2019 Research Forum

Donor Breastmilk Supplementation and Breastfeeding Rates Jasmine Nunez RN, Stephanie Cebreros RN, Monique Lugo RN Kern Medical: Pediatric Unit & Neonatal Intensive Care Unit (NICU)

MATERIALS & METHODS

INTRODUCTION

CONCLUSIONS

Donor milk Kern Medical utilizes 2 human donor milk banks: Prolacta and Mother’s Milk (aka San Jose Milk). Prolacta and Mother’s Milk are milk banks that processes its donations through a rigorous and sterile pasteurization process. The difference between the two is that Prolacta is a calorie specific product and used for premature infants in the neonatal intensive care units (NICU)(Prolacta Bioscience, 2108); Mother’s Milk is not as calorie specific as Prolacta but according to Mother’s Milk Bank (2018) the product can be used for both infants born at term and prematurely. KM Donor breastmilk policy Kern Medical (2018) established a policy for using human donor milk and setting specific rules for staff to abide by on the mother/ baby units and in the NICU. The protocol itself, titled “Pasteurized Human Donor Breast Milk and/or Human Milk Based Products, The Use of” (2018), allows for clear instructions on how to store, prepare, distribute the donor breast milk and also provides eligibility criteria for the use of donor milk as a feeding option for infants. Also, because donor breastmilk is considered a “tissue”, both types of donor breastmilk require a consent form to be discussed and completed with the patients parent(s) along with having 2 RN witnesses prior to the patients use of this feeding alternative. Breast Feeding Rates The implementation of donor milk was started in July 2018. Prior to starting donor milk, breastfeeding rates were being tracked and compared to the use of formula feeding through the use of the “Newborn Discharge Document” note in CareVue. This documentation note helps with the collection of data regarding the type of feeding chosen for that infant (e.g. Breastfeeding, formula, or combination of both). Breastfeeding rates/percentages during hospital stay from January 2018 through June 2018 were tracked with the exception of March 2018 and July 2018; The months of March and July were missing the formula feeding data, but were still included since the percentages for exclusively breastfeeding was documented. During the months of January through November of 2018, the data values for mothers who plan to breastfeed only, plan to formula feed only, plan to do both, and the actual outcome for each were also tracked and compared. The data collected for this project is what is significant in determining if the use of donor milk improves strictly breastfeeding. The total eligible deliveries were first calculated, then this data was broken down to patients who were exclusively breast, exclusively formula, or took any amount of breastfeeding (could be a combination). The data obtained was converted to percentages and tracked until start of donor milk. Once donor milk was initiated, this data was/still is monitored but now with the inclusion of the donor milk. In July 2018, the hospital implemented the use of donor milk to postpartum, pediatrics, and neonatal ICU. The same variables as mentioned continued to be tracked. The only difference now was that donor milk was being tracked for patients who were offered use of donor milk, patient’s who accepted, and patients who declined. Between the patients who were offered and accepted, data was tracked for patients who fed with donor milk until discharge vs patients who initially accepted but eventually gave formula prior to discharge. The results will be further explained with the graphs shown below.

The findings of this research project indicates that breastfeeding rates has overall increased since July 2018 with the introduction of donor breast milk supplementation at Kern Medical. Prior to donor breast milk being utilized at our facility, breastfeeding rates were already slightly higher than formula feeding rates. However, after donor breastmilk was introduced, there was a large increase of mothers who continued to solely breastfeed at the time of discharge. The increase in mothers wanting to breastfeed can be linked to the alternative option of donor breastmilk supplementation made available until the mothers own milk was well established. Donor breastmilk allows mothers to continue to give their infants the best nutrition until their own milk supply is produced enough for the infants feeding demand and has also helped keep their goal of breastfeeding their infant.

Kern Medical has introduced a breastfeeding (BF) alternative to mothers to help promote, facilitate, and support breastfeeding on the Maternal Child units. Our cohort has decided to review the literature and study the process of donor breastmilk as an alternative to formula and identify any barriers to donor milk. PICO Question: Does introducing donor breast milk supplementation improve breastfeeding rates compared to formula supplementation? What is donor milk? Donor milk is defined as breast milk expressed by a mother that is then processed by a donor milk bank for use by a recipient that is not the mother's own baby. Kern Medical (KM) has two suppliers for donor milk - San Jose: Mother’s Milk Bank- Located in Valley Medical Center in San Jose CA and Prolacta Bioscience. Both milk banks use state of the art testing, screening and standardized production process. Types of mothers who would benefit from donated milk: • Premature infants • Infants failing to thrive on formula • Infants facing life threatening diseases or conditions. • Mothers who can’t keep up the milk supply to nourish multi- birth babies. • Mothers who are producing enough milk during the first week of life.

