IX. Effect of A Human Milk Bank on Breast-feeding Rate in Very-Low-Birth-Weight Infants

BACKGROUND Breast-feeding and HM represent the reference normative standards for infant feeding and nutrition particularly for sick and preterm infants. In this regard, in NICUs it is of vital importance to provide mothers of preterm infants the education, support, and encouragement needed to provide human milk for their baby (1). Official bodies such as the World Health Organization (WHO), the American Academy of Pediatrics (2) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (3) in their policy statement recommend that OMM is the first choice for all neonates including preterm infants; when it is unavailable or in short supply, pasteurized DHM offers a safe alternative and is considered the next best choice. To offer this opportunity to preterm infants, HM should be obtained from a human milk bank (HMB). To note that WHO recommendations on optimal feeding of low birth weight (LBW) infants also in low- and middle-income countries recommend feeding LBW infants, including those with VLBW, who cannot be fed OMM with DHM (recommendation relevant for settings where safe and affordable milk-banking facilities are available or can be set up) (4). ADVANTAGES OF HM As for term infants, over the past decades there has been increasing evidence of the benefits of HM in the feeding of VLBW infants, influencing not only short-term health outcomes but also long-term neurodevelopmental, metabolic outcomes, and growth. The main benefit deriving from the use of DHM (vs. formula) in preterm infant feeding is a reduction in the incidence of NEC (5). Meta-analysis by Quigley suggests that feeding with formula more than doubles the risk of NEC. This beneficial effect of DHM exists even when DHM is given as a supplement to maternal breast milk rather than as a sole diet and also when the DHM is fortified. Medium and low existing evidence of the benefits of DHM in preterm concern feeding tolerance, bronchopulmonary dysplasia, long term cardiovascular risk, long term neurodevelopment and allergy. Limited available data from the1980 s support the hypothesis that unfortified DHM results in improved feeding tolerance compared with formula. Studies comparing the effect of fortified DHM versus formula on feeding tolerance are lacking (5). A reduction in the incidence of bronchopulmonary dysplasia has been observed in one RCT (6) but further studies are needed to confirm the observation (5). DHM in early life may have beneficial effects on cardiovascular risk factors measured during adolescence; the significance of these findings for the development of cardiovascular disease is uncertain. A limitation in the evaluation of these findings is that the comparison was made between preterm formula and unfortified DHM (3). There are limited data to conclude whether there are neurodevelopmental advantages associated with DHM compared with preterm formula, although there is some evidence that DHM is better than term formula (3). Only 1 RCT exists studying the effect of DHM on the allergy risk, reporting no protective effect of DHM on the development of allergy later in life, even if a protective effect of DHM against eczema in preterm infants at high risk for allergy was noted (3). According to Quigley, growth is slower in the short term in infants fed DHM than those fed formula (5); however the systematic review include 8 trials but only 1 (6) compared fortified DHM with preterm formula. There are insufficient data to assess also the effects on long-term growth outcomes in VLBW infants, and there are no data available on specific nutrient deficiencies too (5). Promising results we could probably obtain comparing individualized fortification of DHM versus preterm formula. WELL ESTABLISHED Another important benefit of DHM could be the increase of breast-feeding rates in NICUs. DHM has been considered as one of the supportive measures for the establishment of breast-feeding by some authors who applied Baby-Friendly Hospital Initiatives to NICUs (7–9). Yet, occasionally, the concern that the presence of an HMB and the use of DHM might decrease breast-feeding rates is being raised. In a Multicenter Italian Study, Davanzo at al. (10) observed limited breast-feeding and use of HM among NICU infants at discharge. At discharge, 28% of all infants were fed exclusively with HM: 31%, 25%, 22% and 33%, respectively, in the <1500 g, 1500–2000 g, 2000–2499 g and 2500 g birth weight categories. The proportion of infants not fed with HM varied from 6% to 82% across different centers. So according to the author “it is a health care paradox that breast-feeding is not adequately promoted and supported in the population of newborn infants admitted to NICUs.” The role of health care workers, including pediatricians, is to protect, promote and support breast-feeding. Health care workers should be trained in breast-feeding issues and counseling, and they should encourage practices that do not undermine breast-feeding. In fact, the European Milk Bank Association (EMBA), the Italian Association of Human Milk Banks (AIBLUD) and the Spanish Association of Human Milk Banks (AEBLH) state that HMB are not only meant to collect, process, and store donated milk but they also represent an instrument for breast-feeding promotion and support; however, do the presence of an HMB and the use of DHM actually reach this aim? A study planned by the Italian Association of Human Milk Banks (AIBLUD) explored this aspect in Italian NICUs (11); data have been provided by the Italian Neonatal Network (INN) which is integrated to the well-known Vermont Oxford Network (VON). A total of 4350 VLBW infants admitted to the 83 Italian NICUs registered in the INN-VON program (from a total of 98 NICUs in the country) in the year 2010 were evaluated for a comparative analysis about feeding data (parameters in the network: “any and exclusive breast-feeding rates” and “exclusive formula rate” at discharge). Italian NICUs were divided into two groups: centers with an HMB and centers without an HMB. The distribution of the NICUs with and without HMB was similar to that of the population in the three main geographical areas of Italy: north, center, and south (ISTAT, 2010). The newborns admitted to the two groups of NICUs were similar in birth weight, gestational age at birth, and proportion of singletons or multiples. The NICUs with and without HMB were comparable in terms of NICU characteristics and size. Exclusive breast-feeding rate at discharge was significantly higher in NICUs with an HMB than in NICUs without (29.6% vs. 16.0%, respectively). Any breast-feeding rate at discharge tended to be higher in the NICUs with HMB (60.4% vs. 52.8%, P = 0.09), and exclusive formula rate was lower in the NICUs with HMB (26.5% vs. 31.3%), but this difference was not significant. This result represents the first national survey on the positive effects of the availability of DHM on breast-feeding rate of VLBW infants at discharge, confirming the existing data from Australia (12), the United States (13), and Spain (14) which already indicate that the presence of a HMB does not decrease the breast-feeding rate of VLBW infants, but is supportive for breast-feeding promotion. CONCLUSIONS Human milk banking is not only about collecting, checking, processing, storing, and distributing DHM, but also about the extension of the culture of breast-feeding and use of HM in NICUs, and may serve also as a tool for promotion of lactation.