Welcome to another edition of NANN E-News. This month, we have an informative article on the use of colostrum and human milk for oral care.

 

 

Don't forget to forward this newsletter to a friend or colleague. Thank you for being a member of the only nonprofit association exclusively for neonatal nurses!

Diane L. Spatz, PhD RNC FAAN, and Taryn M. Edwards, BSN RNC

 

The benefits of human milk and breastfeeding have been well documented in the literature (American Academy of Pediatrics, 2005; Ip et al., 2007). Vulnerable infants who begin their life in the neonatal intensive care unit (NICU) may benefit most from receiving human milk. Therefore, nurses who work in the NICU must prioritize care to include assisting mothers with the initiation and maintenance of milk supply. The period while the infant may be nil per os (NPO) is a particularly critical time for both the establishment of milk supply and the collection of colostrum for future use. Nurses should assess a mother's pumping regimen and milk yield daily (Spatz, 2004).
 
Colostrum, the first milk that is produced, is known to contain proteins, amino acids, cytokines, and immunoglobulin A. The anti-inflammatory and pro-inflammatory cytokines in human milk help protect the vulnerable infant against infectious organisms. More recently, the pancreatic secretory trypsin inhibitor (PSTI) has been discovered in both colostrum and mature milk (Marchbank, Weaver, Nilsen-Hamilton, & Playford, 2009). PSTI was shown to have protective effects on gastric mucosa and facilitated gastric repair if the mucosal lining was damaged.
 
Because of the critical importance of colostrum, nurses must take special care to collect and store all colostrum and teach family members about the significance of this milk. It is helpful for mothers to pump into smaller collection containers made specifically for this milk. For example, Medela packages sterile 35-milliliter containers with a concave shape that allows even the smallest amount of colostrum to gather at the bottom. The smaller size of these containers is less intimidating to a new pumping mother and sends the message to parents that colostrum is produced only in small amounts (on average no more than 30 milliliters during the first 24 hours after delivery). Any drops of colostrum should be saved for current or future use.
 
Rodriguez and colleagues (Rodriguez, Meier, Groer, & Zeller, 2008) introduced oropharyngeal administration of colostrum for extremely-low-birth-weight infants. Oropharyngeal administration does not involve the infant's swallowing any of the milk. During this intervention, a small amount of the liquid is placed directly onto the oral mucosa in the buccal cavity for absorption via the mucosa. The theoretical background for this practice is systemic absorption of the cytokines and PSTI through the buccal cavity, which provides protection against infection as well as protection of the gastrointestinal tract. In addition, human milk is a rich source of oligosaccharides. Oligosaccharides are able to destroy bacteria, viruses, and fungi. The mouth of an infant who is breastfeeding directly at the breast is continually coated with human milk. By administering milk orally before the infant can begin enteral feeds and before the infant can orally feed, the nurse gives the infant that same benefit of coating the oral mucosa that the infant who is breastfeeding receives.
 
Implementing this practice in your NICU is relatively simple. In our NICU, we request that mothers bring their fresh (never frozen) colostrum to the NICU in order to be able to start oral care prior to freezing. Colostrum and mature milk can be stored up to 48 hours in the refrigerator and then placed in the freezer to be saved for the initiation of enteral feeds. The bedside nurse teaches the parents how to perform oral care with colostrum and mature milk. A sterile swab is dipped into the colostrum or mature milk. The swab should absorb all drops of colostrum or be saturated when there is ample colostrum or mature milk. The parent is then instructed to take the swab and coat the entire buccal mucosa with the colostrum or milk. This can be done for stable infants who are NPO, as well as for those infants who are unstable and who require ventilatory support and possibly extracorporeal membrane oxygenation.
 
Minimally, oral care with human milk (colostrum or mature milk) should be done once daily. If the mother is present and is pumping at the bedside in the NICU, it is ideal to perform oral care every 2-3 hours following each pumping session. One can also provide mouth care with human milk by dipping the pacifier in the milk if the infant is unable to perform nonnutritive sucking at the breast. Oral care with human milk should continue until the infant is able to take feeds by mouth (ideally at the breast and/or bottle).
 
This state-of-the-art research may decrease the risk of infection and protect gastric mucosa during a possibly long NPO status. In addition, infants appear to enjoy oral care with human milk, and parents welcome the opportunity to be able to provide a distinct aspect of care while their infant is critically ill.
 
