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The importance of breast milk in preventing Bronchopulmonary Dysplasia in preterm infants

2024-06-20

© Quirin Leppert Bronchopulmonary dysplasia (BPD), is a chronic lung disease that affects premature infants who required ventilation and oxygen therapy after birth, resulting from lung injury and impaired lung development. It is a leading cause of morbidity in preterm infants. Understanding modifiable factors, such as the quality of nutrition, can offer strategies to decrease the incidence and severity of BPD, reducing its impact on preterm health. Mother’s own milk (MOM) has an antioxidant effect and is effective in preventing severe forms of BPD. When MOM is unavailable, preterm donor milk (PDM) has shown to achieve similar protective effects in prevention.  Comparable outcomes through MOM and PDM   The study, conducted in the Department of Neonatology at Hospital General Universitario Gregorio Marañón in Madrid from January 2020 to December 2022, aimed to compare the incidence of BPD in preterm infants fed predominantly MOM versus those who received mostly PDM. Additionally, it analysed differences in nutritional components of PDM in patients with or without BPD. The study included 199 newborns, classified by the type of milk received (>50% MOM or >50% PDM) and by BPD diagnosis (noBPD/1 or BPD 2-3). Results showed no significant difference in BPD incidence between those receiving mainly MOM or PDM (19% vs. 20%). Of the total participants, 86% received PDM at some point, with 54% predominantly fed PDM and 46% predominantly MOM. The incidence of BPD was similar regardless of milk type, compared to overall lower rates of BPD for infants receiving human milk compared to those that did not. The study concludes that non-pooled PDM matched by gestational age and time of lactation can be a viable alternative to MOM, with a comparable protective effect against severe BPD.  Differences between noBPD/1 and BPD2-3 patients regarding nutrition and growth  When analysing nutritional variables related to BPD, the researchers found that for patients with moderate to severe BPD (BPD 2-3), fortification of feeds started later compared to others (16.62 days vs. 10.96 days).  Exclusive enteral nutrition was also achieved later in the BPD 2-3 patient group versus the rest of the preterm infants studied. (17.28 days vs. 10.34 days). However, these differences were not significant when adjusted for gestational age in a multivariate model. At discharge, 30% of BPD 2-3 patients and 36% of noBPD/1 patients were exclusively breastfed. Despite receiving adequate nutritional intake as per ESPGHAN recommendations, patients with BPD 2–3 exhibited lower growth compared to the noBPD/1 group, particularly in length. Breastfeeding not only offers protection against BPD but also decreases the risk of subsequent hospital admissions within the first 6 months of life, with exclusive breastfeeding showing the most significant effects.   PDM as practicable and effective alternative to MOM  The donor milk in this study was sourced from mothers of preterm infants with similar gestational ages and days of life. The absence of significant differences in BPD diagnosis between patients predominantly receiving MOM and those predominantly receiving donor milk suggests that PDM is a viable and effective alternative when MOM is not available. It potentially offers advantages over pooled mature milk from term mothers typically used in standard milk banks, as mature milk has a different composition regarding nutrients.  In summary, a comprehensive approach to BPD is necessary, considering its multifactorial nature and emphasising preventive strategies to reduce its severity and incidence in preterm infants. This study found no differences in BPD diagnosis between patients predominantly receiving MOM and those receiving PDM. However, further research is needed to evaluate the protective effect of diet on BPD development and severity.  Paper available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10974788/pdf/nutrients-16-00859.pdf  Full list of authors: Amaia Merino-Hernández, Andrea Palacios-Bermejo, Cristina Ramos-Navarro, Silvia Caballero-Martín, Noelia González-Pacheco, Elena Rodríguez-Corrales, María Carmen Sánchez-Gómez de Orgaz and Manuel Sánchez-Luna  https://doi.org/10.3390/nu16060859 

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Once a nurse, always a nurse

