Oral Care: The Immune Powers of Human Milk

 

Are you using colostrum for oral care in your NICU? There are several studies now related to this procedure.

First, this started as a measure to reduce ventilator associated pneumonia (VAP) because adult practices to avoid VAP required regular oral care with an antibacterial solution. NICU clinicians did not feel this solution would be safe in neonates, and in fact, were concerned that it may result in over-growth of pathogenic bacteria.

As a result, colostrum was used as an alternative. It was known that this was safe to put into the infant’s mouth and contained probiotics, immunologics, and commensal bacteria. The procedure has never been studied in relation to VAP prevention, although it is part of many “bundles” to avoid VAP.

However, there are now some rather sophisticated studies about early oral colostrum or breast milk administration and the effect on immunity. The administration of colostrum orally was recently shown to change the microbiota in the mouth when compared to oral care with sterile water.1 This difference continued for at least 48 hours.

Oral care considerations

For a different perspective to the administration of colostrum, consider this:

1. Not only colostrum is beneficial; any human milk is beneficial
   • While colostrum has a high concentration of the immunologic benefits, later breast milk contains these properties as well. They are just not as concentrated.

2. In order to maintain safety, the milk or colostrum should be drawn up into syringes under sterile technique in order to ensure that babies get only the bacteria from the mother’s milk.

3. Oral care implies swabbing the mouth with the milk. This may result in irritation to fragile mucous membranes and cotton fibers released from the swab that could be a potential choking hazard.

And another perspective on the administration of colostrum: Nancy Rodriguez, PhD, spoke at the recent NANN conference and suggested that we call this “immune therapy” rather than oral care.2 Oral care simply implies we are removing debris from the mouth. The intent and evidence suggests we are, and should, be doing much more than this.

Dr. Rodriguez’s studies required the drops of colostrum or breast milk be given via syringe into the buccal mucosa, and then swabbed around the area. The swabbing was done with a special foam applicator that did not result in cotton fibers being left in the oral cavity.

Other researchers³ have put tracers on the lactoferrin in the milk applied in this manner and measured the same lactoferrin with tracers in the urine, showing that these are absorbed through the oral mucosa. Indeed, this and immunoglobulins in the milk provide additional immune protection to the infant when they would normally be getting this from the amniotic fluid. While this was a small study and more study is needed, infants who received colostrum orally did have a lower rate of clinical sepsis.3

Therefore, evidence exists that human milk should be administered in this way in even the smallest babies, and is perhaps more important for them, and continued until they are able to take feedings by mouth. When feedings are typically started for these infants, they are given via feeding tube that bypasses the oral cavity and back of the throat where amniotic fluid would normally provide nutrients and immunologic properties until term birth.

While the use of breast milk for VAP prevention eludes evidence, this is partly due to the difficulty in diagnosing VAP. Furthermore, the evidence we have to date shows that all premature infants should benefit from this procedure, and not just those who are intubated and at risk for VAP.

Let us know: Does your unit use colostrum and human milk for oral care? How have you influenced consistent practice amongst your team? Use the comments area below to share!

Looking for more from Sandra Sundquist Beauman?
Read Standardization of Warming Infant Feeds.

References:

1. Sohn, K., Kalanetra, K. M., Mills, D. A., & Underwood, M. A. (2015). Buccal administration of human colostrum: impact on the oral microbiota of premature infants. Journal of Perinatology.
2. Rodriguez, Nancy, “The Use of Oro-Pharyngeal Therapy with Mother’s Own Milk (OPT-MOM) to Protect Extremely Premature Infants Against Infectious Morbidities: Biological Plausibility and Review of Current Evidence. National Association of Neonatal Nurses National Conference 2016.
3. Lee, J., Kim, H. S., Jung, Y. H., Choi, K. Y., Shin, S. H., Kim, E. K., & Choi, J. H. (2015). Oropharyngeal colostrum administration in extremely premature infants: an RCT. Pediatrics, 135(2), e357-e366.