|Year : 2022 | Volume
| Issue : 5 | Page : 682-686
Effect of human milk banking on immediate neonatal morbidity and mortality: A study in a tertiary care center
Shailaja Vijaykumar Mane, Shradha Salunkhe, Sharad Agarkhedkar, Priyanka Lakhwani, Sudhir Malwade
Department of Paediatrics, Dr. D.Y Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Dr.D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||15-Dec-2020|
|Date of Decision||09-Aug-2021|
|Date of Acceptance||24-Oct-2021|
|Date of Web Publication||04-Oct-2022|
Department of Pediatrics, Dr. D. Y. Patil Medical College Hospital and Research Center, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Human milk banking (HMB) is a service established for collection, screening, processing, storage, and distribution of donated human milk. HMB is the best way of ensuring a safe supply of human milk to all the needy neonates. It helps to decrease infections, neonatal sepsis, and necrotizing enterocolitis, thus reduces neonatal morbidity and mortality. Methodology: This is a short-term student research project conducted as an observational, comparative, cross-sectional study. It was conducted in the neonatal intensive care unit (NICU) and HMB of a tertiary care hospital in a metropolitan city, conducted after approval from the Ethics Committee of the Institute. A total of 50 neonates from the NICU who had received pasteurized donor human milk (PDHM) were enrolled in one group (Group I – PDHM). The data of 50 newborns from NICU of the same institute were also collected retrograded for comparison before the establishment of HMB, as they had not received PDHM and enrolled in another group (Group II – non-PDHM). Results: It was observed that in Group I (PDHM), 55% of neonates were full term and 42.5% were preterm, and in Group II, 45% were full terms and 57.5% were preterm. Sepsis was seen in 30% of Group 1 and 54% of Group 2 and hyperbilirubinemia was seen in 22% of Group 1 and 42% of Group 2. There was a 24% decrease in sepsis and 20% decrease in hyperbilirubinemia in PDHM group. Mortality was seen in 40% of Group 1 and 60% of Group 2. A decrease in mortality was seen in PDHM group. Conclusions: HMB is imperative for the reduction of neonatal morbidity and mortality. It is a feasible, cost-effective option and a boon for neonates, particularly in developing countries like India.
Keywords: Human milk banking, mortality, neonatal morbidity
|How to cite this article:|
Mane SV, Salunkhe S, Agarkhedkar S, Lakhwani P, Malwade S. Effect of human milk banking on immediate neonatal morbidity and mortality: A study in a tertiary care center. Med J DY Patil Vidyapeeth 2022;15:682-6
|How to cite this URL:|
Mane SV, Salunkhe S, Agarkhedkar S, Lakhwani P, Malwade S. Effect of human milk banking on immediate neonatal morbidity and mortality: A study in a tertiary care center. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Nov 26];15:682-6. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/682/357776
| Introduction|| |
Neonatal morbidity and mortality are public health challenges all over the globe, with 3.1 million neonatal deaths worldwide yearly. In India, approximately 1.72 million children die annually before reaching their first birthday, which is highest for any country in the world. Out of these, 72% die during the neonatal period. India contributes to one-fifth of global live births and more than a quarter of neonatal deaths in the world. WHO ascertains that breastfeeding is the most effective way for preserving child health and survival.
Breast milk is an optimum and exclusive source of nutrition for neonates. Breast milk is the excellent source of nutrition for the first 6 months of life (WHO) and may remain part of the healthy infant diet for the first 2 years of life and beyond. Human milk is species specific, and thus, it is superior to all the alternatives available for neonatal feeding. Human milk is important for overall development of the baby. Mother's milk has many advantages like it ensures optimum health and helps in the development of immune function at minimal cost of the family.,
Human milk banking (HMB) is a service established for collection, screening, processing, storage, and distribution of donated human milk. Pasteurized donor human milk (PDHM) from the milk bank shows a decreased risk of necrotizing enterocolitis (NEC) which remains a disease of high morbidity and mortality with long-term effects associated with formula feeding. The chances of infections such as sepsis and meningitis in newborns decrease with the use of PDHM. Therefore, the rate and duration of hospitalization of premature infants are reduced. HMB is the best way of ensuring a safe supply of human milk to all the needy neonates. WHO and UNICEF have made a joint statement: “Where it is not possible for the biological mother to breast feed, the first alternative, if available, should be the use of human milk from other sources. Human milk banks should be made available in appropriate situations.” HMB is needed for the proper nutrition of the neonate by being a consistent source of nutrition to the needy babies, especially the ones in neonatal intensive care units (NICUs).
