID YOU GET THE MESSAGE ???
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81. I DO NOT LIKE JUNK MILK
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82. THANK YOU
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