This document discusses best practices for improving neonatal outcomes through exclusive human milk feeding. It summarizes the nutritional and non-nutritional components of human milk that are beneficial for preterm infant development. Exclusive human milk feeding is associated with reduced rates of necrotizing enterocolitis, sepsis, retinopathy of prematurity, and bronchopulmonary dysplasia in preterm infants. Following standardized feeding protocols and providing human milk is a cost-effective strategy that can improve neonatal outcomes and reduce healthcare costs.
Improving Neonatal Outcomes through Exclusive Human Milk Feeding
1. Best Practices: Improving
Neonatal Outcomes through Exclusive Human Milk
Jae Kim, MD, PhD
Department of Pediatrics
Division of Neonatal-Perinatal Medicine
Division of Pediatric Gastroenterology, Hepatology and Nutrition
CAPH Conference, Halifax, Oct 2016
2. Conflict of Interest Disclosures
• Medical Advisory Board
• Medela
• Speakers Bureau
• Prolacta Biosciences
• Nestle Nutrition
• Nutricia
• Abbott Nutrition
• Mead Johnson Nutrition
• Medela
• Shares
• Pedia Solutions
• I do not intend to discuss an
unapproved/investigative use of
a commercial product/device in
my presentation
3. Human milk is a tissue!
Human Milk Blood
CELLS ENZYMES
HORMONES TRANSPORTERS
CYTOKINES IMMUNE MODULATORS
GROWTH FACTORS
NUTRIENTS
4. Nutritional Components of Human Milk
MACRONUTRIENTS
Lipids
Triglycerides
(167 identified)
Phospholipids
Sphingolipids
Sterols
Fatty acids
Proteins
Caseins
Whey
Amino acids
Mucins
Carbohydrates
Lactose
Glucose
Galactose
Oligosaccharides
Vitamins
vitamin A
niacin
thiamin
vitamin B6
panthothenic acid
biotin
folate
vitamin B12
vitamin C
vitamin D
vitamin E
vitamin K
Minerals
calcium
phosphorus
iron
zinc
copper
manganese
magnesium
sodium
potassium
chloride
sulphur
MICRONUTRIENTS
6. Ingredients of Infant Formula
MACRONUTRIENTS
• water
• nonfat milk
• lactose
• high oleic safflower oil, soy oil, coconut oil, C.
cohnii oil (DHA), M. alpina oil (ARA)
• whey protein concentrate
MINERALS
• potassium citrate, calcium carbonate, potassium
chloride, magnesium chloride, sodium chloride,
ferrous sulfate, choline chloride
TRACE ELEMENTS
• zinc sulfate, cupric sulfate, manganese sulfate,
sodium selenate
VITAMINS
• d-alpha-tocopheryl acetate, ascorbic acid,
niacinamide, riboflavin, calcium pantothenate,
vitamin A palmitate, thiamine chloride
hydrochloride, phylloquinone, pyridoxine
hydrochloride, beta-carotene, folic acid,
cyanocobalamin, vitamin D3, biotin
EMULSIFIERS
• mono- and diglycerides, soy lecithin,
carrageenan, choline bitartrate, taurine, m-
inositol, L-carnitine
BIOLOGICS
1. nucleotides
2. prebiotics (term formula only)
3. probiotics (term formula only)
7. Benefits of mother’s milk to preterm infants
• Cognitive development
• Reduction in necrotizing enterocolitis (NEC)
• Reduction in sepsis
• Favorable alteration of microbiome
• Reduction in retinopathy of prematurity (ROP)
• PLUS all the health benefits known for mother’ milk in term infants:
reduction in infant mortality, SIDS, autism, ADHD, allergy, asthma,
infection, celiac disease, cognitive outcomes, etc.
9. Impact of Neonatology to Healthcare Burden
• Between 7% (CAN) to 12% (US) of live births are preterm (less than 37
weeks gestation)
• NICU patients (preterm and sick newborns) represent a
disproportionate share of hospital costs
• Lifelong impact to healthcare burden and costs enormous
• In the US, NICU is a top generator of financial revenue to hospitals
10. Morbidities of the preterm infant
• Growth
• Impaired growth
• Altered body composition
• Failure to thrive
• Brain
• Intracranial hemorrhage
• Loss of white and gray matter, reduced size
• Cardiovascular
• Effects of patent ductus arteriosus
• Long-term risk of cardiovascular disease and metabolic
syndrome
• Lung
• Chronic lung disease
• Asthma
• GI
• Necrotizing enterocolitis
• Gastroesophageal reflux
• Feeding intolerance/difficulties
• Hematologic
• Anemia
• Neutropenia
• Thrombocytosis
• Renal
• Impaired kidney development
• Immune system
• Skin
11. Goal of Feeding Preterm Infants
Provide nutrients to approximate
the rate of growth and composition
of weight gain for a normal fetus of
the same post-conceptional age
and to maintain normal
concentrations of blood and tissue
nutrients.