| Methodology|| |
This is an observational, cross-sectional, comparative, short term student (STS) research study conducted in the NICU and HMB of a tertiary care center for a period of 3 months. The approval was obtained from the Ethics Committee of the Institute. A total of 50 neonates from the NICU were enrolled in the study after written informed consent from their parents. The study pro forma included demographic data, antenatal history, gestational age of newborns, mode of delivery, and postnatal history with details of feeding along with their course of illness, duration of hospital stay, etc. The preterm and term neonates admitted in NICU and who received PDHM from HMB of the hospital were included. Neonates who had not received PDHM, terminally ill babies, and neonates with congenital abnormalities and chromosomal anomalies were excluded from the study. Similar retrograde data were collected from the NICU of the same institute before the foundation of HMB for comparison. The records of case papers were collected for the similar duration of 3 months.
In NICU, various parameters such as birth weight, gestational age, gender, condition on admission, provisional diagnosis, and course of the illness were noted. Details of feeding such as initiation, duration, quantity of PDHM given per day, and feed tolerance were observed. After starting oral feeding with small quantities to the sick new-borns like NEC, sepsis, hyperbilirubinemia, hypoglycaemia etc.; duration taken to start full-feeding was noted. Final diagnosis along with weight on discharge was recorded.
Data were divided into two different groups for the purpose of analysis and comparison.
- Group I (PDHM): Study Group: Neonates who received PDHM from HMB
- Group II (Non-PDHM): Data of neonates on mixed feeds (top milk, formula feed, and breast milk) before the establishment of HMB in the same institute. They could not receive PDHM.
Data were entered into Excel sheet and analysis was done using SPSS software IBM Corp. Released 2016. (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp).
| Results|| |
This study [Table 1] shows 50 neonates were included from the NICU who had received PDHM feeds, i.e. Group I. The other Group II of 50 neonates was of newborns who could not receive PDHM. The data analysis was done for the results using SPSS software. The main indication of feeding PDHM in Group I was insufficient maternal milk (82%). The other causes were mother in the intensive care unit (ICU), breast abscess, inverted nipples, and maternal death. It was observed that majority of neonates belonging to Group I were fullfed by the end of 2 days, whereas in Group II by 1 day, but it was not statistically significant (P > 0.05). The [Table 2] shows mean weight at birth and at discharge was higher in Group I than Group II but was not statistically significant (P > 0.05). [Table 3] shows that there was a 24% decrease in neonatal sepsis and 20% decrease in hyperbilirubinemia which was statistically significant. It is observed in [Table 4] that there is a decrease in mortality in Group I, but it is not seen statistically significant.
|Table 2: Comparison of weight at birth and discharge in Group I and Group II|
Click here to view
| Discussion|| |
In this STS, observational, cross-sectional, and comparative study, the following findings were noted. The order of occurrence of morbidities in the PDHM group was low birth weight (LBW) (58%), Respiratory Distress Syndrome (RDS) (50%), and sepsis (30%), hyperbilirubinemia (22%), perinatal depression (16%), transient tachypnea (6%), intrauterine growth restriction (IUGR) (4%), and NEC (2%). In the non-PDHM group, it was LBW (68%), sepsis (54%), hyperbilirubinemia (42%), RDS (36%), IUGR (14%), transient tachypnea (14%), perinatal depression (8%), NEC (4%), and HIE (4%). In various studies, the donor human milk from HMB had beneficial effects on neurodevelopmental outcomes, risk of sepsis, risk of NEC, tolerance of feedings, length of stay in the NICU, and direct cost savings.,,,,,,,,,,,,
It was observed that 54% of neonates in non-PDHM group developed sepsis as compared to 30% in PDHM group which was statistically significant (P < 0.05). Similar observations were reported by Schanler et al. and Hylander et al. It could be due to immunologic strength of human milk and the comparatively advanced hygiene practices followed in the NICU. Pasteurized HM is known to retain many beneficial and protective components of fresh HM. A statistically significant difference P < 0.05 was observed in the occurrence of hyperbilirubinemia. It was found 20% more in the non-PDHM group than the PDHM group. Similarly in the study by Chang et al., supplementary feeding with human milk can prevent severe weight loss that leads to hyperbilirubinemia. Breastfed infants are at a higher risk for developing severe hyperbilirubinemia when compared to formula-fed infants, but the known risks of acute bilirubin encephalopathy are very small when weighed against the substantial known benefits of breastfeeding., Support of the breastfeeding mother by individuals having knowledge increases the frequency and duration of breastfeeding. The amount and timing of feeds of PDHM calculated according to the weight of the baby may lead to a decrease in hyperbilirubinemia.
