Comparison of the Effect of Breast Milk and Sodium Bicarbonate Solution for Oral Care in Infants with Tracheal Intubation After Cardiothoracic Surgery

Abstract

Background:

This study aimed to explore the effect of breast milk and sodium bicarbonate solution used in oral care of infants with tracheal intubation after cardiothoracic surgery.

Methods:

A randomized clinical controlled trial was conducted in a provincial hospital in China. Fifty infantile patients were randomly divided into two groups: the patients in the study group (n = 25) used breast milk for oral care and the patients in the control group (n = 25) used sodium bicarbonate solution for oral care. The relevant clinical data were recorded, including the mechanical ventilation duration, length of intensive care unit (ICU) stay, length of hospital stay, and complications.

Results:

The length of ICU stay, length of hospital stay, and duration of mechanical ventilation were shorter in the study group, but the difference was not statistically significant (p > 0.05). However, the incidence of thrush and ventilator-associated pulmonary infection in the study group was significantly lower than that in the control group (p < 0.05).

Conclusion:

The use of breast milk for oral care has a positive effect on the prevention of thrush and ventilator-associated pulmonary infection in infants with tracheal intubation after cardiothoracic surgery.

Introduction

The oral cavity is an excellent environment for many microorganisms to colonize and breed, especially pathogenic bacteria.¹ Compared with normal infants, infants with congenital cardiothoracic disease have poor immunity and stunted physical development. For these patients, endotracheal intubation and mechanical ventilation need to be maintained for some time after cardiothoracic surgery. After intubation and surgery, patients' oral cavity may be kept open for a long time, which may impair the oral and nasal cavities to function as natural barriers to a certain extent and reduce oral immunity due to reduced saliva secretion, dry oral mucosa, and the inability to independently perform oral care.^2–4 Tracheal intubation can easily cause oral ulcers, bad breath, fungal infections, ventilator-associated pneumonia, and other oral complications in infants.⁵

Active and reasonable oral care can remove odor and dirt in the oral cavity, reduce fungal reproduction, and maintain a clean and moist environment in the oral cavity, which is important for preventing thrush and pneumonia.^6,7 In recent years, oral care in patients with endotracheal intubation has attracted increasing attention by researchers.⁸ This study summarizes our experience regarding breast milk oral care for infants with tracheal intubation after cardiothoracic surgery and evaluates its impact on thrush and ventilator-associated pneumonia.

Methods and Materials

Clinical information

This study was approved by the ethics committee of our hospital. (2020YJ181). This study was a randomized clinical trial conducted in a provincial teaching hospital in China. The study population was divided into two groups according to the oral care intervention used. A power analysis with a power of 80%, an error rate of 5%, and an effect size of 0.25 were conducted to determine the sample size needed, which was calculated to be 25 for each group. The study population comprised a total of 50 patients.

The parents of the eligible patients were invited to participate in the study, and written informed consent was obtained after the study process was explained to them. The participants were randomly assigned to the study group or the control group using sealed envelopes with a varied block size prepared by the statistician. The investigator was blinded to the block size and the group assignments.

The clinical data of 50 infants with congenital cardiothoracic disease who were treated in our hospital from January 2020 to April 2020 were collected. Patients were selected through convenience sampling and randomly divided into two groups: 25 patients in the study group received breast milk for oral care and 25 patients in the control group received sodium bicarbonate solution for postoperative oral care. The general information of all infants, such as their age, gender, and weight, are given in Table 1. The following inclusion criteria were used: (1) the mother could provide breast milk, (2) postoperative echocardiography indicated the satisfactory correction of cardiothoracic malformations without pleural and pericardial effusion, (3) no thrush occurred before the operation, (4) no other severe organ complications occurred during the perioperative period, and (5) the parents of the infants agreed to participate in this study and signed the informed consent form. The exclusion criteria were as follows: (1) thrush was present before the operation, (2) severe complications and hemodynamic instability occurred during the perioperative period, and (3) the parents of the infants refused to participate in this study.

Table 1.