References
American Academy of Pediatrics, Section on Breastfeeding. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506.
 
Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. (2007, April). Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153, AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved September 4, 2009, from www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf.
 
Marchbank, T., Weaver, G., Nilsen-Hamilton, M., & Playford, R. J. (2009). Pancreatic secretory trypsin inhibitor is a major motogenic and protective factor in human breast milk. American Journal of Physiology--Gastrointestinal and Liver Physiology, 296, G697-703.
 
Rodriguez, N. A., Meier, P. P., Groer, M. W., & Zeller, J. M. (2008). Oropharyngeal administration of colostrum to extremely low birth weight infants: Theoretical perspectives. Journal of Perinatology, 29, 1-7.
 
Spatz, D. L. (2004). Ten steps for protecting and promoting the use of human milk and breastfeeding in vulnerable infants. Journal of Perinatal and Neonatal Nursing, 18(4), 385-396.
 
Diane Spatz is Helen M. Shearer Term Associate Professor of Nutrition and associate professor of healthcare of women and childbearing nursing at the University of Pennsylvania, Philadelphia, and a clinical nurse specialist and lactation consultant at the Children's Hospital of Philadelphia, Philadelphia, PA. Taryn Edwards is a clinical nurse III in the NICU at Children's Hospital of Philadelphia.

Would you like to be recognized for your acquired knowledge in the field of developmental care?  Completing the Advanced Competency in Developmental Care by assessment through portfolio and online testing is a great way to do this.
 
Three opportunities are available in 2009-2010:

 

Portfolio Submission Deadline     Online Testing

 

NANN member Mia Waldron, MSN RN, president of the Washington Maryland Association of Neonatal Nurses, joined nurses from around the country at the White House on September 10, 2009, for a press conference following President Obama's speech on healthcare reform given to the joint session of the U.S. Congress on September 9. Their presence on the national stage helped President Obama highlight something he considers critical to the success of healthcare reform--the support of nurses. ANA president Rebecca Patton also attended and urged action on healthcare reform that would provide more security and stability to those with health insurance and guarantee access to affordable health care for those without it. 

Moderator, Andrea C. Morris, MSN RNC CCRN
 
Keep your skills sharp and learn new ones! Each Webcast includes a comprehensive presentation, answers to commonly asked questions, and immediate access to your continuing nursing education (CNE) certificate.

The National Association of Neonatal Nurses (NANN) is accredited as a provider of CNE by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA). Each presentation is eligible for 1 CNE credit. The fee for each Webcast is $15 per person. A poster is available for downloading and printing.

Supported through an educational grant from Abbott Nutrition, a division of Abbott Laboratories, Inc.
 
About Webcasts: A Webcast is a media file distributed on the Internet using streaming media technology. The Ask the Professor sessions are recorded PowerPoint presentations (slides) using both audio and video. Please contact NANN Member Services at 800/451-3795 with any questions.

The NNP Excellence Award honors outstanding contributions by a neonatal nurse practitioner (NNP) to the field of neonatal nursing through exemplary practice, leadership, service, and education.
 
Patricia J. Johnson, DNP MPH RN NNP, recipient of the 2009 NNP Excellence Award, is a nationally recognized leader, educator, consultant, speaker, and expert in neonatal care. She was instrumental in the development of the neonatal nurse practitioner role, building one of the first NNP teams in a Level III nursery, and later developed an NNP certificate program at state and private universities. She has authored and coauthored articles, modules, and chapters on topics in neonatal care, including chapters in two editions of the Perinatal Guidelines. She is a founder, past president, and board member of the National Association of Neonatal Nurses (NANN) and a charter member of the National Association of Neonatal Nurse Practitioners (NANNP). She is currently an NNP at Maricopa Integrated Health System/MMC and at Neonatology Associates, Inc., in Phoenix, AZ.

 

 

 

 
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The deadline for abstracts has been extended to October 2, 2009, for the 5th Annual NANN Research Summit, April 6-8, 2010, in Scottsdale, AZ. For guidelines and the submission form, visit the NANN Web site.

The program planning committee invites applications to present at NANN's 26th annual conference September 19-22, 2010, at the Paris Hotel in Las Vegas. The deadline for abstract submission is Friday, October 9, 2009. For guidelines, visit the NANN Web site.