In this study, the occurrence of NEC was equal in both the groups. One case in each group was reported. A meta-analysis of data from five trials demonstrated a significantly higher incidence of NEC in formula-fed infants. Similar reports were seen in studies by Boyd et al., McGuire et al., in 2003, and Bhoomika et al. Adhisivam et al. in their study found that the incidence of NEC was 1.26% of live births pre-HMB when compared with 1.07% post-HMB.
In about 82% of neonates, insufficient maternal milk was the major reason for giving PDHM followed by mother in ICU (10%), breast abscess (4%), maternal death, and inverted nipple 1% each. Decrease in the mortality rate is seen in PDHM group, similarly in the study by Dr. Rajshree Katke et al. It was not statistically significant in this study which may be due to the small sample size.
In this study, 22% of neonates in the PDHM group were full-fed by day 2, whereas 36% in the non-PDHM group were full-fed by day 1, which was contrary in compared to the study by María Isabel Utrera Torres et al. where early commencement of enteral feeding was seen in the newborns' PDHM feeders. The study done by Adhisivam et al. showed that exclusive breastfeeding rate pre-HMB was 34% compared with 74% post-HMB (P < 0.001).
Results from the study indicate that the weight at birth and at discharge was more in the PDHM group as compared with the non-PDHM group. Schanler et al. observed that mother's milk and donor's milk offered short-term advantage over preterm formula. The study by Adhisivam et al. showed that the neonatal mortality was 11.32/1000 live births pre-HMB compared with 10.77/1000 live births post-HMB.
Overall, the variation observed in the two groups in this study may be because of expanded NICU, improvement in the NICU infrastructure, and increase in number of beds and ventilators. The feeding of newborns is improved and taken well care of in the institute with improved outcomes due to the availability of PDHM available in HMB.
Additional observation noted during the study period was no mother had developed mastitis and breast abscess as they were doing voluntary milk donation regularly after counseling by staff.
| Conclusions|| |
HMB is imperative for reducing neonatal morbidity and mortality. The neonates had decreased incidence of sepsis, NEC, and hyperbilirubinemia. Donor mothers had decreased incidence of breast engorgement, breast abscess, mastitis, and lactation failure. HMB will help in reducing the economical and disease burden in the country. Establishment of HMBs will help in improving the neonatal care standards in developing countries such as India. HMB is a feasible, cost-effective boon for newborns.
The cohort study is a prospective, comparative one with follow up of new-borns in NICU till their discharge, and there is a robust follow-up of neonates.
The limitations of the study include that this is a short-term study with small sample size and difficulty in finding an ideal group for comparison.
Every large NICU should establish HMB, and the awareness about HMB should be increased in the community. Medical college hospitals and district hospitals can take the initiative and help in distribution of human milk in the community.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tran HT, Doyle LW, Lee KJ, Graham SM. A systematic review of the burden of neonatal mortality and morbidity in the ASEAN Region. WHO South East Asia J Public Health 2012;1:239-48.
Niswade A, Zodpey SP, Ughade S, Bangdiwala SI. Neonatal morbidity and mortality in tribal and rural communities in central India. Indian J Community Med 2011;36:150-8.
] [Full text]
O'Connor DL, Jacobs J, Hall R, Adamkin D, Auestad N, Castillo M, et al.
Growth and development of premature infants fed predominantly human milk, predominantly premature infant formula, or a combination of human milk and premature formula. J Pediatr Gastroenterol Nutr 2003;37:437-46.
Kim J, Unger S. Human milk banking. Paediatr Child Health. 2010;15:595-602. PMID: 22043143; PMCID: PMC3009567.
Boland M. Exclusive breastfeeding should continue to six months. Paediatr Child Health 2005;10:148.
Kim JH, Unger S. Human milk banking. Pediatr Child Health 2010;15:595-8.
Infant and Young Child Feeding Chapter, Indian Academy of Pediatric, Bharadva K, Tiwari S, Mishra S, Mukhopadhyay K, et al.
Human milk banking guidelines. Indian Pediatr 2014;51:469-74.
