The Impact of Human Milk Oral Care

The NICU infant is one of the most, if not the most, susceptible patient in any hospital to nosocomial infections and morbidities simply because they are immature to start. Despite struggling to maintain every calorie their tiny body fights to keep, they are also up against any little bug that attempts to invade their already severely compromised immune system. Something as simple as oral care, sometimes referred to as immune therapy, plays a crucial role in the vitality of these very vulnerable patients.

The role of human milk

We know that human milk (HM) plays a vital role in the premature gut and critically ill neonate. HM has unique properties that promote babies’ health and development, including maternal antibodies and anti-inflammatory substances which offer protection against disease and infection (such as NEC and sepsis).

During feeding at the breast, the exogenous cytokines in mother’s milk may stimulate the infant’s oropharyngeal-associated lymphoid tissue (OFALT) and gut-associated lymphoid tissue (GALT) in a synergistic manner. This combined response has a potentially greater local and systemic effect than that of a single site of stimulation. The term breastfed infant benefits from this combined effect. ¹

What if an infant is NPO, or cannot breastfeed for several days or several months? What about mother’s own colostrum (MOC) or HM given via the oropharyngeal route? Is this beneficial and is it safe?

Colostrum contains highly concentrated immunologic properties (lysozymes, immunoglobulins, and cytokines) which provide barrier protection and promote bacterial cell wall lysis, anti-inflammation, and immunomodulation. ² HM and/or MOC given via gavage tube provides many vital immunologic properties to an infant.

Research has shown, though, that these immune agents can interact directly with the oral mucosa, be readily absorbed, and coat the gastrointestinal and upper respiratory tracts to promote colonization with the mother’s bacteria. This helps to prevent respiratory and intestinal pathogens from invading the mucous membranes, which would be bypassed if given via NG/OGT.

MOC via the oropharyngeal route is meant to be absorbed, not swallowed, and should be considered for all infants even if they are NPO. This is an increasingly common intervention that has been shown to be safe and feasible in studies. ³

In one study, infants who received oral care with MOC, although sicker and smaller, reached full enteral feeds 10 days earlier than the placebo group. Enhanced intestinal motility and maturation, including growth factors and enzymes contained in MOC, may have been absorbed mucosally and/or traveled to the GI tract, providing effects at the mucosal surface that enhanced maturation. ⁴

Oral care with MOC also provides pleasurable oral stimulation to help reduce adverse oral behaviors secondary to the negative stimuli an infant receives as a patient in the NICU (intubation, OGT placement, etc.). Oral care also promotes family centered care by allowing parents the opportunity for involvement in their infant’s care. It supports early sensory development of taste and smell, and may affirm the mother’s sense of the importance of her milk.

How should oral care with MOC be administered?

Ideas to include when developing protocols/policies around oral care/immune therapy include, but are not limited to:

1. Placing oral syringe in cheek and slowly administer 0.1ml – 0.2ml of MOC so that it can be absorbed by mucous membranes.
2. Dipping a sterile swab into fresh MOC. Ensure the swab absorbs all drops of MOC and is saturated (about 0.2mls). Rest swab on the middle of the bottom lip. Wait until the baby moves lips or tongue towards the swab. Allow the infant to recognize the stimulus & then open his/her mouth. Move the swab slowly towards the cheek. If the infant is comfortable, continue with the top lip, then coat the entire buccal mucosa.
3. Place a pacifier in the baby’s mouth and drip MOC on tongue or drip on pacifier itself.
4. Studies suggest Q3-4H, with cares, or as MOC is available.
5. NPO status should not be a contraindication.

MOC is a powerful antimicrobial agent. Oral care with MOC can provide a front-line defense that impacts the infant’s overall immune system, as well as provide the infant with positive feedback in an otherwise orally aversive environment.

 

References

1. Rodriguez, NA, Meier, PP, Groer, MW, Zeller, JM.  Oropharyngeal administration of colostrum to extremely low birth weigh infants:  theoretical perspectives.  Journal of Perinatology.  2009;29(1):1-7.
2. Edwards, T. M., & Spatz, D. L. (2012). Making the case for using donor human milk in vulnerable infants. Advances in Neonatal Care.  2012;12(5):1–7.
3. Sohn, K., Kalanetra, K.M., Mills, D.A., & Underwood, M.A. Buccal administration of human colostrum:  impact on the oral microbiota of premature infants.  Journal of Perinatology.  2016;36:106-111.
4. Rodriguez, N., Groer, M., Zeller, J., Engstrom, J., Fogg, L. & Caplan, M.  A Randomized Controlled Trial of the Oropharyngeal Administration of Mother’s Colostrum to Extremely Low Birth Weight Infants in the First Days of Life.  Neonatal Intensive Care.  2011;24(4):31- 35.
5. Lee, J., Kim, H., Hwa Jung, Y., Choi, K., Han Shin, S., Kim, E. & Choi, J.  Oropharyngeal Colostrum Administration in Extremely Premature Infants: An RCT.  Journal of the American Academy of Pediatrics.  2015;135(2):e357-e366.