LEEDS TEACHING HOSPITALS TRUST

eClinical Guidelines Template

TITLE:The use of colostrum and expressed breast milk for oral care, in neonates who are unable to be orally fed on the Neonatal Unit
Version 1
Supersedes : New Guideline
Originator: Katherine Dewhurst (Senior Midwife)
Ownership; Leeds Teaching Hospital Trust
Publication date - May 2010
Next Review date May 2013
Status - Guideline
Applies to;
All relevant neonates receiving care within the neonatal service, where maternal factors are such that breast feeding/breastmilk feeding are not contraindicated. E.g HIV, contraindicated medication
All staff directly caring for babies within the neonatal service
1. Guideline
1.1 Aims/Objectives
To ensure that good oral care is maintained in all babies who are unable to orally feed.
To ensure that babies who are unable to be orally fedare able to benefit frommaternal expressed breast milk during oral cares.
1.2 Background
The standard objective of oral care is to keep the mouth in a healthy condition and improve comfort. In the absence of oral feeding it specifically aims to
  • Keep the oral mucosa clean moist and intact thereby minimising the risk of oral infections
  • Keeps the lips clean soft and intact.
  • Promote comfort for the baby
  • Provide a positive oral experience for the baby (1)
The benefits of human milk and breastfeeding have been well documented in
the literature (2,3). Vulnerable infants who begin their life in the neonatal intensive care unit (NICU) may benefit most from receiving human milk. The milk produced by mothers of the least mature infants contains the highest concentrations of protective factors. The immune components that are unique to preterm colostrum may be especially protective during the first week of life when extremely low birth weight (ELBW) infants are the sickest and at highest risk for infection. However, the immature gastrointestinal tract and the presence of comorbidities that cause bowel hypoperfusion usually preclude enteral feedings during this time (4-14).
Rodriguez et al introduced oropharyngeal administration of maternal colostrum for extremely low birth weight infants. Oropharyngeal administration does not involve the infant's swallowing any of the milk. During this intervention, a small amount of maternal colostrum is placed directly onto the oral mucosa and many of the advantageous constituents of the colostrum can be systemically absorbed(14,15). Colostrum is rich in cytokines and other immune agents that may stimulate oropharyngeal-associated lymphoid tissue.This may help protect the vulnerable infant against infectious organisms during the first days of life (4-11). Colostrum is also thought to protect the gastrointestinal tract owing to its anti-inflammatory properties(13). In addition, human milk is a rich source of oligosaccharides which are able to destroy bacteria, viruses and fungi(1,14,17). The mouth of an infant who is breastfeeding directly at the breast is continually coated with human milk.
By administering milk during mouth care, before the infant can begin enteral feeds, and before the infant can orally feed, the infant gains the same benefit of coating the oral mucosa that the infant who is breastfeeding receives (17).
Using the mother's own colostrum during oral cares is easy, inexpensive, and well-tolerated by even the smallest and sickest ELBW infants (16,17)
Sick babies are often subjected to many adverse oral procedures such as suctioning, intubation and indwelling oral gastric tubes. Oral cares with colostrum can provide positive oral experiences; Infants appear to react positively during mouth cares e.g noting to suck on endotracheal tubes during the administration of colostrum drops(15,16).
Using mother’s expressed breast milk (EBM) also supports early sensory development of taste and smell for babies who are unable to feed orally(1,14,15,17). There is limited research on the use of formula for oral care in relation to sensory development and positive oral experiences.
The period while the infant may be nil by mouth (NBM) is a particularly critical time for both the establishment of maternal milk supply and the collection of colostrum for future use. Providing breastmilk is often described by mothers as a unique contribution to the treatment of their sick baby, and using EBM for mouth care, especially when a baby is not enterally fed, may reaffirm, to her, the importance of her milk. Parents also welcome the opportunity to be able to provide this distinct aspect of care while their infant is critically ill (17).
1.3 Management
1.3.1 Obtaining breastmilk for oral cares
  • NICE guidance and Specialist Neonatal Quality Standards promotes the support of mothers to express breast milk and establish lactation (18)
  • Staff who are caring for mothers and babies who have been separated, owing to admission to the neonatal unit, should ensure that they are working within the guidance of the Breastfeeding Policy in supporting a mother to express her breast milk (relevant statements AppendixA)
  • Because of the critical importance of colostrum, staff shouldadvise parents of babies who are unable to be enterally or orally fed, about the value of breast milk, particularly in relation to its anti-infective and anti-inflammatory properties on the vulnerable newborn.
  • Staff should ensure that mothers are aware of the need to initially hand express at least 8 times in 24 hours, with a period of no longer than 6 hours between any episode of expressing. See Appendix A
  • Staff should inform parents that, initially,it is normal for colostrum to be produced in small amounts (on average no more than 30 milliliters during the first 24 hours after delivery).
