A recent post on the intranasal application of breast milk Can intranasal application of breastmilk cure severe IVH? garnered a lot of attention and importantly comments. Many of the comments were related to other uses for breast milk (almost all of which I had no idea about). A quick search by google uncovered MANY articles from the lay press on such uses from treating ear infections to diaper dermatitis. One such article 6 Surprising Natural Uses For Breast Milk certainly makes this liquid gold sound like just that! This got me thinking as I read through the claims as to how much of this is backed by science and how much is based on experience of mothers who have tried using breast milk for a variety of unconventional treatments. I was intrigued by the claim about acne as with several family members nearing that wonderful period of the teenage years I wondered might there have been a treatment right under my nose all this time? Before going on I will tell you what this post is not. This is not going to be about telling everyone that this is a terrible idea. What this is about is breaking down the science that is behind the articles that have surfaced on the internet about its use. I thought it was interesting and I hope you do too!
The Year Was 2009
The story begins here (or at least this is the point that I found some evidence). A group of nanoengineering researchers published a paper entitled The antimicrobial activity of liposomal lauric acids against Propionibacterium acnes. The authors examined the antibacterial effect of three fatty acids one of which was lauric acid (which is found in coconut oil but also in breast milk) against Propionibacterium acnes (P. acnes) the bacterium responsible for acne in those teen years. The results in terms of dose response to lauric acid was quite significant.
This is where the link in the story begins. Lauric acid kills P. Acne and it is found in high concentrations in breast milk so might topical application of breast milk treat acne? From what I can see this concept didn’t take off right away but a few years later it would.
Next we move on to 2013
This same group published In vivo treatment of Propionibacterium acnes infection with liposomal lauric acids. in 2013. This time around they used a mouse model and demonstrated activity against P. Acnes using a liposomal gel delivery system to get the Lauric acid onto the skin of the mouse. Interestingly, the gel did not cause any irritation of the mouse skin but using the traditional benzoyl peroxide and salicylic acid caused severe irritation. From this it appears that the news story broke about using breast milk to treat acne as I note several lay press news stories about the same after 2013. Let’s be clear though about what the state of knowledge is at this point. Lauric acid kills P. Acne without irritating skin in a mouse model. As with many early discoveries people can get very excited and apply the same to humans after extrapolation.
What Happened Since Then?
Well, in late 2018 this study was released Design, preparation, and evaluation of liposomal gel formulations for treatment of acne: in vitro and in vivo studies. This is another animal study but this time in the rat which demonstrated application of the gel led to “∼2 fold reduction in comedones count and cytokines (TNF-α and IL-1β) on co-application with curcumin and lauric acid liposomal gel compared to placebo treated group.” Essentially, comedones were reduced and markers of inflammation. So not only do we see an antimicrobial effect, once the bacteria are erradicated, there is a clinical reduction in acne lesions!
Where do we go from here?
This story is still evolving. Based on the animal research thus far here is what I believe.
1. Lauric acid a fatty acid found in breast milk can kill P. Acne.
2. Lauric acid provided in a gel form and topically applied to rodents with acne can achieve clinical benefits.
3. Whereas current standard treatments of benzoyl peroxide and salicylic acid cause inflammation of the skin with a red complexion, lauric acid does not seem to have that effect.
These are pretty incredible findings and I have no doubt, pharmaceutical companies will be bringing forth treatments with lauric acid face creams (they already exist) with a target for acne soon enough. The question though is whether families should go the “natural route” and apply expressed breast milk to their teenagers face. Aside from the issue of whether or not your teenager would allow that if they knew what it was the other question is what might grow on the skin where breast milk is left. I am not aware of any further studies looking at other bacteria (since P. Acnes certainly isn’t welcome around breast milk) but that is one potential concern.
In the end though I think the research is still a little premature. We don’t have human trials at this point although I suspect they are coming. Can I say this is a terrible idea if you are currently using breast milk in such a fashion? I suppose I can’t as there is some data presented above that would give some credibility to the strategy. I am curious for those who read this post what your experience has been if you have used breast milk for acne or for other skin conditions.
It isn’t often in Neonatology these days that something truly innovative comes along. While the study I will be discussing is certainly small I think it represents the start of something bigger that we will see evolve over the coming years.
There is no question that the benefits of mother’s own milk are extensive and include such positive outcomes as improved cognition in preterm infants and reductions in NEC. The benefits come from the immunological properties as well as the microbiome modifying nature of this source of nutrition and have been discussed many times over. Mother’s own milk contains a couple of very special things that form the basis of the reason for the study to be presented.
