The Dangers Of Ignorance In The NICU
Jae Kim, MD, PhD / September 2015
This past week was an interesting, if not volatile, week for neonatal nurses. On the one hand, it was a week of celebration for National Neonatal Nurses Day, a day to thank and appreciate neonatal nurses everywhere for the dedication and commitment that they have for their patients. (Kudos to all of you!!!) Around the same time, the profession of nursing was ignorantly trashed by hosts of the popular show “The View” who criticized Miss Colorado, an RN, for daring to wear scrubs and have a stethoscope around her neck as if these were only a physician’s privilege. The reaction from the nursing and medical community has been severe. Ouch!
Over the past year the medical community has been shocked at the utter ignorance of public figures in politics, entertainment, media, and parents from all regions of the country on their belief that vaccines are a cause of autism. This rising ignorance and misinformation resulted in an unprecedented recoil in the herd immunity that is so important to keeping these lists of terrible diseases at bay. Unnecessary outbreaks of these past defeated diseases have been reported as a consequence. No amount of scientific evidence could satisfy many of those ignorant on this issue.
These events made me think about the roots of these comments and misconceptions. Our current federal elections reveal through their polls that there are ample amounts of ignorance present in our nation (e.g. not believing that man visited the moon) and the loose comments made on The View are aligned with the state of our nation. It also uncovered an accompanying disrespect for those who care a lot. Nursing as a profession selects out those individuals who openly come into the practice of tending, caring, nursing sick and dying patients for comfort, healing and support. Somehow our society finds it easy to denigrate those who show compassion. Such acts are nothing but bullying where those who appear vulnerable are made fun of. I will stop here as I wish to explore this aspect more in a future blog.
Ignorance is pervasive and the NICU is no exception, and so I pondered about the places in neonatal nutrition where ignorance could lead to trouble and not deliver the best results while we manage such vulnerable babies. So what are the biggest gaps in knowledge I hear and see in different NICUs in the country? Allow me to expand on four misconceptions that I believe still pervade our community.
Misconception: Infant formula and human milk are interchangeable for preterm infants
Many will argue that this is not a misconception. Naysayers will say that we all share a healthy reverence for the power of human milk in its ability to confer immunoprotection like a vaccine along with a maternal-infant specific diet of bioactive factors, prebiotics, probiotics and nutrients. But while I hear from many that breastfeeding and human milk are far more advantageous than providing formula, actions speak louder than words. The vast majority (I would safely guess >90%) of our approximately 1000 NICUs continue to provide infant formula as an exchangeable source of feeding to fortified human milk. For some, the reasons for not addressing this are logistic, financial and/or resource dependent. Many units have not been able to secure the lactation support or donor milk provisions. Some don’t believe that donor milk is superior to infant formula. For others it is habit and reflexive to provide infant formula when mother’s milk is unavailable, and habits are hard to change. Changing to a human milk culture requires a village and a systems approach. (See last month’s blog)
Misconception: Energy and macronutrient content of human milk are fixed
Let’s start with assumptions on caloric content of human milk. Read any textbook and they will tell you that human milk has preterm and term milk composition. Daily our dietitians plug these numbers into our calculations of energy, macronutrient and micronutrient content to know how much we are giving to assist our babies’ growth. To confuse matters, our use of human milk fortification is reported out based on these same assumptions. When something is put down in print it must be gospel. The stark reality is that the textbooks are wrong. No such consistent value exists with an individual mother’s milk feeding, and the response that we need to have, at least at this time, is one of blind compensation, if an infant is not growing well, with the addition of more protein or calories. Human milk varies sufficiently enough that we just don’t know with individual samples of milk. It could be 15 kcal/oz for one sample and 30 kcal/oz for another. There are movements to develop more knowledgeable customized fortification, but this will take some time before the milk analyzers that several of us have worked on enter our NICUs as standard of care.
Misconception: More calories are better
In the 90’s, we were attempting to grow babies better by giving them more carbohydrates and fat through a modular approach with individual supplements. This missed the mark as we were generating fatter babies who still did not have good linear and brain growth. We realize now that adequate protein intake is essential for body and brain growth. Taken that many have already made a faulty assumption that we know the protein content in human milk, we forget that some infants simply aren’t getting enough protein and instead feed on “empty” calories. The increased use of donor milk has further exposed this problem and has led to greater risk of poor growth due to its lower protein content (and absent lipase activity). A preemptive strategy to supplement donor milk with a great amount of protein can be helpful. Fortunately much of the lower protein problem has been resolved by the addition of more protein content in our newer liquid fortifiers (~20% more protein). This is very helpful for those preemies on the lower end of the spectrum. However, it has presented a problem on the higher side as one now needs to be careful on the potential for providing excessive amounts of protein for infants who are moderately preterm. I think we are still a long way from truly understanding the nutrient requirements for brain growth and development.
Misconception: We provide adequate vitamin D to our preterm infants
Many believe that we are giving our babies adequate vitamin D in the NICU. It is supplied in our parenteral nutrition solution and due to generally low levels in human milk, vitamin D is also added in human milk fortifiers. We further supplement with additional enteral vitamin D to ensure the target 400 IU daily recommendations. The problem with vitamin D is that we don’t know that there is a problem. Newborn vitamin D status is linked strongly to maternal vitamin D status. But how many of us look at maternal vitamin D status? When researchers have looked to see what sorts of deficiencies we have in mothers and infants in the NICU, the information is shocking. The percentages are clearly at a level where we should notice, sometimes up to a quarter to half the mothers with insufficient or deficient levels. The other big misconception is that human milk does not or cannot provide adequate vitamin D to infants. Studies have shown that if mothers took larger amounts of vitamin D, in the order of 4,000 to 6,000 IU, their milk actually would approximate vitamin D requirements with adequate volume intake.
There are many more nutrition misconceptions to share, so consider this a beginning. Here are my final thoughts. Ignorance is not bliss, rather ignorance is dumb. Part of an old Asian proverb said the following:
“He who knows not, and knows not that he knows not, is a fool…shun him.
He who knows not, and knows that he knows not, is willing…teach him.”
About the Author
Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, spinprogram.ucsd.edu). He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela, Inc.