  • Staff must take special care to ensure that even relatively small volumes of colostrum are collected and stored correctly for current or future use. (refer to ‘Guidelines for expressing and storing breastmilk’)
  • Freezing and then thawing breast milk can decrease its cellular and host defense properties(19) therefore it is advised that EBM, that has been frozen and then defrosted, is not used for mouth care as it does not have the desired beneficial effect.
  • Refrigerating EBM can also reduce some of the anti-infective properties of EBM but not as significantly as freezing. Priority should be given to fresh EBM for mouth cares, but refrigerated EBM is considered a suitable and effective alternative (19).
  • Staff should request that mothers bring their fresh colostrum to the NNU, in order to be able to start using it for oral care prior to freezing.
  • Colostrum and mature milk can be stored up to 48 hours in the refrigerator and then placed in the freezer to be saved for the initiation of enteral feeds.
1.3.2 How to perform mouthcare with expressed breast milk
  • Mouth care should be performed onstable infants who are NBM, as well as for those infants who are unstable and who require ventilatory support.
  • Mouth care with maternal EBM should be introduced within 48 hours of birth.
  • As a minimum, oral care, with maternal milk (colostrum or mature milk) should be done once daily
  • Mouth care should be performed with cares or with nasogastric bolus feeds. If the mother is present and is pumping at the bedside in the NNU, it is ideal to perform oral care every 2-3 hours following each pumping session. However, consideration should be given to the physiological stability of the infant and the adverse risk of overstimulation.
  • Where ventilated babies have copious oral secretions, it would be advised that these are cleared prior to mouthcare.
  • Draw a small volume, aprox 0.2ml of fresh colostrum or freshEBM into an oral syringe and use to soak the mouth care sponge. Once the infant’s mother is providing larger volumes of milk it would be pertinent to decant a small volume of milk in a separate labelled bottle, for refrigeration, to ensure that in providing the small amounts of milk required for oral care none of the remainder is wasted.
  • Additives such as fortifier should not be used in milk for oral cares.
  • If there is too small a volume or no EBM available, sterile water should be used, or can be mixed with the EBM. Sterile water bottles should be renewed daily.
  • Gently roll the sponge along the lips and, if the baby’s oral cavity is big enough, around the gum lines and over the tongue. Ideally, the EBM should then be used to coat the entire buccal mucosa.
  • Coating the oral mucosa with EBM prior to a tube feed promotes association of tasting milk at feed time. This can be done before each tube feed.
  • Record in neonatal nursing notes and on National Neonatal Badger System.
  • Mouth care can also be provided by dipping a pacifier in the milk, if the infant is unable to perform non-nutritive sucking at the breast (This must only be done with informed consent of the parents, with consideration of the potential benefits and disadvantages to the baby of using a pacifier).
  • Oral care with EBM should continue until the infant is able to take oral feeds.
  • Encourage parental input as soon as possible, as appropriate. NICE Quality Standards recommend that parents of babies receiving special neonatal care should be encouraged and supported in providing care for their baby (18). When parents wish to contribute totheir baby’s care by performing mouth care, it is important that they are taught how to do so safely and are observed performing mouth care until the healthcare professional is happy they are competent.
1.3.3 Training Staff
  • Staff will be made aware of guidelines through written information presented on the neonatal units on notice boards and Monthly breastfeeding updates
  • Staff will be advised of guidelines at annual mandatory training during breastfeeding update.
  • Staff must also be aware of
1)Breastfeeding policy
2) Guideline for expressing and storing
breast milk
1.3.4 Contraindications
  • Where maternal factors are such that breast feeding/breastmilk feeding is contraindicated. E.g HIV, contraindicated medication
1.3.5 Audit process
Clinical audit at approximately 6 months after their introduction via staff skills assessment, and thereafter at 12 monthly intervals unless evidence is produced during audit process that practice is under question.
Clinical Audit will be presented to the speciality clinical audit meeting and an action plan agreed to address the recommendations arising from the audit.
2.Provenance:
2.1 Author name Katherine Dewhurst
2.2 Target patient group: Preterm neonates who are unable to orally feed
2.3 Target professional group: All health care professionals caring for premature neonates
References
1. Spatz.L.D, Edwards T.M The Use of Colostrum and Human Milk for Oral Care in the Neonatal Intensive Care Unit. National Association of neonatal nurses. E-News. Sep 2009. (1) 4
2.AmericanAcademy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics, (2005) 115(2), 496-506.
