“Breaking Good”: Preemie Addiction To Mother’s Milk

Now that it is clear that we are seeing an epidemic in adult prescription narcotic abuse and thereby maternal narcotic addiction, and downstream neonatal abstinence syndrome across the country, it seems fitting that we take some time to discuss a counter movement that has come upon us, the rising positive “addiction” of many preterm infants to mother’s own milk.^1-3

Human milk is a drug, and made up of not just one but many compounds. Like other drugs, human milk has a dose dependent effect in preterm infants on reducing the incidence of necrotizing enterocolitis (NEC) and on reducing neurocognitive impairment.^{4, 5} These facts have been supported by numerous other studies over the past decade and this is driving up the number of preemies that are getting hooked on mother’s milk.

There are two aspects to any drug addiction, chemical and psychologic. While there are no clearly discovered compounds in human milk that convincingly lead to chemical addiction (aside from maternal medications that may cross over), there is indisputable observational evidence that infants breastfeeding or bottle feeding mother’s milk reach a state of complete relaxation and level of satisfaction that if we were able to get a verbal response, infants would confess to euphoria. It is common to hear in the NICU talk about our babies experiencing “milk coma.” They are down for the count, they are in heaven. Frankly if we could grade the quality of sleep thereafter it would be off the charts.

It was not long ago when most preemies everywhere were being fed solely preterm formula. And rightly so since many early studies demonstrated that human milk alone in a small preterm baby would lead to poor growth, bone mineralization and long-term neurodevelopmental outcomes. Preterm formula contained more of practically everything compared to human milk, more energy, more protein, more mineral, more vitamins and more trace elements, all promoting overall better growth. Despite these positive attributes, however, infants feeding preterm formula were still getting sicker at higher rates from sepsis and necrotizing enterocolitis compared to human milk feeding.^{6, 7} Interestingly though, once improved methods for human milk fortification overcame the nutritional deficiencies of intake of plain human milk, many preemies were continued on preterm formula.

Fortunately, over the past decade the recognition of human milk as a natural medical miracle has emerged. One of the first ways was through the classification as a liquid tissue. This makes it not unlike another more familiar liquid tissue, blood. Human milk contains a myriad of biologically active compounds as well as cellular parts. To date, in three states, California, New York and Maryland, human milk is fully recognized as a liquid tissue. Unfortunately too this also increases the stringency of requirements for managing and handling human milk in hospitals in these three states, such as the need to hold a tissue bank license. The last point has been somewhat of an impediment for some NICUs in using donor milk for their babies.

Many of us in the human milk advocacy and quality improvement arenas are really pushing human milk drug. We are figuring out ways to collect it in its most purest form, we are finding fashionable ways to carry the milk around, and in larger hospitals the milk “trafficking” is busy approaching a high throughput operation. The donor human milk industry plays a major role in milk handling too. They too collect, store and process, almost like a distillery in the case of the commercial donor milk entity, in order to secure a safe and consistent product.

As we move to increase human milk use in the NICU we take on greater ownership of the movement or traffic of human milk. So how should we feel being human milk traffickers? Personally, it feels great. We have a great drug to sell that carries with it an amazing assortment of tricks. It gives you energy, boosts your immunity, changes your intestinal microbiome, strengthens your bones and gives you deep restful sleep. It is both an upper and a downer. All babies love it and once they taste it they want more.

For some babies that’s all they want to drink, period. We recently had a preemie girl who had a strong family history of bovine intolerance and we needed to supplement mother’s milk volumes with an amino acid based formula to keep up with her feeds.  She was quite picky with her meals and was only willing to take her mother’s milk straight up with no added flavors. I fully understand her preferences since I was obligated in my pediatric gastroenterology training to taste all the formulas I ordered on our GI kids to appreciate what they had to tolerate. Everyone should try this some time. We solved this child’s feeding over more than a week by alternating feeds instead of mixing and then she did just fine with her oral feeding advancement.

Human milk remains in short supply for preemies. Mothers of preterm infants aren’t usually aware just how special the liquid gold is that they produce. They typically produce less than half of what a mother of a term infant would consume.⁸ Most hospitals in the country don’t have access or provide donor human milk to their babies to cover the gap. These shortages lead to the increasing supply-demand inequity that is currently present. The demand for donor human milk is increasing year by year based on the increasing output of donor milk of existing banks and the increase in number of newly formed donor milk banks in the country each year. The primary driver of this trend is the NICU.

Sadly there are still far too many places in this country where a high risk preemie continues to feed on formula from birth. How we get more babies addicted positively to human milk is going to depend on the willingness of mothers, healthcare providers and administration to recognize the overall value of having all of our preterm infants hooked on human milk. We also need to think about the withdrawal signs when a preemie is taken off of human milk. We see these most prominently in feeding intolerance as formula does not empty out of the stomach at the same frequency as human milk. Coming off human milk suddenly can also lead to more severe bowel consequences such as NEC. Avoiding this transition until a later age seems most prudent now and if mother’s milk is low, donor milk can really be a helpful bridge.

How do we form a good addiction? The first crucial step to all good habit formation is repetition. This is something that we can help with mothers who struggle getting into a pattern of pumping. So let’s be dealers and pushers of a drug we want our babies fully addicted to. Every day our lactation consultants and nurses see mothers who are not prepared to pump milk on a regular schedule. We need to be more organized in trafficking this precious and wanted elixir to our users. Good luck to all fellow human milk traffickers. This rising new movement could give a whole new meaning to “breaking good.”

What can you do to feed the human milk addiction?

1. Talk about making milk in each conversation with mothers
2. Encourage more skin-to-skin
3. Encourage non-nutritive breastfeeding
4. Encourage more mother-baby time of any sort
5. Single patient rooms may help support breastfeeding if it drives more time spent and more opportunities at the breast

References:

1. Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011 Nov 4;60(43):1487-92.

2. Bateman BT, Hernandez-Diaz S, Rathmell JP, Seeger JD, Doherty M, Fischer MA, Huybrechts KF. Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States. Anesthesiology. 2014 May;120(5):1216-24.

3. Epstein RA, Bobo WV, Martin PR, Morrow JA, Wang W, Chandrasekhar R, Cooper WO. Increasing pregnancy-related use of prescribed opioid analgesics. Ann Epidemiol. 2013 Aug;23(8):498-503.

4. Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants’ risk of necrotizing enterocolitis or death. J Perinatol. 2009 Jan;29(1):57-62.

5. Vohr BR, Poindexter BB, Dusick AM, McKinley LT, Higgins RD, Langer JC, Poole WK; National Institute of Child Health and Human Development National Research Network. Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics. 2007 Oct;120(4):e953-9.

6. Patel AL, Johnson TJ, Engstrom JL, Fogg LF, Jegier BJ, Bigger HR, Meier PP. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol. 2013 Jul;33(7):514-9.

7. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990 Dec 22-29;336(8730):1519-23.

8. Henderson JJ, Hartmann PE, Newnham JP, Simmer K. Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. Pediatrics. 2008 Jan;121(1):e92-100. doi: 10.1542/peds.2007-1107.