JOGNN IN FOCUS

CNE What Nurses Need To Know Regarding

Continuing Nursing Education
(CNE) Credit
Nutritional and Immunobiological
A total of one contact hour may be
earned as CNE credit for reading
What Nurses Need To Know
Properties of Human Milk
Regarding Nutritional and Jae H. Kim and Elizabeth B. Froh
Immunobiological Properties of
Human Milk and for completing an
online posttest and evaluation.

AWHONN is accredited as a
provider of continuing nursing ABSTRACT
education by the American Nurses
Credentialing Centers In this article, we discuss the nutritional and immunobiological components of human milk that nurses need to know
Commission on Accreditation.
to offer optimal care and education to their patients and families. We describe the major macronutrients and micronu-
AWHONN holds a California BRN trients in human milk that are essential to the growth and development of the newborn infant, and we discuss the
number, California CNE Provider
#CEP580
immunobiological components of human milk that supplement and boost the newborns immune system.
JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x
http://JournalsCNE.awhonn.org
Accepted August 2011
Keywords
human milk
nutrition
immunobiological
anti-inflammatory
anti-infective

Correspondence
Jae H. Kim, MD, PhD,
Pediatrics, UC San Diego
Medical Center, 200 West
Arbor Dr., MPF 1140, San
Diego, CA 92103-8774
neojae@ucsd.edu
Jae H. Kim reports
relationships with Abbot
Nutrition, Nutricia, and
Medela as a presenter and
member of an advisory
committee and has received
an honorarium and research
grant.
Elizabeth B. Froh and
planners for this activity
report no conflict of interest
or relevant financial
relationships. The article
includes no discussion of
off-label drug or device use.
No commercial support was
received for this
educational activity.
ewborn nutrition is of critical importance from
N a worldwide perspective. The choice be-
tween human milk (HM) and artificial nutrition is
one that every parent has to make, and a choice
that will continue to be a challenging one for future
parents to make. Understanding the science be-
hind the benefits of HM and disseminating that
knowledge to parents of newborn infants is of
utmost importance to the medical and nursing
community. Human milk is an evolutionary wonder
whereby the lactating mother produces a species-
specific nutritional and biologically active (bioac-
tive) product that confers the best health to the
human offspring. Human milk, like blood, is a liquid
tissue with cellular components, nutritional com-
ponents, and bioactive factors. Interestingly, the
number of bioactive factors (>200) far outnum-
bers the nutritional components in HM.
These facts provide the basis for the recommen-
dations that newborns have an exclusive diet of
HM from birth to age 6 months made by the
following organizations: the American Academy
of Pediatrics (AAP) Section on Breastfeeding
(Gartner et al., 2005), the American College of Ob-
stetricians and Gynecologists (ACOG, 2005), the
American Academy of Family Physicians (AAFP,
2007), the Academy of Breastfeeding Medicine
(ABM, 2008), the Canadian Paediatric Society
(CPS) (Boland, 2005), the European Society for
Pediatric Gastroenterology, Hepatology and Nu-
trition (NASPGHAN) (Agostoni et al., 2009), the
World Health Organization (WHO) (2001), and the
United Nations Childrens Fund (UNICEF, 2003).
In this article, we focus on what nurses need to
know about the nutritional and immunobiological
activity of HM to best prepare them for handling,
delivering, discussing, and promoting the use of
HM for sick and healthy newborns.
Nutritional Perspective
Human milk is the ideal and preferred nutritional
source for all preterm and term infants throughout
the first year of life. Although the optimal duration
of breastfeeding is unknown, most health orga-
nizations currently recommend exclusive breast-
feeding from birth to age 6 months. The AAP
further recommends a total duration of breastfeed-
ing for 1 year to maximize the full benefits of
breastfeeding (Gartner et al., 2005). The major
nutritional components of HM are macronutrients,
micronutrients, vitamins, and trace elements (see
Table 1).