American Academy of Pediatrics Committee on Nutrition, In Pediatric Nutrition Handbook, 2013.
12. Matching In Utero Growth
Zeigler et al., Growth. 1976 Dec;40(4):329-41.
WEIGHT CLASS
GROWTH
G/KG/DAY
~ 3 lbs
per day for
70 kg adult
13. The Developing Gut
1st Trimester 2nd Trimester 3rd Trimester
Adapted from Commare and Tappenden, 2007 Nut Clin Pract
Cytodifferentiation
Absorption
Motility
Digestion
Morphogenesis
Swallowing
0wk 14 22 28 40
Viability
Line
STRUCTUREFUNCTION
14. Preterm Risk Factors for Bowel Injury
• Ischemia
• Immature gut and systemic immune system
• Dysmotility
• Underdeveloped physical mucosal barrier (tight
junctions, mucin)
• Poor acid production
• Abnormal bacterial colonization
15. Necrotizing Enterocolitis
• NEC is the most common life-
threatening gastrointestinal
emergency in the newborn period
• NEC is marked by intense
inflammation and acute intestinal
necrosis
• Most common sites include terminal
ileum, cecum and ascending colon
16. The Perfect Storm for NEC
PREMATURITY ISCHEMIA
PATHOGENIC
BACTERIA
ENTERAL
FEEDING
TRANSMURAL
BOWEL
INFLAMMATION
BOWEL NECROSIS
BREAKDOWN OF
MUCOSAL
BARRIER/DEFENSE
20. NEC Morbidity
• Growth failure due to bowel injury
• Intestinal obstruction and subsequent surgery
• Longer hospital stay
• Risk of dying
• Risk for more pain and suffering
• Short bowel syndrome and/or intestinal failure
• Can lead to need for long-term PN use and later bowel
transplantation
• Neurodevelopmental impairment!
23. NEC is the result of a biochemical reaction
WARMTH
MOISTURE
BACTERIA
SUBSTRATE
(MILK OR FORMULA)
24. Standardized Feeding Protocol
Having a feeding protocol is associated with reduced NEC rates
Patole, Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F147-151.
Key Elements of a Great Feeding
Protocol
• Established consensus from
medical faculty
• Visible, nurse-driven
advancement
• Linear advancement
• Trophic feeding for extremely
preterm infants
• Incorporate timing of
fortification and vitamins
25. 10% of very preterm babies developed NEC
30-50% NEED SURGERY
25-50% DIE!
Human milk can reduce NEC
(medical and surgical) by at least 50%
Most very preterm infants are fed formula!!
26. Fractional Human Milk Feeding Reduces Chances of NEC
Fraction of
Human Milk
Feeding
Meinzen-Derr et al. NICHD Network, J Perinatol 2008:1-6
27. Lactation support
• Ideally mothers should initiate
pumping or breastfeeding
within 2h after vaginal delivery
and 4h after cesarean section
• Peak lactation volumes may be
influenced by very early
pumping/expressing milk within
the first hour of life
Parker et al. Breastfeed Med. 2015 Mar;10(2):84-91.
<1h and ≤6h
>6h
29. Exclusive Human Milk vs Preterm Formula: RCT in Extremely Preterm
HM PF p
Birth weight (g) 996 ± 152 983 ± 207 NS
Gestational age (wks) 27.7 ± 1.5 27.5 ± 2.4 NS
Study duration (d) 50 ± 20 50 ± 23 NS
Preterm <1250 g
Planned for Infant Formula
Preterm Formula (PF)
n=23
Exclusive Human Milk (HM)
and Fortiifier
n=29
Cristafalo et al. J Pediatr. 2013 Dec;163(6):1592-1595.e1.