What are neurotrophins and stem cells?
Before discussing the study it is important to understand what these two classes of molecules and cells are capable of. Neurotrophins are molecules that have the capability of promoting growth and survival of neural cells. Included in this class are EGF, brain-derived neurotrophic factor, glial derived neurotrophic factor, nerve growth factor, insulin-like growth factor-1, and hepatic growth factor. It turns out that not only are these found in high concentrations in breast milk but that a woman who produces breast milk at early gestational ages has higher amounts of these substances in her milk. Pretty convenient that substances promoting development of the brain and survival of brain cells increase the earlier you deliver! Stem cells are pluripotent cells meaning that they can develop into pretty much any cell type that they need to in the body. This would come in handy for example if you needed some new cells in the brain after a neurological insult. These are also present in mother’s milk and in fact can represent as much as 30% of the population of cells in breast milk.
The Nasal Cavity and the Brain
Clearly, the distance from the nasal cavity to the brain is relatively short. Without going into exhaustive detail it has been demonstrated in animal models that provision of medications intranasally can reach the brain without traversing the blood stream. This affords the opportunity to provide substances to the neonate through the nasal cavity in the hopes that it will reach the brain and achieve the desired effect. When you think about it, newborns when feeding have contact between the whole nasopharyngeal cavity and milk (as evidenced by milk occasionally dripping out of the nose when feeding) so using an NG as we do in the NICU bypasses this part of the body. Is that a good thing?
Intranasal application of breast milk
Researchers in Germany led by Dr. Kribs published an early experience with this strategy in their article Intranasal breast milk for premature infants with severe intraventricular hemorrhage—an observation. In this paper the strategy;follows; 2 × 0.1 ml of his or her mother’s milk 3 to 8 times a day (0.6 to 1.6 ml total per day). The breast milk was freshly expressed, which means the milk was used within 2 h after expression. The daily application started within the first 5 days of life and was continued for at least 28 days to a maximum of 105 days.
The outcome of interest was whether the severe IVH would improve over time compared to a cohort of infants with severe IVH who did not receive this treatment. Importantly this was not a randomized trial and the numbers are small. A total of 31 infants were included with 16 receiving this treatment and 15 not. The two groups were compared with the results as follows.
The results don’t reach statistical significance but there is a trend at the bottom of the table above to having less progressive ventricular dilatation and surgery for the same. Again this is a very small study so take the results with a grain of salt!
Is this practice changing? Not yet but it does beg the question of what a properly designed RCT might look like. The authors predict what it might look like with a sham nasal application versus fresh mother’s milk. I do wonder though if it may become a study that would be hard to recruit into as when families are approached and the potential benefit explained it may be hard to get them to say anything other than “Just give my baby the breast milk!” Such is the challenge with RCTs so it may be that a larger retrospective study will have to do first. Regardless, be on the lookout for this research as I suspect we may see more studies such as this coming and soon!
* Featured image from the open access paper. (There couldn’t be a better picture of this out there!)
Producing milk for your newborn and perhaps even more so when you have had a very preterm infant with all the added stress is not easy. The benefits of human milk have been documented many times over for preterm infants. In a cochrane review from 2014 use of donor human milk instead of formula was associated with a reduction in necrotizing enterocolitis. More recently similar reductions have been seen in retinopathy of prematurity. Interestingly with respect to the latter it would appear that any amount of breast milk leads to a reduction in ROP. Knowing this finding we should celebrate every millilitre of milk that a mother brings to the bedside and support them when it does not flow as easily as they wish. While it would be wonderful for all mothers to supply enough for their infant and even more so that excess could be donated for those who can’t themselves we know this not to be the case. What we can do is minimize stress around the issue by informing parents that every drop counts and to celebrate it as such!
Why Is Breast Milk So Protective
Whether the outcome is necrotizing enterocolitis or ROP the common pathway is one of inflammation. Mother’s own milk contains many anti-inflammatory properties and has been demonstrated to be superior to formula in that regard by Friel and no difference exists between preterm and term versions. Aside from the anti-inflammatory protection there may be other factors at work such as constituents of milk like lactoferrin that may have a protective effect as well although a recent trial would not be supportive of this claim.
Could Mother’s Own Milk Have a Dose Response Effect in Reducing The Risk of BPD?
