Donor Milk Usage to Prevent NEC
Article Outline
Gastrointestinal issues encompass a wide variety of issues for neonates in the Neonatal Intensive Care Unit. This issue of Newborn and Infant Nursing Reviews will address many of these medical issues; yet recently, the therapy of donor milk administration has been yielding some preliminary positive results. Necrotizing enterocolitis (NEC) remains the “Russian roulette” of prematurity. We poorly predict which baby will develop it, or when. Just when families think the worst is over and let their guard down, the worst hits. Although many risk factors for NEC have been proposed, the only consistent risk factor remains prematurity. The earlier the gestational age at birth, the higher the risk. Despite advances in other areas of neonatal care, there has been no change in the incidence, mortality, or morbidity from NEC in the last two decades. The overall incidence remains between 8% and 12% for infants less than 1500 grams at birth, and up to 40% for infants born at less than 25 weeks. Thirty percent to 50% require surgical intervention, with approximately 30% mortality. Necrotizing enterocolitis is now one of the most common causes of short gut, often resulting in late-onset liver failure requiring transplant or resulting in death.
A variety of interventions have been evaluated in the prevention of NEC. The only intervention found to consistently decrease the rate of NEC has been the use of human milk. Epidemiologic data from Scandinavia and now in the United States showed that the higher the volume of human milk an infant receives, the lower the risk of NEC. A recent meta-analysis of clinical trials involving human milk and NEC found a fourfold decrease in the incidence of NEC with the use of human milk.1 All of these trials were done using donor human milk.
Why then is donor milk not being used routinely in all nurseries for the prevention of NEC? The reasons are multifactorial. Most important has been the quality of the data used to study human milk. The criterion standard for research studies is the randomized control trial. These are impossible to do with mother's own milk, as it would be unethical for a research study to decide which babies receive their mother's milk and which do not. Studies relied then on evaluating those babies in whom mothers decided not to provide human milk, and randomized them to donor milk or formula. These studies tended to be smaller in size. When studying a disease such as NEC with an incidence of 12%, it becomes difficult to obtain enough patients. As a result, although all the studies showed benefit, the true impact was not evident until they were combined in a meta-analysis. Secondly, formula in most hospitals is obtained free. Donor milk is paid for, and not reimbursed by insurance companies. Donor milk banks are run as nonprofit organizations, but must be able to cover their costs. Finally, the concern is raised about potential infections that could be passed in human milk. All donor milk is pasteurized, killing both bacteria and viruses, just like the milk we buy in the grocery store.
Given the strength of the recent data on the benefit of human milk, our Neonatal Intensive Care Unit embarked on a quality improvement project to increase the volume of human milk given to infants less than 1500 grams (very low birth weight). Our approach was to both increase the volume of mother's own milk by supporting pumping and use donor milk as a bridge until maternal milk was available. Over the last 9 months, we have seen an increase in human milk received by our very low birth weight infants. There has been a concomitant drop in our NEC rate to consistently less than 8%. Although these data are encouraging, these are not meant to be taken as casual. Closer analysis of potential confounding variables needs to be accounted for, and NEC is a sporadic disease requiring longer-term monitoring. Nonetheless, donor milk administration is an intervention that seems to be without adverse effects and offers benefits beyond NEC. Cost analyses have previously shown financial savings with donor human milk; therefore, this intervention will soon start to be incorporated into neonatal nutritional practices. The cost saved in physical pain of the infant and emotional suffering of the parents is priceless.
Reference
PII: S1527-3369(07)00067-0
doi:10.1053/j.nainr.2007.06.001
© 2007 Elsevier Inc. All rights reserved.
