Gina:

The link provided for you with the toolkits is an excellent resource. I could not 
connect directly to it initially and started by just going to the website itself 
and navigating through to the toolkits. http://www.cpqcc.org

At any rate that being said I did not see anything necessarily about pumping 
for the moms, treating of the milk (to reduce CMV) and use of donor 
milk/prolacta. It's very important the Mom's of premmies under 1500 grams and 
32 weeks be tested for CMV exposure. If their IgG is positive (tests exposure 
over their life...IgM is not what you want to test for) the milk should be 
treated for 72 hours in a -20 degree celsius deep freezer. We allow colostrum 
to cheeks not to be treated and colostrum for trophic feeds treated only 24 
hrs so we can get the baby going...72 hrs is preferable and is usually achieved 
if mom pumps from the get go. If mom is CMV positive we continue to treat 
milk in the a deep freeze until baby is 32-34 weeks depending on status of 
infant...we may freeze longer if baby is sick...

The most important thing is early pumping for the mom, identifying the 
colostrum (in my unit we consider this the first 28 pumps or 4 days of pumping 
but sometimes composite milk is achieved sooner). We usually start the babies 
off as soon as possible with 0.01 ml of colostrum to the cheeks (directly in the 
mouth) q 6hr to start the gut priming...do this for a couple of days then 
depending on the baby's size 1-3 ml of colostrum q 6 hrs for 3 days as trophic 
feeds...if tolerated we move the baby to 1-3 ml q 2 hrs of colostrum for 
another few days advancing amount as tolerated and described in the 
toolkit...we discontinue colostrum after 4-7 days depending on availibilty and 
stability of infant...usually we have extra colostrum left over we save just in 
case the infants go NPO for whatever reason...when we restart feeds we 
usually restart with colostrum for the first day or so...BTW as you advance 
feedings TPN and lipids are being reduced until you get to full feeds. The baby 
will continue full feeds q 2hrs until about 30 wks then to q 3 hr (really it's a 
weight thing...the total calories stay the same but the cc of feeds is just 
divided by 8 instead of 12 in order to get the volume for each individual feed)

Once at full feeds and tolerating we start human milk fortifying...for all infants 
born under 1000grams we fortify with Prolacta (fortifier derived from human 
milk). We use a 22 calorie/ounce (ha, ha as you'd have to spin mom's milk to 
be able to know actual calorie count) recipe which is 80% breast milk and 20% 
Prolacta +4...unfortunately babies over 1000 grams in my unit must be given 
Ross HMF which is derived from cow's milk, but generally well tolerated...this is 
due to budgetary reasons as insurance companies are not reimbursing for 
prolacta fortification or donor milk...we also use banked donor milk for our 
under 1000 gram babies whose mom's can't produce (due to death, cancer 
breast augmentation and more reasons I can't think of right now)...also for 
the same budgetary reasons we usually stop using donor milk/prolacta when 
babies reach about 32-34 weeks old...eventually we hope to be reimbursed 
and therefore able to keep the babies on throughout their stay. We still will 
fortify the mom's milk if needed but usually with powdered synthetic product.

Eventually, once babies coordinate suck/swallow/breathe at about 32-34 
weeks we start transitioning to PO feeds...right now we are not so good with 
getting the babies on the breast...we have many breast milk babies but not 
breastfed, but that's a personal goal of mine to increase the feeding at the 
breast using test weighting and supplementation via ng tube instead of bottle 
(a whole other topic for discussion).

Hope this information helps you with your policy.
Regards,
Marianne Cesarotti, BSN, RN, CLC

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