The earliest delivery of mother’s milk is a natural and protective event in nature: the suckling of the first drops of colostrum.
The importance of this earliest milk is told based on other mammals that get sick or die if they aren’t able to receive colostrum in a timely manner. Fortunately, we don’t have immediate consequences for most of our healthy term infants that feed on formula, but the argument for harm may be stronger for our preterm or sick newborns who don’t receive the “liquid gold” from their mothers and receive bovine-based formula instead.
Colostrum contains a powerful mixture of concentrated components compared to mature milk that include immune protecting agents as well as microbiome promoting agents (prebiotic oligosaccharides and probiotics), in addition to higher nutritional protein and lower lactose and fat. The richness of this milk has more immunologic value than nutritional value given the low volume of intake.
Oral colostrum care
Theoretical evidence for oral colostrum delivery supports absorption and stimulation in the oral cavity, although whatever is put in the mouth does eventually get swallowed and so does constitute some feeding. Oral colostrum care (OCC) is a practice to deliver the earliest colostrum as soon as it can be expressed on a 3-6 hourly basis until feeds are advancing, generally by the end of the first week. Some are also evaluating the value of OCC for much longer periods with the possibility that oral stimulation with colostrum is important in the gastric tube fed infant.1
While we have great evidence that early trophic feeding with either mother’s milk or formula will stimulate the gut to adapt and mature, the more direct evidence of benefit to the gut with OCC given immediately after birth in the first day is much less studied. There are several studies on OCC that suggest that there may be growth advantages2 and reduction of sepsis,3 although the latter study was difficult to interpret since the sepsis rate was incredibly high (92%). The postulated benefits outweigh the actual proven benefits. However, the paucity of good and large randomized controlled studies in this area has not impeded the rapidity of OCC adoption that was basically non-existent a decade ago.
What is fascinating about this practice is the rapidity of the change in this practice. In areas across the country, the adoption of OCC is becoming widespread, with at least half of the NICUs joining in. My premise, then, for writing about OCC, is actually to examine some of the drivers that help us make such change happen in the NICU.
OCC practice change
So why then are we moving towards this practice? Why are we moving to the “tipping point” where it becomes standard of practice faster than many other practices? What could be the drivers, if not medical evidence? And why so quickly? Could it be that people are more knowledgeable about the properties of colostrum as a unique liquid tissue and assume all applications must be good? Or could they have looked at the evidence and just overinterpreted it? Did they extrapolate the benefits of human milk for the preterm infant and assume that earlier is better?
We tend to think that more is better for lots of practices that have turned out not to be so smart (e.g. antibiotics). Human milk has gained much support in the past decade and we are well past the tipping point for human milk and donor milk use, and so maybe we reached a point where OCC is part of the human milk conversation. As we engaged more and more with earlier and earlier pumping, there was now something we could give early that was not available in the past. Have we activated parents now finding themselves in a position to do more, i.e. now that I have pumped these drops, I want to do something with them for my child? Also, there is no question that mother’s milk evokes an emotional and empathic response, and this may be a hidden driver. Let’s briefly discuss some of the common big drivers of change.
There was and is no regulation that OCC needs to take place, but there has been a general pressure towards the safe and documented delivery of mother’s milk to prevent milk administration errors. When The Joint Commission established best practices for birthing hospitals now expecting benchmark metrics for breastfeeding, especially exclusivity of breast milk, the downstream impact on workflow, resources, equipment, and guidelines led to rapid practice changes over only a few years. Wouldn’t it be great if we could dictate what was mandated for important practices to adhere to?
The risk of litigation is a powerful driver, but there are no such cases I know of where someone sued because OCC was not given. On the other hand, the powdered products that we used frequently in the NICU were pushed to change to liquid form due to a constant risk of infection from powder. Although the incidence of Cronobacter sakasakii was quite low overall, having even one infection from powder infant sources would create a medicolegal nightmare that would make it hard to defend powder products, especially when liquid solutions were available. No wonder then that the move to liquid human milk fortifiers has been so swift and now has permitted an almost complete liquid only nutritional environment in the NICU.
Cost is an important driver in our practice. There are no immediate cost savings for practicing OCC and, in fact, there may be added costs. This practice requires a new workflow and in some cases different delivery devices may be needed that may add some costs. Parents and staff would need upfront and ongoing education on the collection method and approach. Some cost defrayment may occur if less donor human milk or less formula is used.
As mentioned the medical evidence for OCC practice is low. I am always impressed by how slow and poor the impact of medical evidence is when change is desired. In medicine, we were brought up on the value of medical evidence, but more and more its impact on change probably is much lower than we expect and secondary to many other drivers.