Comparison of General Data of the Two Groups of Infants

Variable	The study group	The control group	p
n	25	25
Age (month)	2.6 ± 1.9	3.0 ± 2.3	0.476
Weight (kg)	4.4 ± 0.9	4.5 ± 0.7	0.624
Male/female	16/9	15/10	0.771
Type of diseases
Ventricular septal defect	15	14	0.635
Atrial septal defect	3	5
Pulmonary stenosis	3	1
Coarctation of aorta	2	1
Total anomalous pulmonary venous connection	1	2
Pulmonary artery atresia/VSD	0	1
Tetralogy of fallot	0	1
Interruption of aortic arch	1	0
Operation time (hours)	3.3 ± 1.2	3.6 ± 1.1	0.282
Cardiopulmonary bypass time (hours)	1.5 ± 0.6	1.6 ± 0.9	0.419
Aortic cross-clamping time (hours)	1.0 ± 0.9	1.1 ± 0.8	0.880

VSD, ventricular septal defect.

Oral care methods

All infants' postoperative oral care was standardized by the same researcher, who was a nurse specialist in the cardiothoracic intensive care unit (ICU). The patients in the study group used breast milk for oral care, and the patients in the control group used sodium bicarbonate solution for oral care. The operation protocol was as follows: the researcher checked the oral mucosa of the patient before oral care was performed, cleaned the respiratory tract, and removed oral secretions. A syringe was used to draw the oral care solution (breast milk or sodium bicarbonate solution). During the rinsing process, the researcher slowly rinsed the patients' cheeks, pharynx, tongue, and hard palate from different directions. Negative pressure suction was applied, with the negative pressure maintained between 0.04 and 0.06 MPa. A cotton ball with the oral care solution was gently rubbed from the base of the patient's tongue toward the tip of the tongue. The base of the tongue near the uvula was not wiped to prevent vomiting. During the rinsing process, it was necessary to observe the patient's state for hypoxia, nausea, and vomiting and to maintain a stable level of blood oxygen saturation. Finally, the nurse used a cotton ball dipped in saline to wipe the patients' oral mucosa, tongue coating, teeth, and palate. The patients received postoperative oral care three times a day.

Data collection

Another researcher recorded, summarized, and statistically analyzed the patients' oral condition and counted the cases of thrush in the two groups every day. Postoperative complications, including ventilator-associated pulmonary infection, were also recorded as evaluation indicators. In addition, the patients' mechanical ventilation duration, length of ICU stay, and length of hospital stay were also recorded.

Diagnostic criteria for thrush and ventilator-associated pneumonia

White milk clots, which were not easy to wipe off, were attached to the oral mucosa. If they were wiped with a large force, bleeding might occur. They were usually positioned in the buccal mucosa, tongue, gums, and upper jaw. For difficult diagnoses, microscopic examination was used, and the presence of fungal cells and spores was diagnosed as thrush.⁹ For some of the suspected cases, bacterial and fungal culture of oral cavity site were performed, but due to the possible contamination factor, we did not use these cultures as a basis for routine examination and diagnosis. Thrush is more often diagnosed in combination with clinical symptoms and signs.

Ventilator-associated pneumonia was defined as pneumonia that occurred between 48 hours after mechanical ventilation and 48 hours after extubation. Bacterial and fungal cultures of tracheal specimens were performed routinely and as diagnostic criteria for pneumonia. It was one of the most common infection-related complications that occur during mechanical ventilation and was a type of pneumonia that is commonly acquired in hospitals.¹⁰

Statistical analysis

Quantitative data are expressed as the means ± standard deviations, and the normality of the data was tested. The continuous data that were normally distributed were compared between groups by the t test, and the qualitative data were compared between groups by the chi-square test. p < 0.05 was considered statistically significant.

Results

As given in Table 1, there were no significant differences in age, gender, weight, or surgical data. These results indicated that the two groups of patients were homogeneous and comparable. As given in Table 2, the length of ICU stay, length of hospital stay, and duration of mechanical ventilation were shorter in the study group, but the difference was not statistically significant (p > 0.05). The incidence of thrush and ventilator-associated pulmonary infection in the study group was significantly lower than that in the control group (p < 0.05).

