Michelle Feinberg, MD, Neonatologist, Saint Joseph Hospital in the SCL Health System in Denver, Colorado, talks about how important a mother’s breast milk is in helping prevent NEC, and how having a designated milk preparation area truly helps.
Interview conducted by Ivanhoe Broadcast News in September 2017.
The name of the disease that we’re concerned with today, how do you pronounce it?
Dr. Feinberg: Necrotizing enterocolitis.
What is the shortened way of saying it?
Dr. Feinberg: NEC.
What’s a good, simple way of describing what it is?
Dr. Feinberg: NEC is an inflammation of the intestines that is most likely to strike premature infants. That can vary in its severity from a very mild problem to being lethal to babies at risk.
Tell me about how they get it?
Dr. Feinberg: Well there are many different things that can put babies at risk for NEC and we think that there are many processes that contribute to its development, which is part of the problem with figuring out how to prevent and treat it. Certainly the greatest risk factor is prematurity and growth. And their presentation, how they first develop signs and symptoms of the disease also can vary. It can come on very gradually and be very deceiving in how it presents, or it can come on suddenly and you can have a baby who goes from being very healthy looking to suddenly looking devastatingly ill.
You really don’t know though a specific cause?
Dr. Feinberg: Well there are many lines of thought that have led to numerous lines of research, trying to clarify the underlying factors and processes that result in the damage and destruction of intestinal tissue seen in NEC. . We have struggled for a very long time to pin down a single identifiable cause, but it is clear that NEC is what we call a multifactorial condition.. We certainly know what the risk factors are and we certainly also know things that we can do to to minimize the chances of developing NEC, and that’s where our focus has been.
What’s key among them?
Dr. Feinberg: Breast milk.
That sounds too simple.
Dr. Feinberg: That’s the beauty of it actually because mother’s own milk is what we call liquid gold. It’s important for all babies, but even more important for premature babies and this is one of the biggest reasons why. Mother’s breast milk has, for a long time, been known as the single most protective factor against developing NEC in babies at risk. And supporting the process of babies being able to receive their mother’s milk, especially in the early critical stages of a premature baby’s life, is the largest, most impactful thing we can do to help such babies.
When mom can’t produce enough milk, what do you do then?
Dr. Feinberg: Well unfortunately, many women do struggle especially right after delivery to supply their own milk for their baby and what we consider as an alternative, as the next best thing to mother’s milk, is to use donor breast milk. Having donor breast milk available as a bridge to being able to receive own mother’s milk does help keep babies safe and avoid exposure to formula.
Tell me about formula, why is that a problem for these babies?
Dr. Feinberg: Formula exposure during critical phases of growth and development absolutely increases the risks of necrotizing enterocolitis. The more premature or sick a baby is, the greater is his or her risk for damage from receiving formula. Mother’s own milk protects best against NEC, but not every infant has enough mother’s milk available. Probably the most important thing about donor milk and having it readily available is that it allows babies most susceptible to NEC to avoid having formula.
Donor milk has to be sort of handled or processed, right? Things have to happen to it, tell me what has to happen to it, sort of in a nutshell?
Dr. Feinberg: Well first it comes from volunteers, wonderfully generous women who have been tested and approved for donation. Once donated to the milk bank, it is handled carefully and tested to be made sure that it’s safe for feeding to babies and then it’s pasteurized to eliminate any potential factors that may increase risks to the recipients. The donor milk is frozen after it’s pasteurized.
So there are several steps that it has to go through?
Dr. Feinberg: Correct.
Ordinarily where would all that take place, all the handling?
Dr. Feinberg: It takes place in a milk bank and we have Mother’s Milk Bank of Colorado that’s been our donor milk supply, a wonderful resource for our patient population. There are many such milk banks across the country.
What sets the facility apart that you have here that’s special for babies at risk for NEC, the facility that processes the donor milk?
Dr. Feinberg: I think that one of the most important things is that they are a reliable source of milk for our patients who need it. They have been there for many years, available to provide a safe product to help nourish babies whose mothers are not able yet to give enough of their own milk and therefore allow them to avoid having to be fed formula.
I’m talking about the place where the milk is actually processed and handled that is special for the preemies who are at risk for NEC.. You said that you have a facility here on site?
Dr. Feinberg: You’re talking about our milk preparation here. Our state-of-the-art milk preparation lab is designed to safely prepare feedings for our entire NICU population. All milk that is fed to infants here has to be drawn up in a way that it can be administered, whether that’s in a syringe for tube feedings or in a bottle. And many babies, especially premature babies, also require fortification of their milk. Fortifiers are substances that can be added to the milk to help meet the infant’s excessive nutritional needs. To be able to do that safely and effectively, we have to handle the milk very carefully, following stringent processes we’ve developed and fine-tuned. These processes are performed by nutrition techs who are trained experts performed by nutrition techs who are trained and experts in doing exactly that safely and effectively. To start the process mother’s bring their milk to their baby’s room, milk they’ve either pumped here or pumped at home and brought in. The milk is stored in refrigerators that are in each baby’s room for that purpose, breast milk refrigerators. The nutrition techs collect the milk from those refrigerators each morning. They take that to the nutrition prep room where they use recipes to create a preparation that’s ordered and appropriate for each individual baby using that baby’s mother’s milk. If there is not enough of that baby’s mother’s milk then ideally they use donor milk instead, as the substitute. They mix the recipe and then they aliquot it, divide it in to separate feedings for the baby, all using aseptic techniques, very careful to eliminate any risk of introducing any infection. Then they bring those prepared feedings back to the NICU patient rooms to again store in the milk fridge for the nurses to then administer it to the babies around the clock.
Does every hospital with a NICU have a special prep area like this?
Dr. Feinberg: Not yet. But this is considered state-of-the-art in terms of preparing feedings for NICU patients. And most NICU’s as they are being redesigned and built currently strive to have such a facility to be able to have the ability to prepare feedings most safely in this way.
Let’s talk just briefly about Paxton, his case of NEC was mild?
Dr. Feinberg: Yes.
Do you think it was probably because he had this special nutrition that was available to him?
Dr. Feinberg: I would say that Paxton, like so many of our babies, the majority of our babies, definitely benefitted from having his mother’s milk. NEC has become a very rare occurrence in our NICU, and he was unfortunate to be one of those rare cases. All the things that we’ve been doing, our initiative to try to decrease necrotizing enterocolitis amongst our premature baby population, all those things he benefitted from. Can I say for certain that his case was milder because of those elements? I have no way to prove that. But I am grateful that his case was mild and that he recovered fully and is doing very well.
MORE FROM DR. FEINBERG: With our multipronged initiative, by 2013 we decreased the incidence of NEC among the premature infants in our NICU from a nationally typical rate of about 4% to less than 0.5%, and have maintained that much lower rate since. The key elements of our initiative are:
1) Encouraging and supporting mothers to supply breast milk for their high-risk newborns, and initiating breast milk feedings very early.
2) Making donor milk easily accessible for any infant who needs it, with the goal of avoiding formula exposure.
3) Providing probiotics.
4) Improved, standardized, safe processes for milk preparation, storage, fortification and administration.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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Michelle Feinberg
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