Paola Tonetto

Guidelines for the establishment and operation of a donor human milk bank.

SERTAC ARSLANOGLU, ENRICO BERTINO, PAOLA TONETTO, GIUSEPPE DE NISI, AMALIA MARIA AMBRUZZI, AUGUSTO BIASINI, CLAUDIO PROFETI, MARIA RITA SPREGHINI, & GUIDO E. MORO Italian Association of Human Milk Banks (Associazione Italiana Banche del Latte Umano Donato1⁄4AIBLUD), Milan, Italy, Neonatal Intensive Care Unit, University of Turin, Turin, Italy, Neonatal Intensive Care Unit, S. Chiara Hospital, Trento, Italy, Clinical Nutrition Unit, Bambino Ges u Children’s Hospital, Rome, Italy, Pediatric and Neonatal Intensive Care Units, Bufalini Hospital, Cesena, Italy, Neonatal Intensive Care Unit, A. Meyer Children’s Hospital, Florence, Italy, and Neonatal Intensive Care Unit, Macedonio Melloni Maternity Hospital, Milan, Italy

Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants

Abstract Human milk confers health benefits of vital importance for the sick and preterm infants in neonatal intensive care units (NICUs). Mother’s own milk is the first choice in preterm infant feeding, and every effort should be made to promote lactation. When mother’s milk is not available or is insufficient, donor human milk (DHM) is recommended. Yet, occasionally, the concern that the use of DHM might decrease breastfeeding is being raised. The present data collection planned by the Italian Association of Human Milk Banks (AIBLUD) in collaboration with the Italian Neonatal Network (INN) attempted to address this concern. A total of 4277 very low birth weight (VLBW) infants from 83 Italian NICUs were evaluated for this comparative analysis. The 83 Italian NICUs were divided into two groups: centers with a human milk bank (HMB) and centers without a HMB; the available parameters in the network – “any and exclusive breastfeeding rates” and “exclusive formula rate” at discharge – were compared. Exclusive breastfeeding rate at discharge was significantly higher in NICUs with a HMB than in NICUs without (29.6% vs. 16.0%, respectively). Any breastfeeding 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 report shows that the presence of a HMB and the use of DHM in NICU are associated with increased breastfeeding rate at discharge from the hospital for VLBW infants.

Effect of two pasteurization methods on the protein content of human milk.

The Holder method is the recommended pasteurization method for human milk banks, as it ensures the microbiological safety of human milk (HM). The loss of some biologically active milk components, due to the heat treatment, is a main limit to the diffusion of donor HM. High-temperature short-time (HTST) pasteurization may be an alternative to maintain the nutritional and immunological quality of HM. The aim of the present study was to compare the impact of Holder and HTST pasteurization on the HM protein profile. The protein patterns of HTST-treated milk and raw milk were similar. The Holder method modified bile salt-stimulated lipase, lactoferrin and components of the immune system. The HTST method preserved the integrity of bile salt-stimulated lipase, lactoferrin and, to some extent, of IgAs. Holder pasteurization decreased the amount of bile salt-stimulated lipase and inactivated the remaining molecules, while the HTST method did not alter its activity. Pasteurization increased the bioavailable lysine quantity. HTST pasteurization seems to better retain the protein profile and some of the key active components of donor HM.

Benefits of donor human milk for preterm infants: Current evidence

Its undoubted that optimum nutrition for term infants is breastfeeding, exclusive for the first six months, then followed by a complementary diet and carried on, if possible, for the first year of life or even more. During the last decades several data confirmed the great advantages of fresh mothers milk use also for feeding very low and extremely low birthweight preterm infants. When mothers milk is unavailable or in short supply, pasteurized donor breast milk is widely used in neonatal intensive care units. Pasteurization partially affects nutritional and immunological properties of breast milk, however it is known that pasteurized milk maintains some biological properties and clinical benefits. The substantial benefits of mothers own milk feeding of preterm infants are supported by strong evidence. However, there is increasing evidence also on specific benefits of donor breast milk. Future research is needed to compare formula vs. nutrient fortified donor breast milk, to compare formula and DM as supplements to maternal milk rather than as sole diet and to compare effects of different methods of heat treatments on donor human milk quality.

Effect of prolonged refrigeration on the lipid profile, lipase activity, and oxidative status of human milk.

Objective: The study was aimed at evaluating the effect of prolonged refrigeration of fresh human milk (HM) on its fatty acid profile, free fatty acid content, lipase activities, and oxidative status. Methods: HM from mothers of preterm newborns was collected, pooled, and placed in the neonatal intensive care unit (NICU) refrigerator. Pooled milk was aliquoted and analyzed within 3 hours of collection, and after 24, 48, 72, and 96 hours of storage. The milk samples were analyzed for pH, total and free fatty acid profile, lipase activity at room temperature and at 4°C, lipase activity at room temperature in presence of sodium cholate (bile salt–dependent lipase), total antioxidant capacity, thiobarbituric acid reactive species, malondialdehyde, and conjugated diene concentration. The experiment was replicated in 3 independent trials. Results: Prolonged refrigeration did not affect the fatty acid composition of breast milk, and preserved both its overall oxidative status and the activity of HM lipolytic enzymes. In particular, bile salt–dependent lipase activity, long-chain polyunsaturated fatty acids, and medium-chain saturated fatty acid concentrations were unaffected for up to 96 hours of refrigerated storage. Conclusions: Prolonged refrigeration of fresh HM for 96 hours maintained its overall lipid composition. The limited lipolysis during storage should be ascribed to the activity of lipoprotein lipase, responsible for the decrease in pH. Our study demonstrates that infants who receive expressed milk stored for up to 96 hours receive essentially the same supply of fatty acids and active lipases as do infants fed directly at the breast.

