Conan Gasque (Host): Welcome to Inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Conan Gasque. We were talking about breastfeeding and the Project HOME Initiative with Dr. Allison Black, a neonatologist here at Children's of Alabama. Dr. Black, thanks so much for your time.

Dr. Allison Black: Hi, Conan. It's so nice to be here.

Host: Glad to have you. So, let's start first by talking about breastfeeding in general. I know we hear a lot about it and it's something that soon-to-be-moms certainly want a lot of advice about. So, let's talk a little bit about the benefits of breastfeeding. What are some of the benefits?

Dr. Allison Black: Well, Conan, I know that all of our listeners have probably heard the slogan, "Breast is best," and that is true. There are benefits from breastfeeding to both the mother and to their infant as well. So, I think for this podcast, we're going to concentrate more on the babies, but there's multiple benefits. So, a mother, when she makes human milk, she provides the perfect nutrition, individualized for her baby. Breast milk is the easiest to tolerate for babies. It helps promote better digestion, the perfect growth, the nutrition they need for the growth that they need, which is we'll get into more later with preterm infants because it's tailored just for them and those mothers. And then also, babies get a passive immunity when they get breast milk from their mother.

Now, what passive immunity means is that, for instance, if you are sick with a cold and you're a mother who's breastfeeding, your body is fighting that cold and producing antibodies. Those pass through your breast milk to your infant and they are protected from getting that cold.

Host: That's great. So, that, of course, is one of the many benefits. You mentioned, and I have to ask the benefits to the mother, I feel like that's good information as well. What are some of those benefits?

Dr. Allison Black: There is. Yes, there's lots of benefits. So for mothers, of course, bonding is one of the things that we all talk about. But then physiologically, they help mother's blood pressure to normalize. They help promote uterine contractions. Therefore, the mom, her uterus and her body returns to that pre-pregnancy state a little bit quicker. Those are just two of the big, you know, benefits that you can see.

Host: And as mentioned, I know soon-to-be-moms have a lot of questions about it. Some are wondering, you know, should I breastfeed, should I not breastfeed? What about the common questions? Are there certain common questions that you get all the time about breastfeeding in general from moms?

Dr. Allison Black: So, I can tell you some of the common questions, but I think even better would be some of the common concerns that moms have when they are making the decision to breastfeed.

I think one of the biggest concerns that moms have when they are first starting to breastfeed is, is their baby getting enough milk? Unlike when you bottle feed a baby and you're able to measure the exact amount they get, when you directly breastfeed from the breast, you're not able to that. So, we constantly reassure mothers. There are other things that we can look for. We can look for babies to make sure that they have the right number of wet and dirty diapers. We can follow their weight gain. And even though that is one of their common concerns, there are other ways that we can make sure their babies are getting exactly what they need.

Along those lines, moms are always concerned are they going to produce enough milk? And that's one of the things that, you know, we also can talk to moms. There are ways through just mother making sure she's hydrated, she's well-rested. Those are just two of the things we really encourage mothers to do to make sure that their body is able to produce the milk they need to.

One of the other concerns moms have sometimes, especially in the immediate postpartum period is that they're on medications for certain things that happened either for their pain or for their blood pressure, if they had issues with that during pregnancy. So, their concern is, Is this going to be harmful to my baby? Contrary to what a lot of the common public thinks, there's lots of medications that are perfectly safe to breastfeed while you are taking. Your body does break down and metabolize those medications. So in some instances, there is a very trace amount only that's passed along through the breast milk. Of course, I encourage anyone who is on a medication if your breastfeeding that that's something that needs to be discussed with your physician.

Host: And I guess that kind of goes with any questions you have about it. Certainly talk to your doctor about any problems you might be having, any questions you have about the impact something might have on the child.

Dr. Allison Black: Yes, exactly.

Host: I know that in some cases, some women have trouble breastfeeding. Can you talk about some of the reasons why that might happen and what a woman should do if she encounters that?

Dr. Allison Black: Yes. So, there's multiple reasons. When you think about just pregnancy and the birth process in itself, it's a very stressful situation. And lots of times, mothers, you know, depending on how they've delivered, could have been through a major surgery, they could have had health issues of their own. So, that's one of the main contributors that can cause problems with breastfeeding. Certain medications and certain things that have happened to mom will delay them having breast milk come in to feed their baby.

