Feeding the preterm infant
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7476.1227 (Published 18 November 2004) Cite this as: BMJ 2004;329:1227
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We read with interest the excellent review by McGuire W, et al. We
agree with the benefits of breast milk in infants with one caution. We
found recently that the expressed breast mik had a rather high rate of
bacterial contamination, i.e. 63% of breast milk from 27 mothers had
either total bacterial count >100,000 cfu/ml or any growth of pathogens
like gram-negative bacteria, enterococci or Staph. aureus (1). This
occured despite the fact that proper disinfection was carried out for the
electric pump and circuit. We suspected the reason behind this high rate
to be due to the belief in our community that women should not bath for
one week after delivery.
The next important question would be whether this bacterial growth is
harmful. There were case reports that suggested that necrotizing
enterocolitis (NEC) or sepsis was associated with contaminated breast miik
(2,3). It was noteworthy that all these infections affected preterm
infants with birth weight less than 1kg. We subsequently analysed the
incidence of NEC in prterm neonates fed with breast milk with or without
significant bacterial growth and those with premature formulae in a group
of 50 preterm babies and found no significant difference (p=0.8)
(unpublished data). However, most of these 50 preterm babies had birth
weight more than 1 kg and the population was too small to have enough
power. A study, that involve at least 80 neonates in each arm, looking
into the incidence of NEC or sepsis in preterm babies with birth weight
less than 1 kg among those fed with breast milk with or without
significant bacterial growth and those with formulae is warranted.
References
1. Ng DK, Lee SYR, Leung LCK, et al. Bacteriological screening of
expressed breast milk revealed a high rate of bacterial contamination in
Chinese women. Journal of Hospital Infection 2004;58:146-150
2. Ng PC, Lewindon PJ, Siu YK, et al. Bacterial contaminated breast milk
and necrotizing enterocolitis in preterm twins. Journal of Hospital
Infection 1995;31:105-110
3. Olver WJ, Bong DW, Boswell TC, et al. Neonatal group B streptococcal
disease associated with infected breast milk. Arch Dis Child Fetal
Neonatal ED 2000;83:F48-F49
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor
In their recent clinical review McGuire et al describe the potential
benefits of breast milk for preterm infants.1 It is obviously important to
support mothers to express breast milk and to breastfeed their babies
effectively once the babies are able to feed directly from the breast.
Therefore consideration should be given to some of the current advice
regarding breastfeeding.
McGuire et al state “the initiation of skin to skin contact between mother
and infant…can help…milk production…” However skin-to-skin contact has not
been shown to increase milk production. The Cochrane Review the authors
quote has investigated the evidence for early skin-to-skin contact for
mothers and their health newborn infants.2 The benefit of early mother-
infant contact seems to relate to early suckling and not skin-to skin
contact.3 4
Also advice to breastfeeding mothers now is that feeds should be baby-led;
the baby should be well-attached to the breast and allowed to feed for an
unlimited length of time. The Breastfeeding Management Workbook states
that feeds “may be anywhere between 4 to 40 minutes in length (per
breast)… In the first few days, or with a low-birth-weight baby, it is
common for feeds to be very long.”5
We have carefully observed the feeding patterns and weight gains of full-
term breastfed babies in our General Practice and have come to the
conclusion that prolonged breastfeeds are associated with poor weight
gain.
Further investigation into the above points is therefore needed to enable
these babies to obtain the full benefits of breast milk.
1 McGuire W, Henderson G, Fowlie PW. ABC Feeding the preterm infant.
BMJ 2004;329:1227-30. (20 November)
2 Anderson GC, Moore E, Hepworth J, Bergman N, Early skin-to-skin contact
for mothers and their healthy newborn infants.
Cochrane Database Syst Rev 2003;(4):CD003519
3 Taylor PM, Maloni JM, Brown DR. Early suckling and prolonged breast-
feeding.
American Journal of Diseases of Children. 1986 Vol: 140. Part 2. P
151-4
4 Taylor PM, Maloni JA, Taylor FH, Campbell SB. II Extra early mother-
infant contact and duration of breast-feeding. Acta Paediatr Scand, Suppl
316: 15-22, 1985
5 Breastfeeding Management:A Modular Course. Workbook . p57. UNICEF/WHO 1997
Competing interests:
None declared
Competing interests: No competing interests
In their excellent review, McGuire et al state that "feeding might
not be seen as an immediate concern" after preterm delivery, and advise
"early discussion of breastfeeding".
