Running head: DONOR BREAST MILK KNOWLEDGE 1 Attitudes, Knowledge and Practices Regarding Donor Breast Milk in the Neonatal Intensive Care Unit Jaime Benedict, UFNS4 Dr. Leslie Parker, PhD, NNP University of Florida College of Nursing, Gainesville, FL
2 Abstract provision of donor breast milk ( DBM ) to extremely premature infants is recommended. However, DBM is inferior to MOM in terms of nutritional content and protection against prematurity specific morbidities. In 2012, a DBM program was implemented in a level IV NICU. If MOM was unavailable, infants born less than 30 gesta tion were provided DBM instead of formula, and as a result, infant consumption of MOM decreased. Lactation success in mothers of premature infants is associated with support from health care providers and it is unknown whether health care knowle dge of DBM could have influenced amount of MOM consumed. Therefore, the purpose of this study was to survey health care providers to determine their attitude, knowledge and practices regarding provision of DBM to extremely premature infants. A survey was s ent to health care providers in the NICU and 88 participants responded. Almost 50% of HCP s lack ed knowledge regarding potential risks of providing DBM while n early 25% of HCP either agree d or did not know whe ther DBM is as protective as MOM. Consumption of MOM by extremely premature infants is necessary to i mprove infant health outcomes. The decreased consumption of MOM following implementation of a DBM program may have been attributed in part to lack of knowledge regarding potential risks of DBM by healt h care providers and a lack of communication between staff and mothers regarding potential risks of DBM. Keywords : donor breast milk, lactation, premature, survey
3 the Neonatal Intensive Care Unit Introduction (<30 weeks gestational age) infants. MOM provides the most protection against prematurity specific morbidities such as necrotizing enterocolitis (NEC), late onset sepsis (LOS) and inadequate growth, in the first few weeks after birth ( Cacho et al 2017) When sufficient amount of MOM is unavailable for infant consumption, which is very common in the Neonatal Intensive Care Unit (NICU), the American Academy of Pediatrics recommends provision of DBM over formula to extremely premature infants ( American Academy of Pediatrics [AAP ], 2016 ). It has been found that feeding premature infants with formula, compared with DBM, results in increase d short term growth, but may increase the risk of developing NEC (Quigley & Mcguire, 2014). Since premature infants are at risk of inadequate growth, which is correlated to neurodevelopmental impairment, provision of optimal nutrition to preterm infants is essential (Corpeleijn, Vermeulen, van Vliet, Kruger & van Goudoever, 2010). Although DBM is a more natural alternative than formula, DBM is inferior to MOM (Cacho et. al, 2017). DBM must go through a pa steurization process, which removes many of the beneficial and protective immunologic components found in MOM DBM delivered to Human Milk Banks is pasteurized using the Holder pasteurization method to remove any viral or bacterial agents such as the human immunodeficiency virus (HIV) or cytomegalovirus (CMV) that may be present. Using the H older pasteurization method, DBM is heated to 62.5C for 30 minutes, which kills many pathogens, but also alters specific proteins, such as immunoglobulins
4 and lact oferrin, that have significant immunologic and anti infective benefits for extremely premature infants ( Peila et al., 2016). I n 2012 a DBM program was initiated in the level IV NICU at UF Health Shands H ospital, which provided DBM, instead of formula, to infants born at less than 30 weeks gestation if MOM w as insufficient or unavailable. Post implementation of this program, we found that infants consumption of MOM significantly decreased. Lactation success in mothers of premature infants is associated with support from health care providers ( Giann et al., 2016) If health care providers lack knowledge regarding the risks and benefits of DBM, or do not educate the mothers of extremely prema ture infants on these risks and benefits of DBM less MOM may be available for consumption Therefore, the objective of this study is to survey health care providers to determine their attitudes, knowledge and practices regarding provision of DBM to extremely premature infants in the NICU. The overall purpose is to promote ideal nutrition for extremely premature infants in the NICU by recognizing and removing any possible obstacles to optimal consumption of MOM. Project Narrative Ethics Stakeholders include research professor Dr. L eslie Parker, PhD, NNP as well as Jaime Benedict, a senior BSN nursing student at the University of Florida. Further stakeholders included the participants of the survey, which was comprised of n eonatologists, neonatal fellows /faculty pediatric residents, neonatal nurse practitioners, nursing administrators and neonatal registered nurses. There was n o conflict of interest declared. This was a University of Florida study approved by The Institutional Review Board (IRB). IRB approval was required in order to