30. Results
• First randomized double-blind trial in infants of
exclusive diets of HM vs PF
• The significantly shorter duration of TPN and lower
HM PF p
n 29 23
Duration of TPN (d) 27 36 0.04
NEC 1 (3.6%) 5 (21.7%) 0.08
Surgical NEC 0 4 0.04
Cumulative morbidity 0.7 ± 0.5 1.2 ± 1.0 0.03
Length increment (cm/d) 0.12 ± 0.03 0.16 ± 0.04 0.006
Cristafalo et al. J Pediatr. 2013 Dec;163(6):1592-1595.e1.
31. Exclusive human milk reduces overall NEC and
surgical NEC
Sullivan et al (2010) J Pediatr. 2010;156:562-7
Protocol
violations:
received
bovine product
32. Impact of choosing bovine products
No NEC Medical NEC Surgical NEC
Mortality 10.6% 20.9% 23.2%
Double the risk of death!
Sullivan et al (2010) J Pediatr. 2010;156:562-7
Ganapathy et al. 2011 Breastfeeding Medicine
33. NEC continues to add to long-term costs within the
first three years of life
• Texas Medicaid healthcare utilization database
• Jan 2012 to Dec 2013
• 253 survivors of NEC (73 surgical NEC)
• 2909 matched controls
• Medical NEC incurred higher costs than controls between 6 and 12
months
• Surgical NEC incurred higher costs than controls up to 36 months
• Costs tapered down from ~ 18K to 8K per survivor
Ganapathy et al. BMC Pediatr. 2013 Aug 20;13:127.
34. An exclusive human milk (EHM) diet reduces TPN
need
Ghandehari et al. BMC Res Notes. 2012 Apr 25;5:188.
11-14% Reduction in TPN use
Greater when looking at TPN after initial use
Increased likelihood if HMF started earlier
EHM
36. Decreased cost and improved feeding tolerance in
VLBW infants fed an exclusive human milk diet
• Retrospective study including preterm infants ⩽28 weeks and/or VLBW
(⩽1500 g)
• Single center (The Herman & Walter Samuelson Children’s Hospital at Sinai,
Baltimore, MD, USA)
• March 2009 until March 2014
• (2012-2014)
• group H (exclusive human milk or EHM)
• (2009-2012)
• group B (bovine-based fortifier and maternal milk)
• group M (mixed combination of maternal milk, bovine-based fortifier and formula)
• group F (formula fed infants)
• N = 293 infants between 23 to 34 weeks gestation and birth weights
between 490 and 1700 g
Assad et al. J Perinatol. 2016 Mar;36(3):216-20.
37. Less feeding intolerance (P<0.0001)
Lower number of days to full feeds by 9-10 days (P<0.001)
Lower incidence of NEC (P<0.011)
Shorter length of stay by 4 to 22 days for EHM group
Similar average weight gain per among the four groups
(18.5 to 20.6 g per day)
Assad et al. J Perinatol. 2016 Mar;36(3):216-20.
38. Lower total hospitalization costs by up to $106,968 per
infant (P<0.004) in those fed an EHM diet
Assad et al. J Perinatol. 2016 Mar;36(3):216-20.
39. Beyond Necrotizing Enterocolitis Prevention: Improving
Outcomes with an Exclusive Human Milk-Based Diet
• Retrospective cohort study
• 4 centers, N =1,587 infants (Texas, Illinois, Florida, and California)
• Lower NEC (16.7% versus 6.9%, p < 0.00001)
• Reduced mortality (17.2% versus 13.6%, p = 0.04)
• Reduced late-onset sepsis (30.3% versus 19.0%, p < 0.00001)
• Reduced ROP (9% versus 5.2%, p = 0.003)
• Reduced BPD (56.3% versus 47.7%, p = 0.0015)
Hair et al. Breastfeed Med. 2016 Mar;11:70-4.
40. Continuum of Health Benefits from Human Milk
Newborn SeniorChild
NEC Neurodevelopment
ROP Visual performance
BPD Asthma, Lung Disease, Neurodevelopment
Adult
Sepsis Neurodevelopment
41. Containing Health Care Costs
• What motivates reduction in health care costs?