This is what is being proposed by a study published in early November entitled Influence of own mother’s milk on bronchopulmonary dysplasia and costs. What is special about this study and is the reason I chose to write this post is that the study is unusual in that it didn’t look at the effect of an exclusive human milk diet but rather attempted to isolate the role of mother’s own milk as it pertains to BPD. Patients in this trial were enrolled prospectively in a non randomized fashion with the key difference being the quantity of mothers own milk consumed in terms of a percentage of oral intake. Although donor breast milk existed in this unit, the patients included in this particular cohort only received mother’s own milk versus formula. All told, 254 infants were enrolled in the study. As with many studies looking at risks for BPD the usual culprits were found with male sex being a risk along with smaller and less mature babies and receipt of more fluid in the first 7 days of age. What also came up and turned out after adjusting for other risk factors to be significant as well in terms of contribution was the percentage of mother’s own milk received in the diet.
Every ↑ of 10% = reduction in risk of BPD at 36 weeks PMA by 9.5%
That is a really big effect! Now what about a reduction in costs due to milk? That was difficult to show an independent difference but consider this. Each case of BPD had an additional cost in the US health care system of $41929!
What Lesson Can be Learned Here?
Donor breast milk programs are a very important addition to the toolkit in the NICU. Minimizing the reliance on formula for our infants particularly those below 1500g has reaped many benefits as mentioned above. The availability of such sources though should not deter us from supporting the mothers of these infants in the NICU from striving to produce as much as they can for their infants. Every drop counts! A mother for example who produces only 20% of the needed volume of milk from birth to 36 weeks corrected age may reduce the risk of her baby developing BPD by almost 20%. That number is astounding in terms of effect size. What it also means is that every drop should be celebrated and every mother congratulated for producing what they can. We should encourage more production but rejoice in every 10% milestone.
What it also means in terms of cost is that the provision of lactation consultants in the NICU may be worth their weight in gold. I don’t know what someone performing such services earns in different institutions but if you could avoid two cases of BPD a year in the US I would suspect that nearly $84000 in cost savings would go a long way towards paying for such extra support.
Lastly, it is worth noting that with the NICU environment being as busy as it is sometimes the question “are you planning on breastfeeding?” may be missed. As teams we should not assume that the question was discussed on admission. We need to ask with intention whether a mother is planning on breastfeeding and take the time if the answer is “no” to discuss why it may be worth reconsidering. Results like these are worth the extra effort!
I woke up this morning and as I do everyday, scanned the media outlets for news that would be of interest to you the reader. One such article today was about how breast milk may give babies a metabolic boost due to micro RNA present in the milk. This got me thinking about how natural a thing this breast milk is and how substances within interact with the baby receiving it. After that point I recalled writing about a challenge to the statement that breast milk is natural and thought you might like to see what I considered to be an outrageous piece of journalism from last year.
The premise of the article is that by reinforcing that breastfeeding is natural we may hamper initiatives to increase vaccination in many parts of the world and in particular North America I would think. The idea here is that if we firmly entrench in women’s heads that natural is better then this will strengthen the conviction that we should not vaccinate with these “man made” unnatural vaccines. I am sorry to be dramatic about this but I think the argument is ridiculous and in fact dangerous.
The Definition of Natural
“existing in nature and not made or caused by people : coming from nature”
From the Mirriam Webster dictionary
Breastfeeding satisfies this definition pure and simple and there is nothing that anyone should say to suggest otherwise no matter what the motive is. The shift from formula to breastfeeding has been predicated on this notion and a plethora of literature on the subject demonstrating reductions in such things as infections of many kinds, diarrhoea, atopic disease in the first year of life as examples. In my world of premature infants additional reductions in NEC, bloody stools, have been seen and more recently in some cases improved neurodevelopmental outcomes.
In this case of irresponsible journalism a better approach if you were wanting to use the natural argument with respect to vaccines is to promote just that.
Vaccines are Natural
Someone will no doubt challenge me on this point as it would be a fair comment to say that there are artificial substances added to vaccines but there is no question the organisms that we vaccinate against are natural.
Think about this for a moment. All of the vaccines out there are meant to protect us against organisms that exists in NATURE. These are all bacteria or viruses that have likely existed on this planet of ours for millions of years. They are found everywhere and in many cases what we are doing when we give such vaccines are providing parts of or weakened versions of these natural organisms in order for us the human to mount a protective response.
This protective response is NATURAL. If we didn’t vaccinate and came across the fully virulent pathogen in NATURE our bodies would do exactly what they do when a vaccine is given to us. Our immune system would mount a response to the organism and start producing protective antibodies. Unfortunately in many cases this will be too little too late as the bacteria or virus will cause it’s damage before we have a chance to rid ourselves of this natural organism.
This is the basis of vaccination. Allow our bodies a chance to have protection against an organism that we haven’t been exposed to yet so that when it comes we have a legion of antibodies just waiting to attach this natural organism.