Other things that can make difficulty with breastfeeding is that sometimes babies, if they aren't having the appropriate latch, mom can get sore and they can actually have problems with their own breasts becoming where the breasts aren't expressing the milk like they need to. And that can lead to things such as mastitis, which is an infection or clogged milk ducts. So, that's one of the more common problems we can see too with breastfeeding.

Host: So, let's talk a little bit now about Project HOME. It's something that you spearheaded here at Children's of Alabama. And, you know, I know we talk about breastfeeding being important in general, but this is targeted at a specific population of children, right?

Dr. Allison Black: Yes, it is. This is what I alluded to earlier when I was talking about the importance of breastfeeding and the benefits. So, Project HOME, which is H-O-M-E, which stands for Home on Milk Every Time, is a project that involves about 37 centers throughout the United States and Canada, some of the leading children's hospitals. And it actually looks at increasing breastfeeding rates in specifically level 4 NICUs. So, level 4 NICUs are the NICUs that have the sickest babies.

Host: Which we have here at Children's of Alabama.

Dr. Allison Black: Which we have here at Children's of Alabama, yes. And that we know that, you know, all babies benefit from getting breast milk or human milk, but especially these preterm babies who are so sick, they gain the biggest benefit from having human milk feedings.

Host: And I guess that's just because they're in such a difficult state, such a critical state, that they need those additional nutrients? Is that right?

Dr. Allison Black: That's correct. So, number one, you remember I talked about how that's the easiest form of food for them to digest. So, it's the gentlest on their stomach. It's broken down easier and it's just easier for them to tolerate. Also, those passive immunity that I've talked about is a huge benefit for babies in the level 4 NICU receiving breast milk. There's also a common issue that preterm infants can get called necrotizing enterocolitis, which is actually an infection of the gut. And the only thing that we've proven that really helps prevent that is feeding babies breast milk rather than formula.

Host: Well, that's interesting. So, that just amplifies how big a deal this can be for this population.

Dr. Allison Black: Exactly.

Host: What are some of the strategies that you use? to increase human milk use among this population. How do you talk to to the parents and how do you encourage this use?

Dr. Allison Black: It's interesting, because this really kind of plays into some of the strategies that we're using in this quality improvement or Project HOME. And so, there's certain things that have been looked at and we know are associated with a higher breastfeeding or human milk feeding rates in infants, and specifically infants in the NICU.

So, one of the things that we really target is early parent education. So within 24 hours of admission, we try to have a frank conversation with mother and dad about how important this breast milk is. I think a lot of people have heard it's important, but they don't know the science behind it and there is a science behind it. So, we try to have that conversation with them. We also have very early involvement of our lactation consultants. They meet with the families and they discuss with them how important it is as well, just to reinforce that. And then they also assess what their access is to have the resources they need to be able to breastfeed successfully. So, a lot of our infants in the level 4 NICU, they aren't able to actually go directly to the breast because they're so sick. So, that requires a mom to use a breast pump to express her milk. And then, we feed them that milk she expresses. So, it's very important for us to know that mom has access to one of those breast pumps and that she starts early on expressing her breast milk so we can use it.

The other thing that we target is there are certain milestones that we know if we're performed in infants early on in their admission, they will have higher rates of breastfeeding at discharge. So, it's interesting. It's a series of three milestones that we've looked at. One of those is called kangaroo care. People have heard of this and it's just the baby doing skin to skin being held with their mom. We know that not only does that help with bonding, but it helps the baby sometimes stabilize. Actually, sometimes you'll see babies where their vital signs are more stable. And then also, it helps breast milk production. So, that's one thing we try to do very early on.

Another thing we try to do very early on is all of the oral care. When babies are on a breathing tube and they're not able to take a bottle, we still swab their mouth with things to keep their oral mucosa moist. And so, we try to perform that with human milk. So, they get that. Even though they aren't able to take feeds, they still get that benefit of that first thing that goes into their GI system being human milk.

