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Concurrent Session: Optimizing human milk for the medically compromised infant

Saturday, May 7, 2016
3:30pm - 4:45pm


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Due to its many nutritional and health benefits, human milk is the optimal food for all infants including hospitalized infants who may have elevated nutritional requirements or a unique medical diagnosis requiring adaptation of their enteral feeds. Our improved understanding of drug transfer across the mammary gland, the variability in human milk nutrient composition, availability of donor human milk and new technologies to adapt milk provide an immediate opportunity for clinicians to improve health outcomes in their smallest patients and for researchers in both the private and public sectors to champion innovation in this area.  In this session we will begin by discussing two important issues in providing human milk to medically compromised infants—(1) Understand the impact of maternal drug use (prescription, illicit) on the nursing infant; (2) The impact of donor human milk as a supplement to own mother's milk on the prevention of necrotizing enterocolitis of the very low birth weight infant and neurodevelopment.

Optimizing Human Milk For The Medically Compromised Infant
Dr. Shinya Ito, MD, FRCPC

Drugs a breastfeeding woman takes are excreted into milk, and the infant is exposed to them as an innocent bystander.  Importantly, the magnitude of drug excretion varies tremendously among drugs, and for some drugs, the clinical impact on the infant may be of concern.  Although it is challenging to obtain data on drug levels in milk, as a result of the methodological advance in pharmacokinetic analyses and a new regulatory environment, the information on drug excretion into milk is gradually accumulating.  In addition to drug levels in milk, the other key element for risk assessment is infant drug clearance. If it is very low due to medical conditions, even a small amount of drug may accumulate in the infant, causing unwanted effects. Using the PK modeling and simulation approach, it is possible to simulate pharmacokinetics and effects of drugs in infants with organ dysfunction. Examining the clinical impact of maternal exposure to illicit substances and other toxins during breastfeeding are even more challenging because maternal report on these exposures may not be accurate or reliable. However, anecdotal evidence and some systematic studies exist for us to assess the associated infant risks.  While understanding the principles of drug excretion into milk and their impact on infants is essential for clinicians, it is equally important for us to keep up-to-date knowledge on infant toxicity of individual drugs via milk, or lack thereof. A web-based database focusing on drug safety during breastfeeding, known as LactMed < >, is a useful resource in this regard. 

Optimizing Human Milk For The Medically Compromised Infant
Dr. Sharon Unger

Optimizing Human Milk for the Medically Compromised Infant - Mother's milk is the optimal nutrition for all infants and of particular importance for protecting and promoting the health of medically compromised infants. It is well tolerated, facilitating improved enteral intake and growth. It provides a myriad of bioactive factors protecting from complications related to preterm birth such as sepsis and necrotizing enterocolitis (NEC). NEC, an inflammatory condition of the gastrointestinal tract to which preterm infants are predisposed, is a medical emergency carrying a high morbidity (including adverse neurodevelopmental outcome) and mortality. Despite enormous effort and dedicated lactation support, 70% of mothers of preterm infants are unable to express a full supply of their milk due to multiple factors; including immaturity of the mammary glands as well as stress, maternal illness and being pump dependent. In this case, a supplement to mother's milk is required which has traditionally been formula. With a growing recognition of the health protective effects of human milk, there has been increasing demand for supplementation to be with human donor milk including extending use of donor milk to hospitalized and full-term healthy infants. The past decade has seen an exponential growth in human milk banks. In North America, non-profit milk banks follow guidelines set out by the Human Milk Banking Association of North America to ensure the safety of donor milk, including Holder pasteurization (62.5C for 30 minutes). This presentation will focus on the collection and processing procedures involved in producing donor milk and the resultant similarities and differences compared to mother's milk. Findings from a large Canadian randomized controlled trial that looked at long term health outcomes when donor milk is used as a supplement to mother's milk will be presented.

Feeding a high docosahexaenoic acid maternal diet during lactation beneficially impact the offspring's immune function and establishment of oral tolerance
Caroline Richard (Abstract Presentation)

Food allergies are believed to be the result of a failure to develop oral tolerance (OT) to a dietary antigen. The objective of this study was to determine the effect of feeding a maternal diet supplemented with docosahexaenoic acid (DHA) during the suckling period on the development of the immune system and OT in offspring. Dams were randomized to one of the two nutritionally adequate diets 24h prior to parturition: control diet (N=12, 0% DHA) or high DHA diet (N=8, 0.9% DHA of total fatty acids). Diets were fed to dams ad libitum throughout the suckling period (21 days). At 11-days pups from each dam were randomly assigned to a mucosal OT challenge for 5 days: placebo (sucrose) or ovalbumin (OVA). At 3 weeks pups were euthanized and cytokine production by mitogen- (Concanavalin A (ConA), lipopolysaccharide (LPS)) or OVA-stimulated splenocytes and plasma OVA-specific immunoglobulins (Ig), were measured. Feeding a high DHA maternal diet led to a higher production of interferon-γ by splenocytes stimulated with ConA and a higher production of interleukin (IL)-10 and tumor necrosis factor-α after LPS stimulation (all P<0.05). OVA-stimulated splenocytes from DHA-fed pups also produced significantly more IL-10 and less transforming growth factor-β (both P<0.02), suggestive of enhanced OT. Untolerized DHA-fed pups had lower plasma concentrations of OVA-specific IgE (P for interaction<0.05). Overall, feeding a maternal diet enriched in DHA during lactation favors the maturation of the offspring’ immune system and is beneficial for the establishment of OT.



Dr. Shinya Ito

Professor and Head, Division of Clinical Pharmacology & Toxicology, Department of Paediatrics, University of Toronto

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