Inactivation of high-risk human papillomaviruses by Holder pasteurization: implications for donor human milk banking.

Abstract Aims: Several studies have recently reported the detection of oncogenic human papillomaviruses (HPV) in human milk of a minority of lactating mothers. These findings raised safety concerns in the context of human donor milk banking given the potential risk of HPV transmission to recipient infants. The aim of this study was to investigate whether the Holder pasteurization, a procedure currently in use in human donor milk banks for milk pasteurization, completely inactivates high-risk and low-risk HPV. Methods: HPV pseudoviruses (PsV) were generated, spiked into cell culture medium or donor human milk and subjected to thermal inactivation. HPV PsV infectivity and morphological integrity was analyzed by cell-based assay and by electron microscopy, respectively. Results: The Holder pasteurization completely inactivated the infectivity of high-risk (types 16 and 18) and low-risk (type 6) HPV both in cell culture medium and in human milk causing PsV particle disassembly. Conclusions: The results presented here indicate that the Holder pasteurization is an efficient procedure to inactivate high-risk and low-risk HPV thus preventing the potential risk of their transmission through human donor milk.

Survey of Italian human milk banks.

Background: At present, the Italian Association of Donor Human Milk Banks (Associazione Italiana Banche del Latte Umano Donato, AIBLUD) consists of 31 milk banks, whose management is based on Italian Guidelines. In 2013, AIBLUD performed a systematic survey to collect data on the activities of banks operating in Italy in the years previous to this date. Objective: The purpose of this survey was to evaluate the operational procedures of Italian Human Milk Banks in order to identify both areas of strength and room for improvement. Methods: A questionnaire was utilized to obtain national data from the 28 banks active in the year 2012 in order to evaluate the number of donors, volume of human milk collected, and other information relating to the period 2007 to 2012. Results: In all, 89% of the banks (25/28) responded to the survey. Data received primarily concerned the number of donors, volume of milk collected, and average amount of milk from each donor in the period 2007 to 2012. It was evident that in 2012 human milk banks collected a higher volume of milk than in 2007. Further, the average amount of milk from each donor was higher. Most of the milk banks were following the Italian Guidelines for traceability, control of donors, bacteriological checks, method of pasteurization, storage, thawing, type of containers, and utilization of the Hazard Analysis and Critical Control Points system. Conclusion: This survey identified both areas of strength and room for improvement in the Italian human milk banks.

Neonatal jaundice and human milk

Breastfeeding is linked both to a greater jaundice frequency and intensity in the first postnatal days (“breastfeeding jaundice”) and to visible jaundice persisting beyond the first two weeks of life (“breast milk jaundice”), but the appearance of skin jaundice is not a reason for interrupting breastfeeding which can and should continue without any interruption in most cases. There have been numerous contributions to the literature, which have rescaled the direct role of breast milk, both in early jaundice and in the more severe cases of late jaundice. In fact, the reviewed guidelines for detection and management of hyperbilirubinemia underline, how prevention of badly managed breastfeeding and early support for the couple mother-child are effective prevention measures against severe early-onset jaundice; furthermore, the breastfeeding interruption is no longer recommended as a diagnostic procedure to identify breast milk jaundice because of its low specificity and the risk to disregarding the detection of a potentially dangerous disease.

Communicative strategies in a neonatal intensive care unit

Counseling is a professional intervention based on skills to communicate and to build relationships. The project ‘Not alone’, related to counseling at our Neonatal Intensive Care Unit, is aimed to let counseling become a ‘shared culture’ for all the care givers. The first essential aspect is to form the ability of counseling through periodic courses for all professionals of the department (physicians, nurses, and physiotherapists). In our department, a professional counselor is present assisting the medical staff in direct counseling. The counselors intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counselor discusses difficult situations to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with diverse situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an ‘algorithm’ that follows a pattern: (1) information always given; (2) frequent questions from parents; and (3) frequent difficulties in the communication. We also need to record important moments, for instance the ‘case history of the communication’: in fact it would be desirable to have the case history, a sheet dedicated to important communications that are absolutely to be shared with other professionals.

Benefits of human milk in preterm infant feeding

Mother’s own milk is widely recognized as the optimal feeding not only for term but also for preterm infants. Evidence documents short and long-term metabolic, immunologic and neurodevelopmental advantages of breastfeeding when compared to formula. Moreover benefits of breastfeeding on psychological and relational aspects have to be considered. In order to meet the unique nutritional requirements of preterm infants and preserve the singular benefit of breastfeeding, human milk should be fortified to allow adequate growth and bone mineralization. Best fortification models are still object of research, in order to obtain a balance between the risk of undernutrition and the metabolic risks of a too rapid catch-up growth. When mother milk is unavailable or in short supply, donor milk (DM) represents the second best alternative and although some nutritional elements are inactivated by the pasteurization process, it still has documented advantages compared to formula. The demonstrated benefits of human milk (HM) highlight the importance of health care professional education in the support of breastfeeding.