Short-Term Outcomes following Standardized Admission of Late Preterm Infants to Family-Centered Care.

OBJECTIVE: The study compares the short-term outcomes of late preterm infants (LPI) at an academic center in San Diego, California after a change in protocol that eliminated a previously mandatory 12-hour neonatal intensive care unit (NICU) observation period after birth. STUDY DESIGN: This is a retrospective observational study examining all LPI born with gestational age 35 to 366/7 weeks between October 1, 2016 and October 31, 2017. A total of 189 infants were included in the review. Short-term outcomes were analyzed before and after the protocol change. RESULTS: Transfers to the NICU from family-centered care (FCC) were considerably higher (23.2%) following the protocol change, compared to before (8.2%). More infants were transferred to the NICU for failed car seat tests postprotocol compared to preprotocol. Length of stay before the protocol change was 5.13 days compared to 4.80 days after. CONCLUSION: LPI are vulnerable to morbidities after delivery and through discharge. We found an increase in failed car seat tests in LPI cared for in FCC after elimination of a mandatory NICU observation after birth. The transitions of care from delivery to discharge are key checkpoints in minimizing complications.

Deciphering macronutrient information about human milk.

Clinicians caring for small, vulnerable newborns increasingly have access to specific nutritional information about human milk through point-of-care analyzers and labeled products. It is critical for clinicians to recognize that there is considerable variability in how human milk nutritional data are derived and reported, which impacts the interpretation of nutritional values, comparison of nutritional data between products, and ultimately the ability to deliver optimal nutritional care. This article distills key issues that will enable clinicians to interpret human milk nutritional labels/analysis more effectively, ultimately allowing them to make better decisions about dietary strategies. We aim to empower clinicians to ask questions about milk sampling techniques, reported nutrient values, analysis techniques, and milk bank pooling practices. This knowledge can put human milk nutrient values in context, improve clinical care, and help to drive more rigorous research for exploring the impact of human milk feeding on infant outcomes.

28 NICUs participating in a quality improvement collaborative targeting early-onset sepsis antibiotic use.

OBJECTIVE: There is widespread overuse of antibiotics in neonatal intensive care units (NICUs). The objective of this study was to safely reduce antibiotic use in participating NICUs by targeting early-onset sepsis (EOS) management. STUDY DESIGN: Twenty-eight NICUs participated in this statewide multicenter antibiotic stewardship quality improvement collaborative. The primary aim was to reduce the total monthly mean antibiotic utilization rate (AUR) by 25% in participant NICUs. RESULT: Aggregate AUR was reduced by 15.3% (p < 0.001). There was a wide range in improvement among participant NICUs. There were no increases in EOS rates or nosocomial infection rates related to the intervention. CONCLUSION: Participation in this multicenter NICU antibiotic stewardship collaborative targeting EOS was associated with an aggregate reduction in antibiotic use. This study informs efforts aimed at sustaining improvements in NICU AURs.

Experience of Induced Lactation in a Transgender Woman: Analysis of Human Milk and a Suggested Protocol.

Background: A growing number of diverse familial structures wish to colactate their infant. For transgender and gender diverse (TGD) individuals, chestfeeding or breastfeeding may be within their goals of parenthood. There is limited evidence on how to induce lactation for a nongestational parent on gender affirming estrogen treatment. Case Presentation: We report the case of a transgender woman who successfully underwent lactation induction following a protocol using the galactogue domperidone plus use of a breast pump. The patient had modifications to her hormone therapy with estrogen and progesterone while remaining on antiandrogen therapy with spironolactone. A description of the protocol, medications, laboratory monitoring, human milk analysis including macronutrients, oligosaccharides, and hormones is presented. Discussion: This is the fourth case to date known in the literature of a transgender woman with successful lactation induction, and the third case to remain on antiandrogen therapy during this process. Our report is the second to demonstrate comparable macronutrients, and the first to report on human milk oligosaccharides and hormones in induced milk compared with term human milk of a gestational parent. Conclusions: The opportunity to chestfeed or breastfeed an infant can be profound for many parents. Further research is needed to meet the needs of TGD individuals who wish to induce lactation as part of their parental goals.

Validating Tools to Detect and Inactivate Monkeypox Virus in Human Milk.

Objectives: Breastfeeding and human milk (HM) improve maternal and infant morbidities and mortality. Therefore, monitoring the safety of breastfeeding and access to HM is of critical importance. In this study, we assessed tools to monitor the presence of monkeypox virus (MPXV) in HM and whether standard Holder pasteurization inactivates MPXV. Materials and Methods: Heat-inactivated MPXV was added to HM or viral transport media (VTM) and analyzed using both research and clinical MPXV quantitative polymerase chain reaction (qPCR) tests. Infectious MPXV was added to HM and was exposed to 1 cycle of freeze-thaw, incubation for 1 hour at room temperature, or conditions of Holder pasteurization (62.5°C for 30 minutes) followed by infectious unit quantification by plaque assay. Results: Research and clinical nucleic acid tests detect MPXV that was added to HM but with reduced sensitivity compared with equivalent samples in VTM at low virus inoculum. MPXV added to HM to achieve a starting concentration of 225,000 plaque forming units (pfu)/mL remains infectious after freeze-thaw or 1 hour storage at room temperature. However, Holder pasteurization reduced infectious virus below the limit of detection, >2,000-fold reduction in viral titer. Conclusion: MPXV can be detected when added to HM using a clinical laboratory-developed qPCR test without modification, but the detection limit is reduced compared with equivalent samples in VTM. MPXV remains viable in HM should the virus ever gain access to HM, but Holder pasteurization reduces infectious MPXV to below detection limits and can be used to reduce the risk of MPXV transmission to infants who receive pasteurized (donor) HM.