• Public model of cost-bundled that limit spending per patient (Medicaid)
• Fee for service
• Payer that pay out for sicker patients staying longer in hospital
• Performance or outcomes based incentives
• Value based models
• Perspective matters
• Cost to the patient and family
• Cost to the hospital
• Cost to the healthcare system
• Cost to society
42. Economic Costs of NEC
• One case of medical NEC is almost $75,000 USD
• One case of surgical NEC is almost $200,000 USD
• NEC costs the health care system $5 billion USD annually (assume
10% incidence of NEC and 30% mortality)
• NEC constitutes 19% of the total costs for initial care for all
newborns in the US
Bisquera J et al. Pediatrics 2002;109:423-428
Ganapathy et al. Breastfeed Med. 2012 Feb;7(1):29-37
43. Balancing the cost of an exclusive human diet
Feeding of 160 mL/kg/day
Powder HMF: 1 packet per 25 mL of milk =$0.06/mL
= 100X costs
Ganapathy et al. Breastfeed Med. 2012 Feb;7(1):29-37
44. Cost equation
• Costs CAN 12,500 per patient
• Protocol to 34 weeks according
• Net savings of CAN 10,208 per patient given EHM diet
• If human milk was a drug, would we act differently?
Ganapathy et al. Breastfeed Med. 2012 Feb;7(1):29-37
45. History of Donor Milk
• 1909: the first milk bank was established in Vienna,
Austria
• 1910: milk bank in Boston
• North American history in milk banking is 100 years
old
• 1974: Canada’s first milk bank in Vancouver
• By early 1980’s 23 banks in Canada and 30
in US
• 1981: HIV identified as a pathogen; North
America reduced to 8 banks
• 1985: Human Milk Banking Association of North
America (HMBANA) established
• 2000: Vancouver Milk Bank almost closes
http://en.wikipedia.org/wiki/File:HIV-budding-Color.jpg
Images from Toronto SickKids Archives
HIV
46. Modern Human Milk Banking
• HMBANA
• International Human Milk Banking Association
• Organizations in other countries
• UKAMB & other European countries
• South America – Brazil & Venezuela
• South Africa
• Other countries – India, Japan, China
• National Milk Bank (est. 2005)
• Prolacta Bioscience (est. 2005)
• Medolac (est. 2013)
47. Donor Milk Banking in North America
hmbana.org
Existing Milk Banks Cities Served by Milk Banks
48. Donor human milk
PROS
• Human specific
• Bridges gap when mother’s
milk supply insufficient to
meet infant’s requirements
CONS
• Lower quality milk compared to fresh
milk
• No cellular components or probiotics
• Less protein due to maturity of milk
• No lipase activity that may alter
digestion
• Reduced bioactive components due
to processing
• Reduced salts and vitamins
49. Screening
(Questionnaire and Blood)
Expression of milk
Freezing, storage, and
transport
Thawing and
Bacterial culture
Batching
Pasteurization
Culture of batch
Freezing
Processing of Donor Human Milk
Thawed for use
50. Mothers’ Own Milk Bank of Austin, Texas
HMBANA
NONPROFIT
MILK
BANKING
52. Major Concerns For Use of
Donor Human Milk
• Nutrition
• Loss of bioactivity (immunologic protection)
• Infectious risk
• Tampering
• Cost
• Supply
• Legal
53. Level of Quality of Human Milk
• Breastfeeding
• Fresh human milk
• Refrigerated human milk
• Really frozen human milk (-80ºC)
• Frozen human milk (-20ºC)
• Donor human milk
TRIAGE
• Colostrum > Fresh mature >
Refrigerated > Frozen
54. Recommendations for Donor Human Milk Banking
AAP Committee on Nutrition Statement (in press)
CPS Committee of Nutrition (Kim and Unger) 2012
• Donor human milk is an acceptable alternative to mother’s own milk for
preterm infants when it is not available
• HMBANA or commercial donor banks are suitable sources
• AAP
• The use of donor human milk in appropriate high-risk infants should not be limited
by an individual’s ability to pay.
• Policies are needed to provide high-risk infants access to donor human milk on the
basis of documented medical necessity, not financial status.
• Avoid unpasteurized milk sharing off Internet
• CPS
• Recognized functions of the human milk bank should include the promotion of
breastfeeding and ongoing human milk research.
• Pasteurized human donor breast milk should only be prescribed following written
informed consent from a parent or guardian.