Table 2.

Comparison of Postoperative Conditions Between Two Groups of Infants

Variable	The study group	The control group	p
n	25	25
Thrush	2	8	0.034
Ventilator-associated pneumonia	1	6	0.042
Mechanical ventilation duration (days)	3.3 ± 1.2	4.6 ± 1.7	0.215
Length of ICU stay (days)	5.2 ± 1.8	6.5 ± 2.0	0.102
Length of hospital stay (days)	12.9 ± 3.6	15.3 ± 5.1	0.176
The tracheal cultures
Escherichia coli	1	1
Klebsiella pneumoniae	0	2
Pseudomonas aeruginosa	0	1
Staphylococcus epidermidis	0	1
Candida albicans	0	1

ICU, intensive care unit.

A total of seven (14%) positive sputum specimens were cultured in the airway in this study. One case of Escherichia coli was confirmed in the study group. Six cases in the control group were confirmed, including two cases of Klebsiella pneumoniae, one case of E. coli, and one case of Pseudomonas aeruginosa, one case of Staphylococcus epidermidis, and one case of Candida albicans. There was a statistically significant difference in the culture results between the two groups (p < 0.05).

Discussion

Transoral and transnasal tracheal intubation is an effective treatment to help patients recover spontaneous breathing and is also a common method for assisted breathing in the rescue of critical patients.¹¹ Because cardiothoracic surgery usually needs to be performed under general anesthesia in infants, hypothermia and the need for cardiopulmonary bypass, postoperative long-term endotracheal intubation, and mechanical ventilation are common problems that occur in the clinic.¹² A large number of microorganisms reside in the human oral cavity and jointly maintain oral physiological balance. Once this balance is destroyed by prolonged endotracheal intubation and mechanical ventilation, severe oral and systemic complications occur. Owing to the inability to eat, such infants with tracheal intubation have limited swallowing and chewing functions. Because the oral cavity is kept open, it becomes dry, and saliva secretion decreases; therefore, the cavity's ability to perform self-purification is weakened. Once oral infections occur, the bacteria rapidly multiply and colonize in the mouth. The proliferation of bacteria leads to bad breath and inflammation in the mouth.¹³ Moreover, infants' level of immune function is low, the functions of many organs are not fully developed, and a series of pathophysiological changes caused by surgical correction of cardiothoracic disease may make infants more prone to ventilator-associated pneumonia.¹⁴ In recent years, the occurrence of ventilator-associated pulmonary infection has increased considerably, which not only affects the prognosis of patients but also increases the financial burden related to medical services.¹⁵ Therefore, effective oral care plays a vital role in the routine daily care of patients with mechanical ventilation, especially for these infants after cardiothoracic surgery. Studies have shown that proper oral care can effectively remove and reduce oral pathogens, promote an oral physiological balance, and prevent and reduce the occurrence of ventilator-associated pulmonary infections.¹⁶ Nurses are the most important members of the health care team, so they are responsible for oral care and thrush prevention. Although the management of thrush is an important part of care, previous studies have shown that there is no universally accepted method.¹⁷ Nurses should be informed of the problem and have the ability to provide effective preventive care for thrush and treat it if it occurs.

Infants with long-term endotracheal intubation are often treated with antibiotics for a long time. In the presence of mixed infections, dual-use antibiotics may also be required, and infants with high pulmonary exudation routinely undergo hormone-assisted treatment. These factors cause oral microflora disorders and further increase the incidence of thrush. Thrush is inflammation of the oral mucosa caused by Candida albicans infection, and it is related to the prolonged use of antibiotics or hormones.¹⁸ In the past, hospitalized infants have used normal saline for routine oral care, but normal saline is neutral and cannot reduce the incidence of thrush. On the basis of comparative observation, our results showed that using breast milk for oral care can prevent thrush without side effects and does not increase the workload of nurses. It is an effective oral care method for preventing thrush in infants after cardiothoracic surgery.