In fact, this early discussion should emphasize the importance of
early initiation of milk expression. Early (within 6 hours of delivery)
and frequent (8-10 times per day) milk expression with a hospital grade
electric pump will help a mother to optimize her milk supply until her
baby is ready to feed entirely at the breast. See, for example, Furman L
et al, Pediatrics 2002;109(4):e57 and Meier P, Ped Clin N Am
2001;48(2):425.
Since "supply and demand" drive lactation, and since most preterm
infants do not breastfeed well ("demand") until reaching approximately 40
weeks' corrected gestational age, it is of utmost importance that mothers
be supported in establishing a good milk supply while their babies are
hospitalized.
Competing interests:
None declared
Competing interests: No competing interests
Disinfection of breast pump and other equipment for preterm infants
Maguire and colleagues' useful article on feeding the preterm infant1
emphasises the importance of breast feeding but did not discuss the
difficulties many units face in ensuring appropriate disinfection of
equipment used with electrical breast pumps, as well as dummies/pacifiers
and some other articles involved in feeding. The ideal method is to use
either single use/disposable equipment or SSD (Sterile Service Department)
processing after each use. The former can be expensive. The latter may
result in delays if incomplete breast pump sets are returned to SSD and
there should be enough sets in the system to keep an adequate stock level.
There is also a limit to the number of times breast pump equipment can be
autoclaved. Some units will disinfect items by various methods on site but
use SSD processing or dispose of equipment on discharge of the patient.
On site disinfection may involve use of chemicals, after a detergent
wash. This runs the risk of inadequate disinfection if the process is
incorrectly performed2, or the theoretical possibility of small amounts of
detergent or chemicals being left on the surface of the equipment. Whether
these residues could be damaging to the intestinal mucosa of a very
premature neonate needs consideration. One manufacturer does not recommend
rinsing equipment following immersion in chlorine-releasing disinfectant.
However, the decomposition of liquid disinfectant based on sodium
hypochlorite results in the production of water and small amounts of
sodium chloride (salt). Also, disinfectant tablets made from sodium
dichloroisocyanurate dissociate in water to give hypochlorous acid (the
active compound) and cyanuric acid.
Some neonatal departments have resorted to steam disinfection units
(incorrectly referred to as 'sterilisers') which are commercially
available and often used in the home. These do not allow for separate
processing of equipment from individual mothers and routine washing is
still required before disinfection. They do not comply with the Health
Technical Memorandum 2030 for washers/ disinfectors as they have no lock,
can be opened when in use and have no temperature recording device. Items
inside them are wet at the end of processing with the risk of bacterial
growth occurring after a few hours. Although microwavable steam
disinfection baskets can provide separate processing for equipment from
each mother, some breast pump manufacturers do not consider this method is
acceptable for their equipment. Another possibility is use of dishwashers
but this will not allow for separate processing of items in hospital and
may involve other risks if machines malfunction.
Some units only wash this equipment in warm soapy water, rinse and
air dry.3 This has an advantage in simplicity but still leaves the
possibility of small amounts of detergent not being rinsed off the
equipment. In addition, it may not always be adequate for removal of
pathogens that can be found in some breast milk samples and which may pose
a risk for neonates (lactose fermenting coliforms, beta haemolytic and
group D streptococci, Staphylococcus aureus and Pseudomonas aeruginosa).4
Single use/disposable equipment or acceptable heat methods should be
the aim for equipment involved in feeding these high risk patients. Cost
is often an underlying factor in choice of method. and neonatologists need
to be closely involved.
References
1. McGuire W, Henderson G, Fowlie PW. ABC of preterm birth. Feeding the
preterm infant. BMJ 2004;329;1227-30
2. Reiss I, Borkhardt A, Füssle R, Sziegoleit A, Gortner L.
Disinfectant contaminated with Klebsiella oxytoca as a source of sepsis in
babies. Lancet 2000;356:310
3. Atkinson A. Decontamination of breast milk collection kits: a
change in practice. MIDIRS Midwifery Digest 2001;11(3):383-385
4. Guidelines for the establishment and operation of human milk banks
in UK. 2nd edition April 1999. Published by Royal College of Paediatrics
and Child Health and the United Kingdom Association for Milk Banking
Competing interests:
None declared
Competing interests: No competing interests