BACTERIA AND BIOACTIVITY IN HUMAN MILK

PRODUCTS
RAEANNE JORDAN
DIETETIC INTERN, UHCMC
BACKGROUND – PRETERM INFANTS

Gestation
Term 37-42 weeks
Late preterm 34-36 6/7 weeks
Preterm 28-33 6/7 weeks
Early preterm <28 weeks
Birth Weight
Low birth weight <2500 g
Very low birth weight <1500 g
Extremely low birth weight <1000 g
 BACKGROUND – PRETERM INFANTS

 Nutritional requirements are increased and can be difficult to meet

Weight 1000- Term (~2500-

Weight <1000g
1500g 3800g)
AAP
2014
• 130-150 kcal/kg • 110-130 kcal/kg • 105-110 kcal/kg
• 3.8-4.4 g pro/kg • 3.4-4.2 g pro/kg • 2.5-3 g pro/kg
• 160 mL/kg fluid • 160 mL/kg fluid • 160 mL/kg fluid
BACKGROUND – BIOACTIVE COMPONENTS

 Human milk provides protection against infection

 Mother’s breastmilk (MBM) is preferred food source after delivery
 If MBM is not available, donor breast milk (DBM) is used until 34 weeks corrected and 1700g
 Bioactive components help protect from:
 Sepsis
 Retinopathy of prematurity
 Necrotizing enterocolitis (NEC)
BACKGROUND – LYSOZYME AND SECRETORY IGA

 Lysozyme: degrades outer cell wall of gram-positive bacteria and contributes to destruction of gram-negative
bacteria in-vitro
 sIgA: binds microbes in the infant’s GIT to prevent their passage
HUMAN MILK BANKING ASSOCIATION OF NORTH AMERICA
(HMBANA)

 All donor milk is pasteurized and screened for bacteria

 Holder pasteurization: milk is warmed (62.5°C), held for 30 minutes, rapidly cooled, and then frozen until use.
 Eliminates all pathogenic bacteria except Bacillus cereus
SHELF-STABLE (SS) DHM

 Retort processing: uses high temperature (115-145°C) under

pressure for several minutes to sterilize human milk
 Option for smaller facilities w/ lack of storage & refrigeration
 Meredith-Dennis et al.
 Destruction of bioactive components
 3 samples analyzed per treatment group
 Samples taken from different donor pools
CASE STUDY - KM

 28 3/7 weeker delivered via c-section for breech position in setting of pPROM
 CPAP +5; caffeine for AOP
 Acidosis c/f sepsis  7 day antibiotic trial
 Started on TPN 0 at 2.9 mL/hr (76 mL/kg) with IL 1g/kg (34 kcal/kg, 2.3 g/kg protein, GIR of 3.2 mg/kg/min)
 Switched to D10W 2.9 mL/hr for Ohio newborn screen (GIR of 5.3 mL/kg/hr)

 Per nurse, mom pumping and producing milk.

 Pt had OG tube placed but has did not receive enteral feeds yet
CASE STUDY - KM

 Estimated Needs: 2014 AAP for weight <1000g

 Parenteral – 105-115 kcal/kg, 3.6-4 g pro/kg
 Enteral – 130-150 kcal/kg, 3.8-4.4 g pro/kg
 Fluid – 100 = maintenance

 Nutrition Dx: Increased nutrient needs related to prematurity as evidenced by kcal, protein, and mineral needs to
sustain intrauterine growth rate.
Birth Anthropometrics:

Growth Chart Measurement: corrected for prematurity

Birth Weight (kg): 0.91 kilogram(s)

Birth Weight %: 26 (z-score -0.65)

Birth Height/Length (cm): 33

Birth Length %: 9 (z-score -1.35)

Birth Classification: AGA

CASE STUDY - KM

 Nutrition goals: diurese and regain birth weight by DOL 14

 Nutrition Recommendations:
1. Today, Advance TPN+IL to TPN I and IL 2 g/kg. Continue to advance TPN per NICU protocol towards goal
TPN III vs HP. Monitor and adjust electrolytes as needed.
2. Start enteral feeds of 20 mL/kg/d of MBM and/or DBM. Provide feeds every 3 hours. Advance enteral feeds
per NICU protocol.
 Advance by 20 mL/kg/d
 Once 80 mL/kg reached, fortify MBM/DBM to 22kcal with SHMF.
 Once 100 mL/kg reached, fortify MBM/DBM to 24 kcal with SHMF.
 Goal is 160 mL/kg MBM/DHM SHMF 24 kcal/oz which provides 128 kcal/kg, 4.2 g/kg protein
3. Please measure head circumference as none was documented at birth
4. Please take daily weights and weekly length and head circumference.  
ARTICLE