CNN Didn’t Get It Right
In the article which is based on a paper entitled the Unintended Consequences of Invoking the “Natural” in Breastfeeding Promotion by Jessica Martucci & Anne Barnhill the authors admit that the number of families that this actually would impact is small. the question then is why publish this at all. Steering families away from thinking that breastfeeding is natural is wrong. Plain and simple.
If the goal is to improve vaccination rates, focus on informing the public about how NATURAL vaccinations actually are and don’t drag breastfeeding down in order to achieve such goals. As a someone who writes themselves I am well aware of how personal biases creep into everything we write. I am aware of the irony of that statement since it is clear what side of the argument I sit on. While I peruse CNN myself almost daily I think the editors either missed the larger message in this piece or perhaps felt the same way. A disclosure that “the opinions of the author do not necessarily represent those of the network” does not cut it for what I would consider responsible journalism in this case.
What follows is a news release from today that begins a new chapter in supporting preemies here in Manitoba. There are far too many people to thank who made this possible but to all I say THANK YOU!
New Breast Milk Drop Site at the Birth Centre Benefits Premature and Sick Infants
DECEMBER 2, 2015 (WINNIPEG, MB) – The Winnipeg Regional Health Authority (WRHA) announced today a milk drop site is being established at the Birth Centre (603 St. Mary’s Road) in Winnipeg. Minister Blady announced the collaboration between Women’s Health Clinic and the NorthernStar Mother’s Milk Bank.
Registered donations of breast milk will be accepted by the Birth Centre in Winnipeg and transported for pasteurization at NorthernStar’s lab in Calgary. The pasteurized human milk from donors will be used to help premature and sick babies in neonatal intensive care units in hospitals, and in the community, across Canada.
“There can be a number of reasons why a mother may not be able to provide breast milk for her baby,” said Health Minister Sharon Blady. “This new Milk Drop site will help families ensure premature and sick babies get the best possible start in life by providing pasteurized donor human milk an infant needs to not only survive, but thrive.”
The minister noted that establishing a human milk drop supports recommendations made in the Manitoba Breastfeeding Strategy, released in 2013.
The WRHA purchased a freezer for the milk drop with funds provided by the Winnipeg-based Siobhan Richardson Foundation. The Birth Centre will house the freezer and ensure the safe handling and storage of donated human milk before it is shipped to Calgary for processing.
“My thanks and appreciation goes out to the Siobhan Richardson Foundation for supporting new moms as well as our tiniest patients,” said Dana Erickson, Chief Operating Officer, Health Sciences Centre and WRHA executive responsible for child health and women’s health. “This milk drop initiative in Manitoba is a reality because of their vision and generosity along with the commitment and hard work of our excellent health care team.”
Studies have shown premature infants who receive the nutrients of pasteurized human milk from donors, when their mother’s own milk is not available, have fewer long-term health needs. The use of pasteurized donor human milk instead of formula can reduce the risk of serious health complications in pre-term infants. Having a dedicated milk supply for these babies can save lives.
“Several health outcomes for preterm infants are improved when pasteurized donor human milk, rather than formula, is used in these high risk infants,” said Dr. Michael Narvey, section head of neonatology for the Winnipeg Regional Health Authority. “Pasteurized donor human milk has been proven to reduce the chances of an infant developing a serious condition of the bowel which can lead to lifelong and serious health consequences. Babies weighing less than 1500 grams are significantly less likely to develop this serious condition when they are given pasteurized human milk from donors as opposed to formula.”
Starting January 4, 2016, the Birth Centre will accept breast milk from donors approved by NorthernStar Mothers Milk Bank (formerly the Calgary Mothers Milk Bank). Women must first contact the NorthernStar Mothers Milk Bank to be screened prior to dropping off their donation at the Birth Centre. Women will then need to have further screening including blood tests by their primary care provider to confirm if they qualify as a donor. These donations will be sent to the milk bank’s lab in Calgary where the donor milk is tested, pasteurized, and then prioritized for premature and sick infants.
“We are excited to see Manitoba’s first Milk Drop opening in Winnipeg,” said Janette Festival, Executive Director, NorthernStar Mothers Milk Bank. “This Milk Drop is a testament to cooperation of multiple groups who believe in the medical power of donor human milk for babies in need. We hope this new ‘drop’ will encourage women in the Winnipeg area to consider becoming a milk donor.”
Women’s Health Clinic operates the Birth Centre facility and community programming, and will be collecting the donations and shipping them to the milk bank for testing and pasteurizing.