5 complete the study due to the participation of human subjects. Courses for researchers regarding the IRB and the Health Insurance Portability and Accountability Act (HIPAA) also had to be completed before initiating re search. Design A survey was developed by the investigative team in consultation with a team of experts, including neonatologists, registered nurses, nurse practitioners and lactation consultants, as well as published literature. The survey was first pilot tested with 4 health care providers and modified prior to sending the survey The survey consisted of 13 multiple choice questions in 4 parts: Part 1 collected demographic information (1 question) including the participant s position in the NICU. Other de mographics were not collected to maintain anonymity; Part 2 (4 questions) examined information regarding participants understanding of differences between MOM and DB M including concentration of protective elements and protection against prematurity specific morbidities ; Part 3 (4 questions) gathered information regarding participants knowledge of the safe use and nutritional value of DBM Part 4 (4 questions) questioned the participants on whether DBM had any risks and/or benefits and to specifically identify what the risks and/or benefits were including whether the participants discussed potential risks and/or benefits with the mother. Questions in Part 2 4 used a 5 point scale including strongly disagree, disagree, unknown, agree and strongly agree. In Part 4, participants could comment in a free response box on the specific benefits and risks of DBM. In September, 2017, 19 neonatal fellows /faculty 14 neonatal nurse practition ers, 52 pediatric residents, and 145 registered neonatal nurses were sent an email inviting them to complete an o nline survey using Qualtrics. Participants were given 2 weeks to complete the
6 survey and a reminder was sent after the first week. Consent to p articipate was implied if the subject completed the survey, and all survey responses were kept anonymous. Data Analysis The survey results were analyzed using descriptive statistics to determine the position in the NICU, as well as their attitudes, knowledge, and practices regarding the use of DB M in the NICU. Bar graphs and charts were exported into Microsoft Word from data reports in Qualtrics to further analyze the survey results. Procedural Barriers and Solutions This being my first research project, I faced some barriers and complications throughout this project. The first obstacle that I anticipated encountering before sending the survey wa s receiving a low response rate due to the multiple e mails that health care providers receive and the little idle time they have to check their e mail. To overcome this obstacle the research team sent a reminder via e mail after one week. 230 emails were sent ou t and we received 88 responses with a 39 % response rate, which far exceeded our expectations. Another obstacle that I faced included scheduling difficulties and effective time time school schedule s A timeline was created and agreed upon by the research team to have the survey questions completed, sent for a pilot trial and then emailed to health care providers in the NICU, data analyzed, and a poster presentation completed by early February for the Southern Nursing Research So ciety (SNRS) Conference in Atlanta, GA. Abstracts for SNRS were due October of 2017, so all time had to be utilized effectively to complete all tasks amongst a challenging school schedule. With the use of effective time management and communication
7 Table 1 Survey Participants skills and a diligent research team, we were able to overcome a ll of the barriers encountered during this study Results The survey was sent via email to 230 health care providers, including pediatric residents (n=52) neonatal nurse practitioners (n=14), fellows/faculty (n=19) and bedside nurses (n=145). The survey received a response rate of 39% (n =88 ) with specifically 48% (n=25) pediatric residents, 57% (n=8) neonatal nurse practitioner s 31.6% (n=6) fellows/faculty and 33.8% (n=49) bedside nurses resp onding. Table 1 shows demographics and number of survey responses. Table 2 depicts the results to Parts 1 3 of the survey, with the question and number of responses on the left and the answer response s, using the 5 point scale on the right. Health Care Provider N=88 Pediatric Residents 28% (25) Nursing Administrator 1% (1) Neonatal Nurse Practitioners 9% (8) Fellow/Faculty 7% (6) Bedside Nurses 55% (48)
