Human Milk and Breastfeeding in Surgical Infants

Introduction

We indicate as “surgical infants” all newborns undergoing surgery in the neonatal period who continue with postoperative assistance in the neonatal intensive care unit (NICU) and then in the neonatal surgery unit (NSU). We refer to newborns undergoing major surgery such as correction of a diaphragmatic hernia, esophageal atresia, gastroschisis, omphalocele, bowel atresia, pulmonary malformations, and several cardiac or neurosurgical diseases. Although several studies have shown that human milk might reduce operative procedural pain,^1–4 only few data are available about the rate of breastfeeding and the benefits of human milk in surgical infants. Human milk might help to reduce intolerance feeding and septic episodes. ⁵ It is particularly advantageous in infants undergoing surgery because it is well tolerated and absorbed. ⁶ These benefits permit faster full enteral intake, parenteral nutrition suspension, and central venous catheter removal.

Human Milk and Breastfeeding: Always the Best Choice

The American Academy of Pediatrics and the World Health Organization (WHO) recommend exclusive breastfeeding from birth up to 6 months of life^7,8 and continuing breastfeeding at least for the first year of life. The United Nations Children's Fund (UNICEF) and the WHO proposed in 1991 a worldwide initiative known as the “Baby Friendly Hospital Initiative” (BFHI), aimed at offering a suitable setting to support, protect, and promote breastfeeding. ⁹ Breastmilk is the food of choice not only for healthy term infants, but also for preterm and for those affected by several types of diseases. ⁷ Whenever the mother's milk is unavailable, human milk from a donor human milk bank might represent the first choice. ¹⁰ These recommendations are based on the demonstrated superiority of human milk over any formula milk, with many health benefits in the short and long term. ⁸ It has anti-infectious/inflammatory activities, and its use is associated with a reduction in the incidence of respiratory and gastrointestinal tract infections^11,12 and necrotizing enterocolitis. ¹³ Some studies have shown neurodevelopmental advantages ¹⁴ and reduction of metabolic disease incidence.^8,15 Furthermore, breastfeeding creates a unique relationship between the mother and child, with all the psychological advantages involved. ⁸

What Are the Experiences with Human Milk and Breastfeeding in Surgical Infants?

Generally, after birth, surgical infants are hospitalized, and they stay in the NICU after surgery, until weaning from mechanical ventilation and stabilization of vital functions. The connection between the newborn and the mother will take place only afterward, in the NSU. The 10 Steps of the BFHI are difficult to apply and implement as a consequence of “barriers” interposed between the mother and newborn. In fact, mothers of infants with major congenital malformations breastfeed less frequently than those of infants without risk factors and, whenever they start, continue for a shorter time. ¹⁶ Only 71% of children with congenital malformations are breastfed (48% exclusively and 23% partially), compared with 85–95% of healthy newborns. ¹⁶ The maternal decision is the most important factor related to the beginning and the continuation of breastfeeding. ¹⁷ The mother–child separation during hospitalization and the lack of support from the hospital staff may further reduce the success. ¹⁷ Factors that motivate the choice of formula milk are represented by low birth weight, ¹⁸ maternal finding of the baby's poor weight gain, and subjective perception of insufficient milk production (almost never the disease affecting the child). ¹⁶

Only few data are available about the effects of human milk on the postoperative outcomes among surgical infants. Two studies, carried out in 1977 and in 1978, highlighted the importance of breastmilk in preterm infants with surgical short gut bowel syndrome ¹⁹ and the superiority of human milk compared with formula milk in postoperative management. ²⁰ Breastmilk allows proper growth and prevents postoperative complications in infants operated on for heart defects.^21,22 It might have a protective role on infectious complications that may occur during the first 6 months following ventriculoperitoneal shunt intervention for hydrocephalus, with a dose–effect relationship. ²³

How the Use of Human Milk and Breastfeeding in Surgical Newborns Can Be Improved

Mother's milk should always be offered as soon as possible, and to this purpose the mother should be motivated to extract and maintain milk production. The extraction should be started within the first 6 hours after birth through a breast pump and continued for about eight sessions per day. ²⁴ When feeding can be started, colostrum should be administered as “priming” for the gut. At this stage human milk is often given throughout intermittent intragastric probe or continuous enteral mode, based on clinical conditions. In many circumstances, like for preterm infants at risk for necrotizing enterocolitis, a minimal enteral feeding to test the tolerance should be administered.^25–27 The mothers should be helped by a lactation consultant to extract their own milk in the “lactation room” milk and should offer it as soon as it is pumped. During this first period, the stimulation of the baby's suction through the “nonnutritive suction” could facilitate the subsequent breastfeeding. ²⁸ This is possible using an already emptied breast, the finger, or a pacifier, which might help in relieving the pain and to calm the newborn. ²⁹

When the child's condition improves, the gradual rapprochement to the mother's breast should be considered an essential objective before hospital discharge. Continuous and prolonged skin-to-skin contact, like “kangaroo mother care,” promotes optimal maternal milk volume ³⁰ and the beginning of an exclusive and prolonged breastfeeding. ³¹

A room dedicated to collection of breastmilk should be expected as part of the NSU and equipped with adequate breast pumps. The hospital should ensure the closeness between mother and newborns, providing appropriate hospital accommodation. The staff should share competencies and motivations to provide all the necessary information also through the distribution of brochures specifically written for mothers. Because often the diagnosis is reached during pregnancy, the information about the disclosure of BHFI might be given during prenatal counseling. ¹⁰ Less experienced surgeons should be sensitized and involved in the planning and management of this program.

Conclusions

Human milk should be the food of choice for surgical infants. In this perspective the breastfeeding should be protected, promoted, and supported. ⁹ Although the best option is to offer to surgical infants their own mother's milk, a donor human milk bank can be considered the first alternative. ³² The beginning of breastfeeding may be delayed. Then, to reduce unnecessary barriers, ³³ the mothers of newborns hospitalized in the NICU and NSU should be informed and encouraged by the staff. The 10 Steps of the WHO/UNICEF should be modified and adapted to the organization of the NSU such as for the preterm newborn in the NICU.^29,34 An example of such modifications ³⁵ and integration for surgical infants may be summarized as follows:

1. Inform, especially during prenatal diagnosis, about benefits of mother's milk, breastfeeding difficulties, and how to maintain milk production.

Although several studies have been conducted on the difficulties of breastfeeding in NICU preterm infants, studies focusing on newborns undergoing major surgery in the NSU^17,36 should be carried out. Finally, a shared protocol between the NSU and the NICU should be created.