2024-05-28

A guest article by ESCNH Ambassador Livia Nagy Bonnard © Livia Nagy Bonnard I felt honoured and proud when the representative of the Council of International Neonatal Nurses (COINN) Helle Lønstrup Haslund-Thomsen approached me and offered me the opportunity to open the bi-annual COINN conference in Aalborg, Denmark, this year. My first surprise and question was: what could I possibly contribute, since I am currently not working as a bedside nurse? I can only share what kind of care we  – as parents of a preterm born son – experienced, and what I disliked during our NICU stay. Their answer was: „This is exactly what we are looking for. You can speak both from your perspective as a former nurse and as a mother who lived through this traumatic situation”. I was sceptical, even afraid of the task. I was not sure they would understand my thoughts and hoped they would not misunderstood me or take it as an attack, since they have enough problems in their daily clinical reality. Today, one of the cores values in neonatal nursing is facilitating infant- and family-centred developmental care (IFCDC) to support the closeness – both physical and emotional – between the newborn and the parents, siblings or extended family. But are the professionals getting all the help they need to provide this? Do they get enough training, supervision, support, and appreciation to achieve this? My nursing education started in the late 80s, and I quickly experienced all the bliss and challenges of working in the healthcare system. I worked in intensive care with adult cardiac patients, but I always loved taking care of those too-early and wise mini adults whose cronic disease made them grow too fast. The „drive” to become a nurse came from my family; somehow it was „obvious” I was continuing the family path. But just like today, enthusiasm and dedication to paediatric care alone was not enough to keep a young healthcare professional to the bedside. I felt undervalued and underpaid, which drove me in a different direction. Every road led to the NICU. Today, I know it was my destiny, but two decades ago, I found myself all of a sudden on the other side of the patient bed, as a mother with an extremely preterm baby, and the NICU was the last place I wanted to be. Today I know, as research backs me up, what to advocate for as a patient expert, and most importantly, how to do it. But 18 years ago, I found myself in a ward what I could not even imagine or have professional experience with because, in the late 80s and early 90s, Hungarian neonatal care was still in its infancy. Today we know – I know – that every aspect of care affects the brain and we have to protect the brain of every preterm baby. However, when I look at all the evidence and all the the consequences we have to live with for the rest of our lives, I feel sad. I wish I knew back then… Today I know it was the best decision to open up my heart (and the family photo book) to share our lived experience with colleagues from around the world. My son received outdated, non-evidence-based neonatal care during his 14-week stay 18 years ago. I had two 20-minute visits a day to see my baby. I could only look at him, and I had to ask permission even to touch him or take a picture of him. The main reason given was to avoid infection. I imagined myself as a biological bomb; that idea was planted in my head from the first moment I set foot in the NICU and it went on for 14 weeks. I was afraid to kiss my own child for a year, and did not let anyone touch him. They gave formula milk to my baby as my breast milk became less very quickly, due to the stress and misleading information. He received cluster care where his sleep cycles, pain, and stress were ignored. He was positioned on his back in his incubator, without any support for his shoulders, legs, or knees. How can a parent become part of the care procedures? What type of information does a parent need to dare to dream of taking that baby home one day from intensive care? Why is the first touch so important, and how can we guide a parent to observe and watch their baby? How can something as simple as the smell of a baby support attachment? And: How can nurses make parents feel welcome at the NICU? Thanks to COINN, I had the opportunity to attend one of the most memorable and comprehensive professional conferences of my life, where the speakers touched on the most important issues facing neonatal nurses. In addition to pain management, we heard many international examples of parental involvement. I watched in awe as my young colleagues presented their latest research in different areas of neonatal nursing. To my great pleasure, the ESCNH project initiated by EFCNI was also featured several times during the presentations, covering NICU design, Nutrition, Patient safety & hygiene practice, and pain management. I am proud that the nurses find those standards, which are co-created by parents and patients, useful and apply them in their everyday care. © Livia Nagy Bonnard Of course, a recurring theme of the conference was how to attract more young people into nursing and how to keep nurses at the bedside. How can we support them and prevent burnout? We know that NICU babies are healed by nurses, whose careful and gentle care is the foundation for a healthy future for our children. Today, what the nursing profession needs most is our support to stand up for them. I was proud to show how, in my tiny country of Hungary, we are helping neonatal nurses through training (e.g., FINE: Family and Infant Neurodevelopmental Education) and support programmes for their mental health. We advocate for them at the governmental level and help their education, e.g. through the translation and publication of the Neonatal Nursing Care Handbook written by Judy Wright Lott and Carole Kenner (former COINN president). © Livia Nagy Bonnard During this conference, I had the opportunity to provide all the guidance I could, showing how to avoid the pitfalls that can create challenges for preterm born babies and their families. I feel like I succeeded because, for three days, almost all of the nearly 300 participants approached me, even if it was just for a word or a hug, and thanked me for my sincere thoughts. I felt heard, and that they had understood what parents need to have the best NICU experience possible. I once read this quote: „Once a nurse, always a nurse. No matter where you go or what you do, you can never truly get out of nursing. It’s like the Mafia… you know too much”. And it is absolutely true. I’m proud to be part of this family.

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Kangaroo Mother Care: Improving newborn health through early skin-to-skin contact!

