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.

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.