And then, the third thing, or the third milestone that we really work to try to attain is the first time that a baby is able to feed by mouth, because as you remember, a lot of these babies can't eat by mouth at first. They're too premature or have other issues. The first time that happens, we'd like for it to be at the breast. We'd like them to be able to go directly to mother's breast and to breastfeed for that first feed.

Host: And does that just set the stage for what's to come so that the baby, you know, understands that this is how I feed?

Dr. Allison Black: It does. It does. It sets the stage. But again, that's one of those things that helps with maternal bonding and helps with breast milk production. If you think about moms who have babies in the NICU, they have a huge amount of stress. Not just about the illness of the baby, they have competing things going on in their life. They want to be here with their baby, but if they have other obligations at home, they're not able to be here like they want to with their baby all the time. They aren't able to hold and touch and love on their baby if they're very sick. So just that first feeding, being actually at the breast and that bonding that they get is a huge promoter of milk production. And like I said, the bond between the mom and them.

Host: And I guess that just, you know, goes back to what we were talking about earlier that, you know, during this process, the mom's health is also very, very important to making sure that she can produce the milk and that she's able to breastfeed.

Dr. Allison Black: Exactly. If the mom's not healthy, she's not going to be able to produce the breast milk for us to give to the baby. So, it's one of our main concerns.

Host: And I know that donor milk can also have a lot of benefits as well, right?

Dr. Allison Black: Donor milk does. Yes, donor milk, it has a lot of the benefits than mother's own milk. It is slightly different and that it does go through a slight pasteurization process. And so, some of those antibodies that are there, we don't see as well. And then if you remember, I said, the human body is really complex and unique, and it's a fantastic thing in that moms, when they do produce human milk for their infant, it is specific to their infant.

For example, if you have a premature infant, your milk is going to have a higher calorie content. Your body just knows to do that, whereas that's not exactly the case with donor milk. We're very fortunate to have it, because it is better digested and it has a lot of the benefits and the protective effects that I talked about. But there are certain things that donor milk cannot give that only a mother's own milk can.

Host: So, I guess if you have a situation where a mom, for whatever reason, is not able to breastfeed, then that's a case where the donor milk would be a good use.

Dr. Allison Black: Yes, exactly. Or sometimes we see a case where the mom just can't produce enough. And so, what we would do is always give that mother's own milk first. But then the rest of the volume could be given, would be a donor milk.

Host: So, this is a multifaceted program. There's a lot of really fascinating science behind this. You all have certainly done a lot of research. What kind of impact have you all seen in the time that you all have been doing this?

Dr. Allison Black: Well, the program we that we started, the collaborative, we just started in January. So, we're coming up on a year now. And so far, we've seen some really great effects. So, we've seen parents become very involved. You know, the milestones I talked about, we've seen parents who are excited to do those, who really want to be involved. And now, they understand what kind of an impact it is just on their baby's health. And not just from the bonding standpoint, from the standpoint of like I'm physically able to do something now that is going to provide protection and help the outcome of my baby. We have seen a slight uptick. It's a little early to call it a trend, but we have seen an uptick in our baseline of about 5%. The measure we're looking at is breast milk at discharge or at 120 days. We have seen an improvement in that.

The thing that I'm the most excited about is I think the entire care team, from the bedside nurses to the lactation consultants and nutritionists, our nurse practitioners are all really engaged and excited about the project. So, everyone has become, I think, much more comfortable with discussing and educating others about the benefits of breastfeeding. And in turn, that just makes everyone a much better person to have the resources to provide the support to our families.

Host: Having that kind of multifaceted approach or that multidisciplinary approach, I should say, can really make a big difference, right?

Dr. Allison Black: It makes a huge difference. I think just for parents, like I said, this is such a stressful time and just receiving the same message from everyone and having support from different areas, not just from your bedside nurse or your doctor, but know that there's four other people who are cheering for you and helping you and want you to succeed, I think makes a huge difference for these families.

Host: All right. Well, it's a great project that you all are working on. I know you all have spent a lot of time on this and you want to keep moving it forward. So, thanks for all the work you're doing and thanks for your time today.

Dr. Allison Black: Thank you so much.

Host: All right. Once again, Dr. Allison Black, neonatologist here at Children's of Alabama. Thanks for listening to Inside Pediatrics. For more podcasts like this one, go to childrensal.org or wherever you find podcasts.