2024-05-24

© Quirin Leppert The 13th International Conference on Kangaroo Mother Care (KMC) held in Madrid from 21-22 November gathered 272 participants from 47 countries to discuss KMC practices, focusing on good practices, immediate implementation, nutrition, and basic ventilation. The present study summarises the results of the conference and highlights the importance of KMC for maternal and neonatal care. Initially developed in Colombia, KMC has spread globally as an evidence-based method for reducing adverse outcomes in preterm or low birth weight infants. The WHO defines Kangaroo Mother Care as involving continuous skin-to-skin contact for 8–24 hours daily, exclusive breastfeeding or breastmilk feeding, and timely discharge from the NICU to a lower level of care or home with ongoing monitoring. Benefits include lower mortality, reduced infection and hypothermia, and improved breastfeeding rates . KMC as best practice in neonatal care The study authors argue that countries should adopt official recommendations promoting KMC as essential care. In Colombia, the Ministry of Health has published technical guidelines for KMC. Workshop participants agreed that policies should support parents’ rights to stay with their infants and advocated for guidelines to be updated every 3-5 years. Additionally, hospital infrastructure should accommodate parents around the clock with beds, food, and bathroom access. Well-coordinated multidisciplinary teams and staff training in KMC are crucial, despite challenges like high staff turnover. Immediate KMC ensures better outcomes KMC should start as soon as possible, ideally within the first hours of life. Immediate Kangaroo Mother Care (iKMC) involves initiating skin-to-skin contact immediately after birth, even if the newborn is not clinically stable. This approach aims to prevent the stressful separation of mother and infant and has significant benefits, including reduced parental stress, shorter hospital stays, fewer infections, and better long-term outcomes. Neonatal Intensive Care Units (NICUs) should therefore be open to parents at all times. Implementation of (i)KMC varies by country. In high-income countries, early discharge in the kangaroo position is uncommon. Typically, infants are not discharged until they attain a specific gestational age, a predetermined length of hospital stay, or a certain weight. Middle- and low-income countries, however, often transition infants to KMC wards or home with close monitoring. Conference participants state that follow-up is generally essential, starting daily, then weekly, until the infant reaches 40 weeks gestational age. Continuous multidisciplinary follow-up up to 12 months corrected age, potentially extended further, is also advised. iKMC criteria and contraindications Current iKMC criteria differ significantly across countries. A WHO study showed lower mortality at 28 days for infants receiving iKMC compared to those with conventional care [1]. Implementation requires professional training, space adaptation, and resuscitation equipment. In some countries, iKMC is practiced extensively, while in others, logistical challenges limit its application. General contraindications include severe asphyxia, severely depressed infants, fear of the mother or the health team, and situations where no bed is available for both newborn and mother to receive care together. Caesarean sections are not considered as contraindications. Nutrition recommendations Recognising the crucial role of nutrition, especially breastmilk, in KMC, participants discussed the need for standardised guidelines. Growth charts like Fenton-2013 and Intergrowth-21 are used to monitor growth. Access to fortifiers varies; some countries lack them, while others have detailed protocols for their use. Feeding is supplemented by tube initially, gradually reducing as suckling improves. Non-nutritive sucking usually starts at 28-32 weeks gestational age, progressing to direct breastfeeding at 34-35 weeks. Stance on basic ventilation Maintaining respiratory stability is essential for the successful implementation of KMC. Nasal Continuous Positive Airway Pressure (nCPAP) is unavailable in many resource-limited countries. It benefits preterm infants with respiratory distress and can prevent lung collapse. Challenges include skin and nasal injuries from nCPAP use. Some countries have developed protective measures, but transferring preterm infants to NICUs remains problematic, especially where facilities are separate. The conference highlighted inequalities in care for low birth weight and preterm infants. Suggested improvements include public health policies, staff training, encouraging parental involvement, and multidisciplinary follow-up programmes. Ensuring proper care immediately after birth is critical, with iKMC being an effective intervention. Nutritional assessments should be routine, and a basic neonatal package including nCPAP and iKMC protocols is recommended. In summary, KMC provides significant benefits for preterm and low birth weight infants, but its implementation varies globally. Efforts to standardise and support KMC practices are crucial for improving newborn health outcomes. Paper available at: https://pubmed.ncbi.nlm.nih.gov/37667990/ Full list of authors: Carmen Pallás-Alonso, Adriana Montealegre, María Teresa Hernández-Aguilar, Bárbara Muñoz-Amat, Laura Collados-Gómez, Lucía Jiménez-Fernández, Nadia García-Lara, Marta Cabrera-Lafuente, María Teresa Moral-Pumarega, María López-Maestro, Nathalie Charpak https://doi.org/10.1111/apa.16960   [1] Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight. N Engl J Med. 2021;384(21):2028–38.

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