8 T able 2 Survey Parts 1 3 Question Strongly Disagree Disagree Unknown Agree Strongly Agree DBM is as beneficial as MOM. N=87 19.5% (17) 49.3% (43) 5.75% (5) 19.5% (17) 5.75 % (5) The concentration of protective elements is equal in DBM and MOM. N=85 20% (17) 57.6% (49) 12.9% (11) 7.1% (6) 2.4% (2) DB M is as protective against NEC as MOM. N=85 11.8% (10) 38.8% (33) 23.5% (20) 24.7% (21) 1.25 (1) D BM is as protective against LOS as MOM. N=83 11.8% (10) 31.5% (28) 30.3% (27) 18% (16) 2.3% (2) Sufficient evidence exists to support the use of DBM. N=84 0% (0) 9.8% (8) 28% (23) 51.2% (42) 9% (11) DBM is safe. N=82 1% (1) 0 0 80.5% (66) 18.2 (15) Fortified DBM provides sufficient nutrition for growth. N=82 2.4% (2) 19.5% (16) 12.2% (10) 59.8% (49) 6.1% (5) DBM is superior to formula. N=82 0% (0) 12.2% (10) 12.2% (10) 59.8% (49) 15.9% (13) There are potential risks providing DBM to infants. N=82 1.2% (1) 15.9% (13) 29.3% (24) 45.1% (37) 8.5% (7) There are potential benefits providing DBM to infants. N=82 0% (0) 0% (0) 12.2% (10) 70.7% (58) 17.1% (14) Yes No Do you discuss potential benefits of DBM with mothers? N=81 53.1% (43) 46.9% (38) Do you discuss potential risks of DBM with mothers? N=63 11.8% (10) 65.4% (53)
9 T able 3 Survey Part 4 Out of the health care providers who completed the survey 26% believe that DBM is as beneficial as MOM and greater than 22% either agreed or did not know that the concentration of protective elements in DBM were equivalent to MOM. When specifically asked whether they thought DBM provided as much protectio n against NEC and LOS almost 26% stated it was as protective against NEC and about 31% stated it was as protective against LOS The majority (62.2%) stated there is sufficient evidence to support the use of DBM, and the majority (98.7%) also believed that DBM is safe. Only 22% believed that DBM did not contain sufficient nutrition for growth and 62 % agreed DBM is superior to formula. While 44% of the health care providers surveyed agreed there are potential risks associated with providing DB M, only 28% discussed these risks with the infant s mother Comparably 72% agreed there were possible benefits of DBM, but only 43% discussed these benefits with the mother. Part 4 of the survey concerning h explanations regarding potent ial risks and b enefits are presented in T able 3 Only 12 participants wrote about the potential benefits of DBM question, while a mere 5 wrote about the potential risks of DBM. What are some potential benefits of DBM? (n=12) What are some potential risks of DBM? (n=5)
10 Discussion The use of DBM, over formula, in NICUs across the country has significantly increased in the past decade with 73.3% of level IV NICUs reporting the use of DBM in 2015 ( Perrin, 2018 ). There is little research on the correlation between the availability of DBM and infant feeding patterns ( Kantorowska et al., 2016). Therefore, the impact of the availability of DBM on infant consumption of MOM remains uncertain Since MOM provides the greatest protection against prematurity specific morbidities consumption of MOM for extremely premature infants is critical The survey found that n early 25% of HCP either believe or do not know whether DBM is as protective as MOM. 44% of the health care providers surveyed agreed there are potential risks associated with providing DB M, but only 28% discussed these risks with the infant s mother These results reveal a lack of knowledge regarding DB M and a n inclination of health care providers to avoid reviewing its potential risks with mother s of extremely premature infants There could be a decrease in lactation support when health care providers are unaware of the differences between MOM and DBM, which may decrease lactation success for mothers of extremely premature infants. The lack of communication between HCPs and mothers regarding potential risks of DBM may have also Consumption of MOM by extremely premature infants is necessary to improve infant health outcomes. W hen health care providers lack knowledge regarding the differences between DBM and MOM, the provision of DBM may be seen as a reasonable alternative. Results of the survey reveal that education of health care providers rega rding the differences between DBM and MOM is necessary so that they can properly educate mothers on both the pote ntial risks and benefits of DBM.