RESULTS

Graph #2

REFERENCES

Graph #1

1. Arslanoglu, S., Moro,G., Bellù,R.,etal. (2012). Presenceofhumanmilkbank isassociatedwithelevated rateof exclusivebreastfeeding inVLBW infants. JournalofPerinatal Medicine,41(2), pp. 129-131.Retrieved 7Nov. 2018, fromdoi:10.1515/jpm-2012-0196 2. Bradford, V., Walkinshaw, L., Steinman, L.,Otten, J., Fisher,K., Ellings,A.,… Johnson, D. (2017). Creating Environments to SupportBreastfeeding: TheChallengesand FacilitatorsofPolicyDevelopment inHospitals, Clinics,EarlyCareand Education,andWorksites. Maternal &ChildHealth Journal,21(12), 2188–2198. https://doi.org/10.1007/s10995-017-2338-4 3. Center forDiseaseControl andPrevention. (2018). BreastfeedingReportCardUnited States,2018. Retrieved from https://www.cdc.gov/breastfeeding/ 4. Committee Opinionno. 570. (2013). Breastfeeding inunderservedwomen: Increasing initiationandcontinuation ofbreastfeeding. Obstetrics &Gynecology,122(2 part 1), 423–427. https://doi.org/10.1097/01.AOG.0000433008.93971.6a 5. Costa, S.,Maggio, L.,Alighieri,G., Barone, G.,Cota, F., &Vento,G. (2018). Toleranceofpreterm formulaversus pasteurizeddonorhumanmilk inverypreterm infants:a randomizednon-inferiority trial. Italian Journalof Pediatrics, 44(1), N.PAG. https://doi.org/10.1186/s13052-018-0532-7 6. Hongo, H., Nanishi,K., Shibanuma,A.,& Jimba,M. (2015). IsBaby-FriendlyBreastfeeding Support inMaternity HospitalsAssociatedwithBreastfeeding SatisfactionAmong JapaneseMothers? Maternal &ChildHealth Journal,19(6), 1252–1262. https://doi.org/10.1007/s10995-014-1631-8 7. Kellams,A. L.,Gurka,K.K., Hornsby,P.P., Drake, E.,Riffon,M.,Gellerson,D., …Coleman,V. (2016). The Impactof aPrenatal EducationVideoonRatesofBreastfeeding Initiationand Exclusivityduring theNewbornHospital Stay ina Low-incomePopulation. Journal ofHuman Lactation, 32(1), 152–159. https://doi.org/10.1177/0890334415599402 8. KernMedical. (2018). Pasteurized HumanDonor BreastMilkand/orHumanMilkBasedProducts, TheUseof. 9. Mother’s MilkBank (2018). Retrieved from http://www.mothersmilk.org 10. Nelson,M. M. (2013). The BenefitsofHumanDonorMilk forPreterm Infants. International JournalofChildbirth Education, 28(3), 84–89.Retrieved from http://falcon.lib.csub.edu:2048/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=1042 09191&site=ehost-live 11. Panczuk, J.,Unger, S.,O’Connor, D.,& Lee, S.K. (2014). Humandonormilk for the vulnerable infant:aCanadian perspective. International Breastfeeding Journal,9(1), 1–10. https://doi.org/10.1186/1746-4358-9-4 12. Parker,M.G.K., Burnham, L., Mao,W., Philipp,B. L.,&Merewood,A. (2016). ImplementationofaDonorMilk Program IsAssociatedwithGreaterConsumptionofMothers’OwnMilkamong VLBW Infants inaUS, Level3 NICU. JournalofHuman Lactation, 32(2), 221–228. https://doi.org/10.1177/0890334415598305 13. Prolacta BioScience. (2018). Retrieved from http://www.prolacta.com 14. Requejo, J., &Black,R. (2014). Strategies for reducingunnecessary in-hospital formula supplementationand increasing ratesofexclusivebreastfeeding.J ournal ofPediatrics, 164(6), 1256–1258. https://doi.org/10.1016/j.jpeds.2014.03.012 15. Sriraman,N.K., &Kellams,A. (2016). Breastfeeding:What are theBarriers?WhyWomen Struggle toAchieve Their Goals. Journal ofWomen’sHealth (15409996), 25(7), 714–722. https://doi.org/10.1089/jwh.2014.5059 16. Williams, T., Nair,H., Simpson, J.,& Embleton,N. (2016) . UseofDonorHumanMilkand Maternal Breastfeeding Rates:A SystematicReview. JournalofHuman Lactation, 32(2), 212– 220. https://doi.org/10.1177/0890334416632203