56. California Milk Banking
MMB of San Diego 2017
• All of California is currently served
by one milk bank
• UC San Diego is developing a milk
bank in San Diego for Southern
California
57. Benefits of Donor Human Milk to Preterm Infants
• DOMINO Study (Canada)
• Recently completed
• Saw reduction in NEC
• Long-term followup data pending
• NICHD (Donor milk trial)
• Ongoing recruitment
• Slowing recruitment due to loss of equipoise
• Optimom study (Canada)
• Donor milk derived fortifier study
• Closed but not reported
58. Oral Colostrum Care
Oropharyngeal administration involves
placing small amounts of a liquid directly
onto the oral mucosa with expectation that
the liquid, or any of its components, is
absorbed by the mucous membranes.
Rodriguez, N.A., et al., Oropharyngeal administration of colostrum to extremely low birth weight
infants: theoretical perspectives. J Perinatol, 2009. 29(1): p. 1-7.
Colostrum Breast Milk
Total Protein (g/100mL) 3.7 1.3
IL-6 (pg/mL) 978.8 86.92
Fat (g/100mL) 2.9 4.2
Lactose (g/100mL) 57 7.4
IgM (mg/g protein) 30 4
IgA (mg/g protein) 175 20
IgG (mg/g protein) 3 2
59. Colostrum
• Produced when the tight junctions in the mammary epithelium are
open
• Paracellular transport of immunologically derived protective components
from mother’s circulation into milk
• Contain various immunomodulatory agents
• Secretory immunoglobulin A [sIgA]
• Growth factors
• Lactoferrin
• Anti-inflammatory cytokines
• More highly concentrated in mother’s of preterm infants
60. Evidence that oral colostrum care benefits preterm
babies
• Seigel 2013
• Retrospective cohort study of 369 inborn ELBW infants, 5 day treatment
• Mortality, surgical NEC, SIP rates unchanged
• Higher weight at 36 weeks (1666g vs. 1380g p<0.001)
• Lee 2015
• Double blind, placebo-controlled trial of 45 infants <28 weeks gestation in South
Korea
• Increased urine levels of immunoglobulin A and lactoferrin
• Significant decrease in clinical sepsis
• Sohn 2016
• Impact of buccal administration of human colostrum on the oral microbiota of 12
VLBW infants
• OCC altered the colonization of the oral cavity with effects lasting after the
intervention
ELBW = birth weight less than 1000 grams; VLBW = birth weight less than 1500 grams
61. Human milk derivatives: value of a cream
supplement
• HM-derived cream supplement if energy density of HM
<20 kcal/oz using a near infrared HM analyzer
• Treated until 36 weeks PMA
• HM-derived cream should be considered an adjunctive
supplement to an exclusive HM-based diet to improve
growth rates in premature infants
Human
Milk
Human
HMF
Exclusively
Human
Human
milk
cream
Velocity Cream supplemented
(n=39)
No cream
(n=39)
p
Weight (g/kg/d) 14.0 +/- 2.5 12.4 +/- 3.0 0.03
Length (cm/wk) 1.03 +/- 0.33 0.83 +/- 0.41 0.02
62. Terminology
Microbiota
The collection of microbes in a
particular environment
Microbiome
The catalog of microbes and their
genes in a particular environment
Metagenomics
The collection of genes and
genomes from microbiota
64. The human gastrointestinal microbiota
• First inoculation during birth with passage
through birth canal
• Influenced by prebiotics and probiotics
• Adult microflora by 2 years of age
• Over 500 bacterial species
• 1010 organisms (at least ten fold higher than
human cells)
• Symbiosis between man and bacteria
• 5-10 lbs of bacteria, about 60% of fecal mass
• The “forgotten organ”
65. We need microbes!
N Engl J Med. 2002 Sep 19;347(12):911-20.
FALL OF INFECTION
RISE OF AUTOIMMUNITY
AND IMMUNE DYSFUNCTION
66. Dysbiosis
• sick ecosystem
• low diversity of species
• Imbalance
• lack of functional redundancy
• susceptibility to disease
67. Type of birth
Vaginal birth C-section
• Sterile environment
• Frequent use of antibiotics
• Preterm infants born ~70% by C/S
• Exposure to nosocomial microbes
• Long-term risk of food allergy
• Papathoma et al. 2016
• Long-term risk of immune dysfunction
• Asthma, laryngitis, gastroenteritis, ulcerative
colitis, rheumatoid arthritis, celiac disease
• Kristensen et al. J Allergy Clin Immunol. 2016
Feb;137(2):587-90.