11 Further Studies Studies vary as to whether or not the availability of DBM in NICUs affects infants consumption of MOM. The Italian Association of Human Milk Banks completed a study in 2013 that revealed availability to DBM was correlated with increased consumption of MOM ( Kantorowska et al., 2016). H owever, hospital policies regarding breast milk and lactation support varies across different centers, which potentially affects the amount of MOM available for consumption. On the contrary, other single center studies have reported no difference in consumption of MOM when DBM is available ( Utrera et al., 2010) Our study found that health care providers lack knowledge regarding the risks of DBM, which may have contributed to the decreased infant consumption of MOM in our NICU Our next step is to educate HCPs in the NICU on the benefits and risks of DBM an d to determine whether this education increases infant consumption of MOM Limitations Study limitations included the fact that this was a single site study, which potentially decreases generalizability. Another limitation was demographics of HCP were unknown in order to maintain confidentiality Lastly n ot all survey questions were answered by all of the participants. Additional studies at other institutions are necessary in the future to draw further conclusions about health care consumption of MOM. Summary and Conclusion s Following implementation of a DBM program in a level IV NICU, infant consumption of MOM significantly decreased which may be due in part to k of knowledge on DBM. Therefore, t he objective of this study wa s to survey health care providers to
12 determine their attitudes, knowledge and practices regarding provision of DBM to extremely premature infants in the NICU. The overall purpose wa s to promote ideal nutrition for extremely premature infants in the NICU by recognizing and removing any possible obstacles to optimal consumption of MOM. To begin, an anonymous online survey was sent to health care providers working in the NICU t o determine th e knowledge, beliefs and practices of neonatal health care providers regarding the use of D BM in extremely premature infants in the NICU After analysis of the collected data from the survey, t his study demonstrated that health care providers lack knowledg e regarding the benefits and risks of the provision of DBM for extremely premature infants in the NICU. Since DBM is inferior to MOM, in terms of concentration of protective elements and nutritional content, results of this survey are discouraging and highlight the crucial need to recognize and implement new practices t hat increase the amount of MOM available for infant consumption Further education of health care providers and parents on the risks and benef its of DBM is also necessary. The results of this study suggest that lactation support for mothers of extremely premature infants is imperative to increase infant consumption of MOM. Additionally e ducation of mothers and health care providers regarding the inferiority of DBM to MOM is necessary M others may not know the difference between DBM and MOM, so n urses are essential for this patient education and for advocat ing for proper lactation support Since s ubstituting MOM with DBM in extremely premature infants decreases the immunologic benefits and protection that MOM offers it is critical that mothers receive proper education on the inferiority of DBM to MOM. This study has shown me that nurses have a significant impact on better patient outcomes and are the leaders in the patient education process. Nurses must pay close attention to the
13 obstacles that prevent mothers from lactation success such as stress and lack of sleep while also emphasizing the need to produce breast milk for their premature infant T he best patient care can be provi ded by del ivering patient centered and compassionate care that is supported by current evidenced based research As for my own learning and professional development this project has sparked my interest in the research of proper nutrition for extremely premature infants in the NICU. After graduation, I will be working as a NICU nurse in the level IV NI CU at Vanderbilt Medical Center and I am intrigued to see the current practices regarding the use of DBM in their NICU and to discover if the availability of DBM affects infant consumption of MOM. This research project also taught me the importance of advocating for your patients and problems that you see on the unit to ultimately create better patient outcomes.
14 References Cacho, N. T., Harrison, N. A., Parker, L. A., Padgett, K. A., Lemas, D. J., Marcial Lorca, G. L. (2017). Personalization of the Microbiota of Donor Human Milk with Frontiers in Microbiology 8 1470. Corpeleijn, W. E., Vermeulen, M. J., van Vliet, I., Kruger, C., & van Goudoever, J. B. (2010). Human Milk Ban king Facts and Issues to Resolve. Nutrients 2 (7), 762 769. Donor Human Milk for the High Risk Infant: Preparation, Safety, and Usage Options in the United States. (2016). Pediatrics, 139 (1). doi:10.1542/peds.2016 3440 Giann, M. L., Bezze, E., Sannino experiences. BMC Pediatrics 16 179. http://doi.o rg/10.1186/s12887 016 0722 7 Kantorowska, A., Wei, J. C., Cohen, R. S., Lawrence, R. A., Gould, J. B., & Lee, H. C. (2016). Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates. Pediatrics 137 (3), e20153123. http://doi. org/10.1542/peds.2015 3123 (2016). The Effect of Holder Pasteurization on Nutrients and Biologically Active Components in Donor Human Milk: A Review. Nutrients 8 (8), 477. http://doi.org/10.3390/nu8080477 Perrin, M. T. (2018). Donor Human Milk and Fortifier Use in United States Level 2, 3, and 4 Neonatal Care Hospitals. Journal of Pediatric Gastroenterology and Nutr ition, 66 (4), 664 669. doi:10.1097/mpg.0000000000001790
15 Quigley, M., & Mcguire, W. (2014). Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database of Systematic Reviews doi:10.1002/14651858.cd002971.pub3 Utrera Torres, M. I., Medina Lpez, C., Vzquez Romn, S., Alonso Daz, C., Cruz Rojo, J., Fernndez Cooke, E., & Palls Alonso, C. R. (2010). Does opening a milk bank in a neonatal unit change infant feeding practices? A before and after study. International Bre astfeeding Journal 5 4. http://doi.org/10.1186/1746 4358 5 4