Sometimes we do things when we find out our peers are doing things. I get so much new information through travel and discussions with others at conferences when I find out the varying practices of other places in the U.S. or other countries. Comparing notes and finding better rationale for doing things helps. This is particularly good with some of our fearful notions that held us back from adopting, whereas others were early adopters. A good example was the use of high flow nasal cannula. Years ago, many of us were concerned when this first started as a practice that the pneumothorax rate would increase due to unregulated and unmeasured pressures. Talking to early adopter units showed that they were not experiencing any higher rates of pneumothorax which was reassuring and likely influenced my view on this, even in our still present inability to measure it. Finding out that others are doing OCC could be a driver.
Nursing and healthcare staff
The role of non-physician healthcare professionals often is a key driver for change that we underestimate. I have seen many teams of nurses, OT, and dietitians pushing for the OCC practice. Since they are “on the ground” more, they see the impact of work to make this precious volume of milk and then to be able to provide it to infants. Even the smallest preterm infant will react orally to the colostrum in their mouth with sucking movements. Many practices we adopt really happen due to the expertise, experience, and championing of non-physician neonatal care providers.
When a parent asks for us to consider a different path or process or treatment, we take this very seriously, and in my experience, may trigger us to do things differently from our routine practice. The movement towards more family involvement in neonatal care has been increasing, and encouragement to have parents more involved with feeding may have been responsible for some of this practice acceleration. Like the healthcare staff, we generally underestimate the value and importance of parents in delivering the best care to our infants.
So, to summarize, what do not appear to be drivers in OCC adoption are any rules and regulations, any medicolegal pressures, and prominent medical evidence – although this could have been extrapolated from the human milk literature. There are no immediate cost advantages, and adopting OCC practices involves time, teaching, new workflows and materials, guidelines, and EMR integration. Collecting of colostrum is an art as it is a challenge to collect the very small volumes in containers. So, the biggest drivers that remain seem to come from healthcare staff and the parents.
Moving forward with oral care
In truth, I am beyond thrilled that this practice is getting prime time, but some caution does need to be put down. The readout for benefit or harm needs to be examined with any new practice change. These need to be both short term such as with feeding tolerance, spontaneous intestinal perforation, or sepsis, and long term in terms of necrotizing enterocolitis and late onset infection. I’m not sure how many NICUs have structured their OCC implementation with quality data collection.
I keep going back to our past Aquaphor enthusiasm to show that short term gains in skin quality ended up being balanced by the presence of higher bacterial infection risk once examined with larger scale adoption in a study. We need to consider all possible causes of harm in the earliest feeding. We also need to manage the process so that milk is collected and delivered safely, since this may introduce new, unsafe steps. Can the earliest feeding set up a vulnerable gut to predispose to intestinal perforation by stressing it very early when they are generally the most sick? Is the gut microbiome more favorably primed by this measure? How will we measure these possible effects?
The example of OCC helps ask the more general question of what we need to do before making any change in practice. OCC may be a powerful example of change that is grass roots driven, emotionally flavored, and infant connected. Available medical evidence has taken a lower position in driving this change. OCC extends the well-known trust we have in mother’s milk to do good for the infant both biologically and nutritionally. OCC is a powerful action that increases parental involvement by having them collect the milk and save and deliver the precious fluid to their babies, which promotes early bonding.
When you are considering change, take a good look at yourself and your unit and evaluate what the drivers are, what is the carrot or the stick, where are the emotional links that motivate and impassion individuals to accept change. Perhaps with a better understanding of these factors we can create more such self-driven practices for the good of our babies.
- Rodriguez NA, Vento M, Claud EC, Wang CE, Caplan MS. Oropharyngeal administration of mother’s colostrum, health outcomes of premature infants: study protocol for a randomized controlled trial. Trials. 2015 Oct 12;16:453. doi: 10.1186/s13063-015-0969-6. PubMed PMID: 26458907; PubMed Central PMCID: PMC4603349.
- Seigel JK, Smith PB, Ashley PL, Cotten CM, Herbert CC, King BA, Maynor AR, Neill S, Wynn J, Bidegain M. Early administration of oropharyngeal colostrum to extremely low birth weight infants. Breastfeed Med. 2013 Dec;8(6):491-5. doi: 10.1089/bfm.2013.0025. Epub 2013 Jun 27. PubMed PMID: 23805944; PubMed Central PMCID: PMC3868273.
- Lee J, Kim HS, Jung YH, Choi KY, Shin SH, Kim EK, Choi JH. Oropharyngeal colostrum administration in extremely premature infants: an RCT. Pediatrics. 2015 Feb;135(2):e357-66. doi: 10.1542/peds.2014-2004. PubMed PMID: 25624376.