Human Milk SARS-CoV-2 Antibodies up to 6 Months After Vaccination.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific antibodies have been detected in human milk up to 6 weeks post-coronavirus disease 2019 (COVID-19) vaccination. We evaluated SARS-CoV-2-specific antibodies, neutralization activity, effect of pasteurization, and persistence through 6 months after vaccination. METHODS: This prospective longitudinal study enrolled 30 pregnant or lactating women. SARS-CoV-2 antibodies and neutralization capacity were analyzed using an enzyme-linked immunosorbent assay compared at prevaccination and 1, 3, and 6 months postvaccination, and through Holder pasteurization. RESULTS: Human milk SARS-CoV-2-specific IgG levels peaked at 1 month postvaccination and persisted above prevaccination levels for at least 6 months (P = .005). SARS-CoV-2-specific IgA was detected at 1 and 3 months (both P < .001) but waned by 6 months compared with baseline (P = .07). Milk SARS-CoV-2-specific IgG and IgA correlated with serum IgG at the same time point (R2 = 0.37, P < .001 and R2 = 0.19, P < .001). Neutralization activity was seen in 83.3%, 70.4%, and 25.0% of milk samples at 1, 3, and 6 months postvaccination. Neutralization most strongly correlated with SARS-CoV-2-specific IgG (R2 = 0.57, P < .001). Pre- and postpasteurization samples showed similar IgG (0.84 vs 1.07, P = .36) and neutralizing activity (57.7% vs 58.7% inhibition, P = .27), but lower IgM and IgA levels postpasteurization (0.09 vs 0.06, P = .004 and 0.21 vs 0.18, P = .043). CONCLUSIONS: The data suggest that human milk SARS-CoV-2-specific antibodies may be available to milk-fed infants for up to 6 months. In addition, donor milk from vaccinated mothers retain IgG and neutralizing activity.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant.

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Pooling expressed breastmilk to provide a consistent feeding composition for premature infants.

OBJECTIVE: We hypothesized that pooling a mother's expressed breastmilk for 24 hours compared with individual pump session collection of milk would provide a more consistent caloric product without increasing bacterial contamination. STUDY DESIGN: We investigated 24-hour pooled breastmilk collection by enrolling 19 mothers who were expressing milk for their infants. Mothers followed a standardized milk collection protocol for 4 study days: daily milk was pooled in a sterile 1-L bottle on Day 1, and on Day 2 milk was aliquoted for each pump session into a sterile 120-mL container. The next week the order of collection was reversed. Milk samples were plated, incubated, and evaluated for bacteria colonization. Milk samples were analyzed for protein, fat, and carbohydrate content. RESULTS: There was inherently less variability in the caloric and nutrient content of pooled milk compared with individual samples, in which caloric density varied by as much as 29%. Mother's milk had highly variable bacterial counts ranging from 0 to greater than 100,000 colonies/mL. High bacteria counts (>100,000 colonies/mL) occurred in 14.7% (31 of 211) of individual samples compared with 8.6% (three of 35) of pooled samples (p=0.39). CONCLUSIONS: Twenty-four-hour pooling of human milk reduces nutrient and caloric variability without increasing bacterial counts.

Challenges in the practice of human milk nutrition in the neonatal intensive care unit.

The use of human milk for preterm infants has increased over the past decade reflecting an improved awareness of the benefits of human milk. Inherent in this paradigm shift is the recognition that human milk is a living tissue; full of immune cells, probiotics and hundreds of compounds that confer bioactivity and immune protective properties. Together these factors deliver a powerful effect in reducing clinical morbidities such as necrotizing enterocolitis and sepsis in the preterm infant. However, as breastfeeding is not possible for the very premature infant, human milk needs to be introduced in the neonatal intensive care unit through alternative means, resulting in significant handling and manipulation of maternal milk. This presents risks in quality control and provision of optimal nutrition delivery. Therefore, a comprehensive approach to standardizing preterm infant nutrition is essential to optimize the collection, storage, fortification and delivery of human milk to preterm neonates. In this paper we discuss the challenges presented by supporting human milk nutrition, and the rationale for the development of the Supporting Premature Infant Nutrition (SPIN) program at our institution.

Transmission of meropenem in breast milk.

A case is presented of a breast-feeding mother receiving meropenem treatment for a postpartum urinary tract infection caused by extended-spectrum beta-lactamase producing Escherichia coli. Five milk samples were collected in a 48-hour period during meropenem therapy. The average and maximum meropenem concentrations in milk were 0.48 and 0.64 µg/mL, respectively. Based on the maximum concentration, the calculated infant daily exposure from breast milk was 97 µg/kg/d, and the infant weight-adjusted percentage of maternal dosage was 0.18%. There were no dermatologic or gastrointestinal side effects noted in the breastfed infant. Meropenem appears to be acceptable to use during breast-feeding.

Breast milk hydrocodone and hydromorphone levels in mothers using hydrocodone for postpartum pain.

OBJECTIVE: To estimate the extent of passage of hydrocodone and its active metabolite, hydromorphone, into breast milk. METHODS: This is a pharmacokinetic study of 30 postpartum women receiving hydrocodone bitartrate for postpartum pain in the inpatient setting. Mothers donated timed breast milk samples for the analysis of hydrocodone and hydromorphone. RESULTS: Fully breastfed neonates received 1.6% (range 0.2%-9%) of the maternal weight-adjusted hydrocodone bitartrate dosage. When combined with hydromorphone, the total median opiate dosage from breast milk is 0.7% of a therapeutic dosage for older infants. Most mothers excreted little to no hydromorphone into breast milk. CONCLUSION: Standard postpartum dosages of hydrocodone bitartrate appear to be acceptable to use in women nursing newborns. Prolonged use of high dosages is not advisable.