“Women and families come to the Birth Centre every day for a range of maternal health and wellness services, making it an ideal location for the new Milk Drop site,” said Joan Dawkins, Executive Director of Women’s Health Clinic. “Women who are interested in donating can get the process underway now by contacting NorthernStar Mothers Milk Bank.”
To donate, mothers can contact the milk bank at 1-403-475-6455 or visit NorthernStarmilkbank.ca.
There is the potential for a very significant issue to arise in the NICU environment in the coming years. As I was preparing the last blog piece following the decision by SCOTUS to allow same-sex marriage in all 50 states I began to think about the so-called ripple effect. In other words, now that the law has been changed, what impacts could this have that might have been unforeseen. The first thought that crept into my mind was that as male same-sex parents they would read the same literature that promotes breast milk feeding in the NICU and no doubt want the best for their infant in the NICU or for that matter any baby. In many NICUs however there are weight or gestational age restrictions indicating who will receive donor breast milk if the mother is not able or not willing to produce her own. In our unit for example we given DBM to all babies currently under 1250g and those recovering from NEC or other bowel surgery. Might men in a same-sex marriage who have adopted a child or used a surrogate who is not willing to breastfeed demand the same?
In looking into this I came across a very strange story from 2013 in which a nurse in the UK offered to “rent her breasts” to gay parents. The story at the time caused a fairly big stir as it raised a number of questions as to safety and the morality of it all. In some ways it was ahead of its time as there have been a number of articles recently addressing the very issue of safety of milk (will be addressed further in the article obtained outside of HMBANA approved breast milk banks.
As same-sex couples increase and many then choose to have children of their own to raise what demands will be made of access to breast milk? There is no question “breast is best” and I have either written or posted to Facebook many articles suggesting decreased incidence of allergy, necrotizing enterocolitis, improvements in the microbiome and many other benefits as well. What do we do in the situation of the same-sex family who declares that they want to provide breast milk to their infant in hospital as it is the best source of nutrition for their infant. If we say for example that their 2 kg, 34 week infant is too big to qualify for DBM is this fair given that they have no option for producing their own milk in the setting of male same-sex partners? Could we as health care providers be labelled as discriminating?
One option is to allow such parents to bring in their own milk but then where do they source it from? Milk purchased online or from the community may be contaminated with bacteria, viruses or contain some cow’s milk as some recent publications have demonstrated. Can we knowingly allow families to bring such milk into the hospital to feed their infant? Perhaps, but only if we have medical legal safeguards in place that protect the hospital from knowingly allowing patients to bring in milk which could be contaminated. Waivers of liability would need to be in place in each hospital permitting such sourcing of milk. If however we strongly discourage such practice will we direct them to the milk bank supplying our local hospital. Herein lies the challenge though. If availability of volume was not an issue, we could provide to all infants in the unit but the reality is there is simply not enough to go around. Furthermore, the larger the infant, the more donor milk they utilize and the more depleted the supply becomes for those of our smallest infants who are most in need of avoiding formula. Finally, who should pay for this milk if the family cannot produce any as in this situation. This is not a case of a mother who could produce but chooses not to but rather a family who is desperate to use what they have read is best but physically is incapable of producing. The same of course could be said for those women who try and cannot or due to prior surgery are unable to produce milk. I believe this is an issue that will come up across the US and Canada and I will be interested to see how it plays out and what role Bioethics may play in helping to resolve some of these questions.
This will be a slippery slope. If male same-sex parents are provided with free access to donor milk I don’t see how donor milk will not be made available to all families who cannot provide their own. Why would the male parents who biologically be unable to provide milk be given this “liquid gold” while other mothers who are pumping round the clock, taking domperidone and seeing a lactation consultant and getting only drops be denied as their newborn is 1600g and above the weight cutoff. I hope you can see the issue of equity popping up in this discussion.
Finally why not allow those parents who are male same-sex partners to simply pay for the milk they need if they don’t qualify for “free” milk under a unit’s program? Sadly the issue then becomes one of equity again. Do we want to care for infants in an environment where the wealthy who can afford to pay for the donor milk from an HMBANA milk bank get it and the poor are only offered formula? I have to admit I realize there are health care systems where this is the case but in Canada where we have a socialized medical system this kind of two tiered system would cause many to become nauseated.
I fear that this issue will come up as the number of people marrying and choosing to have children in same-sex relationships increases. If it leads to a 100% human milk diet for infants in the NICU I would say that is a good thing but I think the road like Winnipeg will be paved with many potholes that we will have to do our best to navigate around.