• Delivery through birth canal
• Direct contact to and ingestion
of vaginal flora
• Vaginal flora a mix of maternal
vaginal and colonic flora
68. Risk of the preterm infant
• Often not delivered from birth
canal
• Frequent use of broad
spectrum antibiotics
• Delay in enteral feedings
• Sterilization of infant formulas
• Nosocomial bacterial
colonization
69. Impaired Colonization of the Preterm Gut
• Delay in establishment of gut flora
• Reduction in the number of bacteria
• Reduction in the diversity of bacteria
70. Dietary differences and predominant
organisms
Bifidobacteria
Lactobacilli
E. coli
Bacteroides
Clostridia
Harmsen et al., J Pediatr Gastroenterol Nutr. 2000;30(1):61-67.
Gronlund et al. Clin Exp Allergy. 2007 Dec;37(12):1764-72.
Breastfed Formula fed
71. Mai et al 2011 PLoS One. 2011; 6(6): e20647.
MICROBIOTA BEFORE NEC OCCURS
73. Human Milk Microbiome
• Human milk has its own
microbiota
• Phyla include Firmicutes,
Proteobacteria and
Actinobacteria
• Each mother’s microbiota is
unique
• Donor human milk is pasteurized
and therefore microbe-free
Hunt et al. PLoS One. 2011;6(6):e21313.
74. BIFIDOBACTERIA LACTOBACILLI
• B. infantis
• B. breve
• B. adolescentis
• B. longum
• B. bifidus
• B. catenulatum
• B. animalis
• B. suis
• B. globosum
• L. reuterii
• L. fermentum
• L. rhamnosus
• L. salivarius
• L. gasseri
• L. caseii
• L. planarum
infant
adult
Bold found in human milk
75. Human Milk Oligosaccharides (HMO)
• Third largest component in human
milk!
• Small chain sugars (>150 variations)
• Resist digestion
• Substrate for beneficial intestinal
microflora
• Support favorable bacteria population
in infant colon (“BIFIDOGENIC”)
• Beneficial microflora stimulate the
developing immune system
Bode, J Nutr 2006;136:2127-30.
Boehm J Nutr 2007;137(3 Suppl 2):847S-9S.
78. Trend in feeding in last decade
Human milk based fortifiers
Preterm formula
Mother’s milk
Donor milk
Hydrolyzed bovine
Oral colostrum care
S Curve
79. Mother
pumps
Milk in bottle
Milk in
storage
container
Milk in home
freezer
Milk in cooler
for transport
Milk in NICU
freezer
Milk thawed
Milk
measured
Milk fortified
Milk drawn
into syringes
Milk in tubing
Milk in baby
(finally!)
MILK “TRAFFIC” CHAIN
80. Changing the clinical practice towards a
dominant mother’s milk culture in
hospitals is very challenging but cost
effective in promoting a healthier long
term outlook for premature infants
81. The future…
Exclusively
Human
Human Milk
Human
HMF
Donor milk
derived
additives
• Maternal lactation support
• Donor human milk banking
• Lacto-engineering science
• Addition of cream
• Addition of protein
• Human milk derivative bioactive additives
• Refinement of processing of human milk for
preservation of function
• Increased cost benefit analysis for other long-term
morbidities
Priorities
1. Maternal lactation
2. Donor human milk
3. Human milk fortifiers
4. Human milk derivatives
82. The SPIN Program Ten Steps
1. Have a NICU nutrition/human milk policy
2. Educate all mother/baby staff in SPIN 10-steps
3. Educate NICU families about optimal premature
infant nutrition
4. Prevent extra-uterine growth restriction
5. Standardize enteral feeding procedures
6. Target 100% human milk nutrition
7. Maximize mothers’ milk production
8. Optimize milk quality and safety
9. Encourage skin-to-skin care and breastfeeding
10. Plan a nutritional discharge from NICU
NUTRITION LACTATION
83. THE SPIN TEAM
• Medical director
• Lactation director
• NICU F/U Neo
• NICU CNS
• Lactation
• OT
• NICU Dietician
• Research RN
• NICU Staff RN
85. Take home points
• Human milk is the single most powerful
intervention to optimize the best health
outcomes in all babies
• In the absence of maternal milk, donor human
milk is a superior substitute to formula
• Donor milk derivatives now support the
provision of an exclusively human milk diet
• Initiating and maintaining a balanced gut
microbiota begins with maternal milk
• Moving towards an exclusively human milk diet
will show increasing cost savings and long-term
healthcare benefits to preterm infants