Prioritizing Neurologic Outcomes in the NICU: How Can Human Milk Help?

As we go through life, our priorities change from time to time. As a child, I enjoyed reading and could spend hours outside reading books. I would often check out ten books (the maximum you could check out at once) at the library for two weeks, and have them read before the two weeks were over.

Then, my priority became nursing school and getting finished, so I could go to work and pursue my career. Later, work was the priority, leaving little time for family or self-care such as exercise. Thankfully, priorities seem to have righted themselves in the last few years. Work is still important, but so are time for exercise, travel, and friends and family.

What about clinical priorities?

Our clinical priorities can often be influenced in different ways. Science we have uncovered and continue to discover in the care of premature infants, particularly, should influence our priorities. While oxygenation, ventilation, warmth and nutrition are certainly important, what are all of these without brain care? They all contribute to brain development and health, but there is so much more that can and does also influence a baby’s brain development. Often, once infants get past the critical stage, we relax our vigilance. But the brain is continuing to develop, not only in the NICU but well beyond, we hope!

Some things that we know can and do have an effect on neurologic outcome are uncontrolled hypoglycemia, sepsis, uncontrolled pain, lack of sleep (yes, in adults too!), and perhaps most importantly, the ongoing relationship between parents and their infant. There are many places where more extensive discussion can be found on measures to be taken to treat brain injury from, for instance, hypoxic ischemic encephalopathy and other types of brain insult.  But, the ones listed above that are known to lead to worse neurodevelopmental outcome are often within our control. With adequate monitoring in high-risk infants as recommended by the American Academy of Pediatrics,¹ hypoglycemia should be recognized early and treated effectively in the vast majority of cases.

Early onset sepsis may be avoided with provision of adequate prenatal care and neurologic impact lessened if recognized and treated quickly. There are many peer-reviewed papers available now describing successful measures to decrease or altogether avoid late onset sepsis.^2-6

Pain assessment and management

Pain assessment and management in neonates has long been a focus, although we have not been really successful at either assessment nor management. There are various pain assessment tools published⁷  that may prove helpful, but there is nothing like someone being able to tell you when their pain is intolerable for them, which we, of course, don’t get because our patients are infants.

Pain management, while much improved over the past 20 years, can still be problematic. Lack of sleep and pain management can both be influenced by the provision of developmental care. Possibly one of the most convenient ways, and seemingly without side effects, to treat mild pain is sucrose water.⁸ This certainly shows a decrease in pain-related behaviors or physiologic signs, so much so that it may be overused. There are very few studies evaluating any negative short- or long-term effects related to repeated doses of sucrose, but further research in this area is certainly needed, based on preliminary evidence.⁹

Human milk impact on development

Human milk has also been shown to decrease an infant’s response to pain,¹⁰ although it is not used as often as sucrose water in the NICU, perhaps due to the inconvenience of dosing human milk in this manner. One recent meta-analysis discusses the benefit of odor of maternal milk for managing procedural pain.¹¹ Providing this intervention would be convenient, and may benefit infants, although more study is needed.

Breastfeeding provides another mode of pain management, as sucking has also been shown to provide pain control. As the mother is holding, suckling at the breast can provide comfort as well as some human milk which can alleviate minor pain.

As we incorporate developmental care, family care, and neurologic care into our practice, all of these support pain management and improved sleep.

Most of these issues identified as having an effect on neurodevelopmental outcome are influenced by the provision of human milk.^{12, 13} Whether it is all related to the nutrition of the milk or other factors is not clear, and cause and effect would be difficult to prove. Hypoglycemia, late onset sepsis, pain, and parent-infant attachment are all improved with the provision of human milk.  A lower blood glucose level is better tolerated in infants who receive human milk early in their lives.¹  The existence of other nutrients are available in the milk to provide energy. Even so, it has been shown that carefully managed breastfeeding can be effective at managing blood glucose even in high-risk infants.¹⁴

Many studies have shown a decrease in late onset sepsis in infants who receive human milk. We know that the antibodies passed in milk aid the infant in fighting off infection. Fresh milk is more beneficial to this point but even stored, previously frozen milk confers benefit on the infant.^{15. 16}

The benefits of human milk in the management of minor pain have already been reviewed. Parent-infant attachment is often improved with the provision of human milk as well. Therefore, perhaps our priority at this point (if it isn’t already) is to provide human milk to the infants for whom we care. Many of the studies already mentioned find a dose response to the benefits of human milk, meaning that the more human milk an infant receives, the greater the benefit. It is not only important to provide human milk during the critical period of infancy to prevent necrotizing enterocolitis, but important to continue provision of this “medicine” for months, even after discharge. There is such an overarching long-term benefit to something so basic that it really must be a priority.

 

References:

1. Adamkin DH. Committee on fetus and newborn. Postnatal glucose homeostasis in late-preterm and term infants. Pediatrics. 2011;127(3):575-9.
2. McPherson C, Liviskie C, Zeller B, Nelson MP, Newland JG. Antimicrobial Stewardship in Neonates: Challenges and Opportunities. Neonatal Network. 2018 Jan 1;37(2):116-23.
3. Payne V, Hall M, Prieto J, Johnson M. Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2018 Sep 1;103(5):F422-9.
4. Nzegwu NI, Rychalsky MR, Nallu LA, Song X, Deng Y, Natusch AM, Baltimore RS, Paci GR, Bizzarro MJ. Implementation of an antimicrobial stewardship program in a neonatal intensive care unit. Infection control & hospital epidemiology. 2017 Oct;38(10):1137-43.
5. Aceti A, Maggio L, Beghetti I, Gori D, Barone G, Callegari M, Fantini M, Indrio F, Meneghin F, Morelli L, Zuccotti G. Probiotics prevent late-onset sepsis in human milk-fed, very low birth weight preterm infants: systematic review and meta-analysis. Nutrients. 2017 Aug;9(8):904.
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7. Walden M, Gibbons S. Newborn pain assessment and management. National Association of Neonatal Nurses. September 2012.
8. Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane database of systematic reviews. 2016(7).
9. Angeles DM, Asmerom Y, Boskovic DS, Slater L, Bacot-Carter S, Bahjri K, Mukasa J, Holden M, Fayard E. Oral sucrose for heel lance enhances adenosine triphosphate use in preterm neonates with respiratory distress. SAGE open medicine. 2015 Oct 27;3:2050312115611431.
10. Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database of Systematic Reviews. 2012(12).
11. Zhang S, Su F, Li J, Chen W. The Analgesic Effects of Maternal Milk Odor on Newborns: A Meta-Analysis. Breastfeeding Medicine. 2018 Jun 1;13(5):327-34.
12. Bhatia J. Human milk and the premature infant. Annals of nutrition and metabolism. 2013;62(Suppl. 3):8-14.
13. Lechner BE, Vohr BR. Neurodevelopmental outcomes of preterm infants fed human milk: a systematic review. Clinics in perinatology. 2017 Mar 1;44(1):69-83.
14. Chertok IR, Raz I, Shoham I, Haddad H, Wiznitzer A. Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. Journal of Human Nutrition and Dietetics. 2009 Apr;22(2):166-9.
15. Lewis ED, Richard C, Larsen BM, Field CJ. The importance of human milk for immunity in preterm infants. Clinics in perinatology. 2017 Mar 1;44(1):23-47.
16. Miller J, Tonkin E, Damarell R, McPhee A, Suganuma M, Suganuma H, Middleton P, Makrides M, Collins C. A systematic review and meta-analysis of human milk feeding and morbidity in very low birth weight infants. Nutrients. 2018 Jun;10(6):707.