To assess the ability of retort processing to eliminate bacteria and to quantify the difference in lysozyme and
sIgA activity between HP and SS human milk
METHODS

 WakeMed Mothers’ Milk Bank (Cary, NC)

 60 approved raw milk samples
 Total pool = 260 oz (7.69 L)
 12-3oz. samples 12-3oz. samples 12-10oz samples
• Raw human • Holder • Retort
milk pasteurized processing
• WakeMed (62.5°C for 30 (121°C, 20 PSI
Mothers’ Milk min) for 5 min)
Bank • WakeMed • North Carolina
Mothers’ Milk State University
Bank
METHODS

 Bacterial analysis: per standard protocols

 HP and SS underwent full postprocessing culture
 Raw human milk screened for bacteria of concern in DHM setting

 sIgA activity: modified indirect ELISA

 Lysozyme activity: change in turbidity of a microbial suspension of Micrococcus lysodeikticus
 Lysozyme (U/mL) = [mean change in absorption/(0.001 x volume of sample in mL)] x dilution factor of milk samples
RESULTS - BACTERIA
RESULTS – SIGA ACTIVITY & LYSOZYME ACTIVITY
DISCUSSION/CONCLUSION

 Imperative to scrutinize nutritional interventions to avoid expensive, life-threatening complications

 Evidence on full-spectrum of feeding choices is needed to inform best practice
 MBM is encouraged, but DHM can be used to maintain exclusive human milk feedings
DISCUSSION/CONCLUSION - BIOACTIVITY

Holder Shelf-stable
Raw human
pasteurized • 11% & 0%
milk
• 87% & 54%

* % bioactivity of sIgA activity & lysozyme activity,

respectively
DISCUSSION/CONCLUSION - BACTERIA

Raw human milk Holder Pasteurized Milk Shelf-stable Milk

All except B. cereus All except B. cereus All

LIMITATIONS & FUTURE RESEARCH

 Limitations:
 Small sample size
 Observed effects on only 2 heat-sensitive bioactive components
 Processing & packaging may slightly differ from manufacturers of SS human milk

 Future research:
 Effects on other bioactive components
 Effect on nutrients
 Health outcomes of medically fragile infants fed retort processed human milk
BACK TO OUR PATIENT…

 Finished 7-day course of antibiotics for c/f sepsis

 Briefly intubated after respiratory events
 Extubated, placed on CPAP, now on 2L NC

 Most recent active issues: ELBW, apnea of prematurity on caffeine, respiratory failure, MRSA conjunctivitis on
polymyxin
 Feedings: 160 mL/kg EBM/DBM fortified to 24 kcal/oz  increased to 26 kcal/oz
 Current Anthropometrics:
Birth Anthropometrics:

Growth Chart Measurement: corrected for prematurity Growth Chart Measurement: corrected for prematurity

Birth Weight (kg): 0.91 kilogram(s) Weight (kg): 1.16

Birth Weight %: 26 (z-score -0.65) Weight %: 16%

Birth Height/Length (cm): 33 Weight Z Score: -1.01

Birth Length %: 9 (z-score -1.35) Height/Length (cm): 36 centimeter(s)

Birth Head Circumference (cm): 24 centimeter(s) Height/Length %: 6%

Birth Head Circumference %: 11% (z: -1.24) Height/Length Z Score: -1.55

Birth Classification: AGA Head Circumference (cm): 24.5 centimeter(s)

Head Circumference %: <3%

Head Circumference Z Score: -2.41

THANK YOU BECKY LEVIN, MS, RDN, LD &
HALEIGH GAINES, MS, RDN, LD
REFERENCES

1. American Academy of Pediatrics. Nutritional needs of the preterm infant. In: Kleinman RE, Greer FR (eds).
Pediatric Nutrition, 7th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2014:80-21.
2. Lima HK, Wagner-Gillespie M, Perrin MT, Fogleman AD. Bacteria and bioactivity in Holder pasteurized and
shelf-stable human milk products. Current Developments in Nutrition. 2017;1(8). doi: 10.3945/cdn.117.001438
3. Brown J. Nutrition through the life cycle. 7 th ed. Cengage learning. Published 2017.
4. Mothers’ Milk Bank Northeast. Comparison of Holder pasteurized (frozen) and retort processed (shelf-stable
human milk). Human Milk Banking Association of North America.
5. Meredith-Dennis L, Xu G. Goonatilleke E, Lebrilla CB, Underwood MA, Smilowitz JT. Composision and
variation of macronutrients, immune proteins, and human milk oligosaccharides in human milk from nonprofit
and commercial milk banks. J Hum Lact. 2017:890334417710635.
QUESTIONS