3.Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. (2007). Breastfeeding and Maternal and Infant Health Outcomes in Developed
Countries . Evidence Report/Technology Assessment No. 153, AHRQ 07-E007. Rockville,
4. Montagne P, Cuilliere ML, Mole C, Bene MC, Faure G. Immunological and nutritional composition of human milk in relation to prematurity and mother’s parity during the first 2 weeks of lactation. J Pediatr Gastroenterol Nutr. 1999;29:75–80
5. Buescher ES. Anti-inflammatory characteristics of human milk: how, where and why. Adv Exp Med Biol. 2001;501:207–222.
6. Buescher ES, Malinowska I. Soluble receptors and cytokine antagonists in human milk. Pediatr Res. 1996;40:839–844.
7. Mathur NB, Dwarkadas AM, Sharma VK, Saha K, Jain K. Anti-infective factors in preterm colostrum. Acta Paediatr Scand. 1990;79:1039–1044.
8. Goldman AS, Garza C, Nichols B, Johnson CA, Smith EO, Goldblum RM. Effects of prematurity on the immunologic system in human milk. J Pediatr. 1982;101:901–905
9. Araujo ED, Goncalves AK, Cornetta M, Cunha H, Cardoso ML, Morais SS, et al. Evaluation of the secretory immunoglobulin A levels in the colostrum and milk of mothers of term and preterm infants. Braz J Infect Dis. 2005;9:357–362.
10. Dvorak B, Fituch CC, Williams CS, HurstNM, Schanler RJ. Increased epidermal growth factor levels in human milk of mothers with extremely premature infants. Pediatr Res. 2003;54:15–19.
11. Koenig A, de Albuquerque Diniz EM, Barbosa SF, Vaz FA. Immunologic factors in human milk: the effects of gestational age and pasteurization. J Hum Lact. 2005;21:439–443
12. Ronayne de Ferrer PA, Baroni A, Sambucetti ME, Lopez NE, Cernadas JMC. Lactoferrin levels in term and preterm milk. J Am Coll Nutr. 2000;19:370–373.
13. LaGamma E, Brown L. Feeding practices for infants weighing less than 1500 g at birth and the pathogenesis of necrotizing enterocolitis. Clin Perinatol. 1994;21:271–306.
14. Rodríguez NA, Miracle DJ, Meier PP. Sharing the science on human milk feedings with mothers of very low birth weight infants. J Obstet Gynecol Neonatal Nurs. 2005;34:109–119.
15. Rodriguez, N. A., Meier, P. P., Groer, M. W., & Zeller, J. M. (2008).
Oropharyngeal administration of colostrum to extremely low birth weight infants:Theoretical perspectives. Journal of Perinatology, 29, 1-7.
16. Rodriguez.N.A, Meier.P.P, Groer.M.W, Zeller.J.M, Engstrom.J.L, Fogg.L, Dowling.D . A Pilot Study to Determine the Safety and Feasibility of Oropharyngeal Administration of Own Mother's Colostrum to Extremely Low-Birth-Weight Infants. Advances in Neonatal Care.August 2010(10) 4 p206-212
17. Spatz, D. L. Ten steps for protecting and promoting the use of human milk and breastfeeding in vulnerable infants. (2004). Journal of Perinatal and Neonatal Nursing, 18(4), 385-396.
18. National Institute for Clinical Excellence (NICE) (2011) Specialist neonatal care quality standards. London. NICE
19. Wight.N.E. Donor human milk for preterm infants. J Perinatology. 2001; 21 249-54
Evidence levels:
Meta-analyses, randomised controlled trials/systematic reviews of RCTs
Expert consensus.
Appendix A
Extracts from the Breastfeeding Policy. Staff Guidance related to supporting a mother who is expressing breast milk for her baby on the NNU or Transitional Care.
  • ‘All breastfeeding mothers should be shown how to hand express their milk and the ‘Off to the best start’ leaflet (should) be provided for women to use for reference.’
  • ‘Mothers should be encouraged to begin hand expressing as soon as possible after delivery, ideally before transfer from delivery suite, as early initiation has long-term benefits for milk production’.
  • ‘When a mother and her baby are separated for medical reasons, it is the responsibility of all health professionals caring for both mother and baby to ensure that the mother is given help and encouragement to express her milk and maintain her lactation during periods of separation’.
  • ‘Mothers who are separated from their babies should be encouraged to express milk at least eight times [preferably 10] in a 24 hour period.’
  • Mothers whose babies are born before 28/30 weeks gestation will be given the information that expressing 10-12 times in 24 hours for the first 2 weeks is advised to stimulate catch up development of breast tissue and can positively effect breast milk production.
  • Mothers with premature babies will have regular discussions and support from the midwifery and neonatal team to ensure expressing is effective and milk volumes remain optimum.
  • Parents should be shown how to clean and sterilise equipment.