The current oral care solutions commonly used in clinical practice include 3.8% chlorhexidine, physiological saline, hydrogen peroxide solution, and 2% sodium bicarbonate solution. However, clinically, 3.8% chlorhexidine is not suitable for newborns. A study by Ahn et al. showed that using sterile physiological saline for oral care can slightly reduce the average number of bacteria in the patients' mouth, has no effect on the type of bacterial colonization, and does not lead to any adverse reactions.¹⁹ However, after the evaporation of physiological saline, a hypertonic solution is formed locally, which easily causes mucosal bleeding and drying, and its salty taste is likely to cause patients to feel sick and vomit.²⁰ Hydrogen peroxide solution has an effective bactericidal effect, which is effective in preventing thrush, but it has a damaging effect on cells. In addition, it will generate a large amount of foam during care, which will inconvenience the health care providers. The 2% sodium bicarbonate solution is most widely used in the clinical work of oral care, but it is only effective for preventing fungi, and the effect is limited, which is consistent with our findings in the control group.

Some scholars have suggested that the use of breast milk as a new oral care solution can be included in the cluster management of thrush prevention in patients with tracheal intubation. Breast milk contains a variety of beneficial bacterial strains and immune components; thus, it is the first choice for oral care because it can balance the oral microbiome and prevent infectious diseases.²¹ The content of the immune components may be higher in premature breast milk than in standard breast milk.²² Therefore, the colostrum of premature mothers is better for oral care. Studies have shown that the use of colostrum from premature mothers for “oral immunotherapy” can reduce the incidence of hospital infections in the neonatal intensive care unit (NICU).²³ It has been reported that olfactory stimulation of breast milk can reduce gastric retention and improve digestive function in premature infants without causing discomfort.²⁴ A meta-analysis showed that placing a small amount of colostrum directly on the buccal mucosa of infants in the early neonatal period might provide immune and growth factors that can stimulate the immune system and promote intestinal growth. These benefits might reduce the risk of infection and necrotizing enterocolitis and improve survival and long-term outcomes.²⁵ However, strict requirements should be followed for the retention and storage of breast milk. Carre and his team collected milk from 114 newborn mothers admitted to the NICU, and only 44 samples (39%) were eligible: most of them (76%) had a large number of aerobic bacteria.²⁶ Their results showed that the safety of breast milk for oral care cannot be ensured.

The incidence rates of thrush and ventilator-associated pulmonary infection in our study group were significantly lower than those in the control group. Although this study lacked bacteriological results, such clinical results still reflected, to some extent, the advantages of breast milk used in the oral care of infants with tracheal intubation after cardiothoracic surgery. Although there were no statistically significant differences in the mechanical ventilation duration, length of ICU stay, or length of hospital stay between the two groups, the breast milk group still had an advantage in time spent, indicating that when used in oral care, breast milk has a positive effect on the prognosis of infants with tracheal intubation after cardiothoracic surgery.

This study still has some limitations. This study had a small sample size, and the selected evaluation index is limited, so there may be deviations in the results. The subjects of this study were infants who underwent cardiothoracic surgery, and other patients may have had different results. In addition, other studies in different regions, different centers, and different interventions may have different results. Therefore, a multicenter prospective randomized long-term study is expected to be completed to determine the results of this study.

Conclusion

The preliminary results of this study indicate that breast milk can be used for oral care of infants after cardiothoracic surgery. It is very safe for oral care and can effectively reduce the incidence of thrush and ventilator-associated pulmonary infection. It is worthy of being promoted and applied in clinical practice.

Footnotes

Acknowledgments

We highly acknowledge the contribution by the participating researchers: Qi-Liang Zhang, Ze-Wei Lin, Li-Wen Wang, Jing Wang, and Ling-Shan Yu.

Authors' Contributions

X.-R.Y. and Q.C. designed the study, performed the statistical analysis, participated in the operation, and drafted the article. S.-T.H., N.X., W.-S.D., Z.-C.W., and H.C. collected the clinical data. All authors read and approved the final article.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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