Graph #1 is a line graph that shows the percentages over the 11 month span of tracking total exclusive breastfeeding, exclusive formula feeding, and giving any amount of breastfeeding. Result: As you can see, exclusive breast has always been higher than the exclusive formula feeds. But both have been surpassed by the “any amount of breastfeeding line” which includes some formula feeds as well. If you look at where the implementation of donor milk began, you can see an elevation of exclusive breastfeeding. Which shows us that donor milk is increasing the likelihood of mothers to breastfeed their babies. We would like to see the breastfeeding line continue to increase while the formula feed line decreases. With that outcome we expect the 3 rd (any breastfeed line) to decrease since exclusive breastfeed will rise.

Graph #2 is a bar graph which shows the patients who accepted donor milk: continued use until discharge vs giving formula at any point between accepting and discharge. Results: With this graph we tracked the months since starting donor milk, August to November. Use of donor milk is relatively high compared to giving formula. Slight fluctuations are noted, but not significantly enough to rule out what the benefits of using donor milk have on mother continuing to breastfeed.

Graph #5

Graph #4

Graph #3

Graphs #3, #4, and #5 shown below are a set of graphs that correlate to each other. They show the values for plan to breastfeed only, plan to formula feed only, plan to do both, and the actual outcome for each. Results: The more prominent results here are the planned to breastfeed vs. the outcome. As you can see a great number of patients ended up breastfeeding compared to the ones who planned to do so originally. There was a great increase of actual breastfeeding that resulted, and we can feel confident that a lot of it has to do with implementation of donor milk and the education that comes along with it. The downside is that the second graph also shows a slight increase in actual formula fed babies than originally planned, but equals out for the months of October and November. But, when looking at the 3rd graph (planned to both breastfeed and formula feed), the number who planned to do both did actually decrease at the end. This was expected since we did have more who ended up actually breastfeeding than planned or expected, as shown in the first graph.

OBJECTIVES

• Review the current literature on breast feeding and donor milk • Discuss and review Kern Medical’s donor milk policy • Identify current methods for obtaining breast feeding rates and formula feeding rates at Kern Medical • Identify barriers to breastfeeding • Share results of our findings with colleagues at Kern Medical Maternal Child department.

Barriers to Breastfeeding Common barriers to BF were identified and discussed with lactation nurses at KM and it was concluded that education was a key and vital part to improving BF rates along with the use of donor milk. To support this conclusion, a study done by Nastasha Sriraman and Ann Kellams (2016) identified barriers to BF and the many struggles mothers face to achieve their BF goals. In the study Sriraman and Kellams (2016) mentioned that mothers make the decision on how they will feed their baby before conception and/or during pregnancy, making education on BF significantly important to successful BF rates and continuation. Properly educating mothers on the benefits of breastfeeding, breastmilk and the use of donor milk supplementation-- as a opposed to formula-- would, in theory, also help increase BF rates. Some of the other barriers noted to be related to poor BF success includes aspects such as the mothers’ own perception of her milk supply, her support system at home/work, societal influences, limited financial resources, the physiology of the mother's nipple, or infant’s oral anatomy (ie “tongue-tie”, cleft lip), infantile jaundice, NICU admission, and certain treatments for mother or infant. All of these barriers are just a few that were identified or observed on the pediatric unit and NICU.

Diane Nicholls, RN/NP – NICU Kern Medical Pamela Gavin, RN – Nurse Residency Coordinator Kern Medical ACKNOWLEDGEMENTS

Janet Barrett, RN- Lactation Consultant Maternal & Child Services Kern Medical Lisa Elswick, RN - Lactation Consultant II, Maternal & Child Services Kern Medical Eva Flanagan, RN – Clinical Supervisor NICU/Pediatrics/Post-Partum Kern Medical Marinda DuToit, RN – Director Maternal Child Services Kern Medical

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