Patel BK, Shah JS. Necrotizing enterocolitis in very low birth weight infants: A systemic review. ISRN Gastroenterol 2012;2012:562594.
Corpeleijn WE, de Waard M, Christmann V, van Goudoever JB, Jansen-van der Weide MC, Kooi EM, et al.
Effect of donor milk on severe infections and mortality in very low-birth-weight infants: The early nutrition study randomized clinical trial. JAMA Pediatr 2016;170:654-61.
Wight NE. Donor human milk for preterm infants. J Perinatol 2001;21:249-54.
Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. J Perinatol 2009;29:57-62.
McGuire W, Anthony MY. Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: Systematic review. Arch Dis Child Fetal Neonatal Ed 2003;88:F11-4.
Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: Systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2007;92:F169-75.
ESPGHAN Committee on Nutrition, Arslanoglu S, Corpeleijn W, Moro G, Braegger C, Campoy C, et al.
Donor human milk for preterm infants: Current evidence and research directions. J Pediatr Gastroenterol Nutr 2013;57:535-42.
Bertino E, Giuliani F, Baricco M, Di Nicola P, Peila C, Vassia C, et al.
Benefits of donor milk in the feeding of preterm infants. Early Hum Dev 2013;89 Suppl 2:S3-6.
Arslanoglu S, Moro GE, Bellù R, Turoli D, De Nisi G, Tonetto P, et al.
Presence of human milk bank is associated with elevated rate of exclusive breastfeeding in VLBW infants. J Perinat Med 2013;41:129-31.
Arnold LD. The cost-effectiveness of using banked donor milk in the neonatal Intensive Care Unit: Prevention of necrotizing enterocolitis. J Hum Lact 2002;18:172-7.
Isaacs EB, Fischl BR, Quinn BT, Chong WK, Gadian DG, Lucas A. Impact of breast milk on intelligence quotient, brain size, and white matter development. Pediatr Res 2010;67:357-62.
Rønnestad A, Abrahamsen TG, Medbø S, Reigstad H, Lossius K, Kaaresen PI, et al.
Late-onset septicemia in a Norwegian national cohort of extremely premature infants receiving very early full human milk feeding. Pediatrics 2005;115:e269-76.
Updegrove K. Nonprofit human milk banking in the United States. J Midwifery Womens Health 2013;58:502-8.
Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med 2012;7:29-37.
Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: Beneficial outcomes of feeding fortified human milk versus preterm formula. Pediatrics 1999;103:1150-7.
Hylander MA, Strobino DM, Dhanireddy R. Human milk feedings and infection among very low birth weight infants. Pediatrics 1998;102:E38.
Italian Association of Human Milk Banks Associazione Italiana Banche del Latte Umano Donato (AIBLUD: wwwaibludorg), Arslanoglu S, Bertino E, Tonetto P, De Nisi G, Ambruzzi AM, et al.
Guidelines for the establishment and operation of a donor human milk bank. J Matern Fetal Neonatal Med 2010;23 Suppl 2:1-20.
Chang RJ, Chou HC, Chang YH, Chen MH, Chen CY, Hsieh WS, et al.
Weight loss percentage prediction of subsequent neonatal hyperbilirubinemia in exclusively breastfed neonates. Pediatr Neonatol 2012;53:41-4.
Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr 2002;140:396-403.
Maisels MJ, Gifford K. Breast-feeding, weight loss, and jaundice. J Pediatr 1983;102:117-8.
Jin YT, Duan Y, Deng XK, Lin J. Prevention of necrotizing enterocolitis in premature infants – An updated review. World J Clin Pediatr 2019;8:23-32.
Adhisivam B, Vishnu Bhat B, Banupriya N, Poorna R, Plakkal N, Palanivel C. Impact of human milk banking on neonatal mortality, necrotizing enterocolitis, and exclusive breastfeeding – Experience from a tertiary care teaching hospital, south India. J Matern Fetal Neonatal Med 2019;32:902-5.
Katke RD, Saraogi M. Socio-economic factors influencing milk donation in milk banks in India: An institutional study. Int J Reprod Contracept Obstet Gynecol 2014;3:389-93.
Torres U. MI, López MC, Román VS. Does opening a milk bank in a neonatal unit change infant feeding practices? A before and after study. Int Breastfeed J 2010;5:4. https://doi.org/10.1186/1746-4358-5-4
[Table 1], [Table 2], [Table 3], [Table 4]