What Nurses Need To Know Regarding Nutritional and Immunobiological Properties of Human Milk

Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice

Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.

Use of test weights for breastfeeding infants with congenital heart disease in a cardiac transitional care unit: a best practice implementation project

OBJECTIVES

The goal of this project was to promote breastfeeding among infants with congenital heart disease in a quaternary care academic children's hospital. We aimed to increase the total number of breastfeeding episodes among all patients in the Pediatric Cardiac Transitional Care Unit with implementation of pre- and post-breastfeeding (test) weights.

INTRODUCTION

Infants with congenital heart disease are able to breastfeed, but are often not encouraged to do so by healthcare providers. Fears and concerns relating to the inability to account for exact intake volumes through breastfeeding often prevent providers from supporting breastfeeding in these patients.

METHODS

This project used Joanna Briggs Institute's Practical Application of Clinical Evidence System (JBI PACES) and Getting Research into Practice (GRiP) audit tool for promoting health practice change. A baseline medical record audit was conducted, followed by staff nurse education on breastfeeding test weights and the development of a parent education program. One follow-up audit measured compliance with best practice criteria for using breastfeeding test weights in infants with congenital heart disease.

RESULTS

Compliance rates for use of breastfeeding test weights and provision of parent education, with baseline rates of 7% and 0%, respectively, rose to 90%. Identification of maternal intent to breastfeed upon admission to the unit increased to 78% compliance from 0%. Eighty-four percent of healthcare staff were educated on breastfeeding test weights.

CONCLUSIONS

The safety of breastfeeding very ill infants was established. Breastfeeding episodes of all patients in the unit significantly increased after implementation of breastfeeding test weights and mothers of the sample patients expressed more confidence in breastfeeding their sick infants. Although barriers to breastfeeding for patients with congenital heart disease still persisted, this project had a positive impact on the culture of breastfeeding within the project unit. Increased healthcare provider education on breastfeeding will be essential to sustaining outcomes of this implementation.

Human Milk and Breastfeeding Outcomes in Infants With Myelomeningocele

BACKGROUND

In 2015, the study setting instituted an enteral feeding pathway, "PO Ad Lib Feeding to Support Breastfeeding." Many infants admitted to the study setting's newborn/infant intensive care unit with a primary diagnosis of myelomeningocele fall within the setting's enteral feeding pathway's inclusion criteria.

PURPOSE

The primary objective of this study is to describe the enteral feeding exposure and trends, by type and method, among infants with myelomeningocele.

METHODS

Retrospective descriptive cohort design. Participants were infants with a primary diagnosis of myelomeningocele between 2013 and 2016. The electronic health record was used to collect descriptive data (demographics and daily enteral feeding exposure). Data were analyzed using descriptive statistics.

FINDINGS/RESULTS

More than 80% (n = 148, 81.3%) of the participants' mothers had a personalized prenatal nutrition consultation and the majority of those mothers (n = 102/118, 86.4%) had a goal to breastfeed for more than 6 months. The majority (n = 144/182, 79.1%) of the study cohort was exposed to mothers' own human milk as their first feed. It is also notable that 80.8% (n = 147) fed at least once directly at the breast; however, infants were also fed by bottle or by feeding tube.

IMPLICATIONS FOR PRACTICE

It demonstrates that with appropriate evidence-based breastfeeding interventions, mothers having infants with myelomeningocele can expect to feed their infants human milk as well as direct breastfeed.

IMPLICATIONS FOR RESEARCH

Future research should focus on human milk/breastfeeding outcomes of infants with myelomeningocele post-hospital discharge. Long-term breastfeeding may have an important role in the development of infants with myelomeningocele.

Physiology of Stress and Use of Skin-to-Skin Care as a Stress-Reducing Intervention in the NICU

Advances in neonatal care have allowed for the increasing survival of critically ill infants. These infants experience significant stress related to painful procedures and physical separation from their parents. The purpose of this article is to describe the physiologic stress mechanisms that contribute to mortality and morbidity in infants in the NICU and the physiologic mechanisms by which skin-to-skin care (SSC) acts on the stress response system. Findings from current literature supporting the use of SSC and barriers and facilitators to implementation are reviewed. SSC is a safe and effective intervention to reduce stress for infants and their parents. Nurses play a key role in facilitating SSC to optimize outcomes of care in the NICU.

Human milk and breastfeeding: An intervention to mitigate toxic stress

The American Academy of Nursing has identified toxic stress in childhood as a health policy concern of high priority. Adult diseases (e.g., obesity, diabetes, hypertension and cardiovascular disease) should be viewed as developmental disorders that begin early in life that could be reduced with the alleviation of toxic stress in childhood. The provision of human milk/breastfeeding is an evidence-based intervention that may hold the greatest potential to mitigate the effects of toxic stress from the moment of birth. Assisting families to make an informed choice to initiate and continue breastfeeding from birth has the potential to address both the disparity in the quality of nutrition provided infants and the economic stress experienced by families who purchase formula. The Expert Panel on Breastfeeding endorses initiatives to improve the initiation, duration, and exclusivity of breastfeeding to mitigate the effects of toxic stress in this call to action for research to build the evidence to support these critical relationships.

Health Professionals' Attitudes and Beliefs About Breastfeeding

The aim of this descriptive study was to investigate how health-care providers perceived their role in breastfeeding and maternal support. Data was collected via interviews of 53 health-care professionals that provided care to breastfeeding women. The emerging themes included (a) understanding the benefits of breastfeeding: often lacking current knowledge, (b) lacking consistency: gaps between knowledge of benefits and actual clinical practice, (c) not knowing how to help: lack of assessment and therapeutic skills, and (d) understanding the barriers to breastfeeding: how health-care providers can make a difference. Data analysis suggests inconsistencies between the health-care provider's perceived support and behaviors, lack of knowledge, and significant lack of skill in the assessment and management of breastfeeding couples.

Nutritional and immunological considerations relevant to infant nutrition

Optimal nutrition during infancy is critical not only to support the dramatic growth and development that takes place during the first 12 months following birth but also for establishing a healthy immune response throughout childhood and across the life span. The normative standards for infant feeding and nutrition are breast-feeding and human breast milk. However, in cases in which human breast milk is not available, infant formula is substituted. Providing optimal patient care that results in the best clinical outcomes depends on understanding the unique attributes of the 3 main sources of nutrition for newborns. This state of the science review provides an update on the macronutrient and immunological content of human milk, donor milk, and infant formula and highlights the relevance of these sources of infant nutrition on the development of immune system.

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.

Innovations in the provision of human milk and breastfeeding for infants requiring intensive care

Infant admission to the Neonatal Intensive Care Unit requires that the family receives the scientific rationale for the importance of providing human milk for their child. The initiation and maintenance of maternal milk supply must be a priority. Understanding variation in milk composition is crucial so that the infant receives the most appropriate milk throughout the hospital stay. For mothers who wish to breastfeed, a detailed and planned process is essential to ensure success.