http://jognn.awhonn.org 
C 2011 AWHONN, the Association of Womens Health, Obstetric and Neonatal Nurses 122
Kim, J. H. and Froh, E. B. IN FOCUS
CNE
http://JournalsCNE.awhonn.org

Macronutrients
Fats. Fat is the largest single source of energy in With a sound knowledge base, the nurse can provide the
HM. The principal fat found in HM is in the form parents with the information needed to make an informed
of triglycerides (>98%) that are structurally three
decision regarding infant feeding.
fatty acids linked to a 3-carbon glycerol molecule.
The mammary gland packages these triglycerides
Human milk contains its own lipases, which is a
uniquely compared to the triglycerides found in
convenient design for improving fat digestion and
commercial infant formulas. The mammary ep-
is most active in fresh milk. The fat globules appear
ithelium processes triglycerides into membrane-
unaffected by refrigeration but may disrupt with
bound globules that contain a surface of gly-
freezing. The relevance of this disruption is with
coproteins, glycolipids, phospholipid, cholesterol,
some mothers, generally later in lactation, who
and enzymes with a dense triglyceride core (See
produce milk with high lipase activity. Their stored
Fig. 1). Fat globule size varies over the first week of
milk can develop a significant soapy or rancid
life postpartum and then gradually increases over
odor and taste, and infants may refuse to drink.
the next several months. This process appears to
Heat, such as that applied during pasteurization,
depend on the abundance of cell membrane from
can readily inactivate lipases. Unfortunately, no
which the globules are made (Michalski, Briard,
proven practical method for reducing lipase ac-
Michel, Tasson, & Poulain, 2005).
tivity without losing other bioactive properties is
available.
Unlike infant formula, the fatty acid profile in
HM highly reflects the dietary fatty acids of the
Fat digestion is superior in HM compared to that
mothers diet. For instance, a mother who eats
in formula milk. Triglycerides in HM are broken
a generous amount of omega-3 oil not typical of
down into free fatty acids and glycerol by the ac-
the North American diet will pass on these long
tivity of bile saltdependent and pancreatic lipase-
chain fatty acids into her milk and change the
related lipases found within HM (Lindquist &
fractional portion of omega-3 fats in her milk (Lau-
Hernell, 2010). The digestion of formula milk re-
ritzen & Carlson, 2011). A study in mother/infant
quires the primary activity of pancreatic lipases
dyads where mother and infant were supple-
that are more restrictive and digest triglycerides to
mented with omega-3 supplements during preg-
fatty acids and 2-mono-glycerol chains (one fatty
nancy and afterwards demonstrated an increased
acid in middle carbon position of a glycerol chain).
omega-3 content in mothers milk and favorable
As a result, some plant sources of triglycerides
outcomes in a subset of girls (Olsen et al., 2008).
found in formula milk have saturated fats in the
Fish oil taken by pregnant mothers may affect later
outer positions of the glycerol chain that make their
health outcomes in their children, as one longitu-
digestive products more prone to calcium bind-
dinal study found a reduced incidence of asthma
ing, soap formation, and subsequent energy loss
in infants of supplemented mothers (Smithers,
(Koo, Hockman, & Dow, 2006).
Gibson, McPhee, & Makrides, 2008). Trans fatty
acid content is a prime negative example of di-
Fat content in HM varies the most of any nutri-
etary influences on HM. Trans fatty acids was
ent component. This variation is largely due to the
prevalent in the North American diet, but after
graded increase in fat content of milk during a lac-
tighter regulation in the food industry resulted in
tation cycle where foremilk is relatively fat poor and
decreased levels of trans fatty acids in daily food,
hind milk is relatively enriched in fat and can con-
a corresponding reduction in trans fatty acids in
tain 3 times the fat content (Bishara, Dunn, Merko,
HM was seen (Friesen & Innis, 2006).
& Darling, 2008; Saarela, Kokkonen, & Koivisto,
2005). For the breastfed infant, this variability is Jae H. Kim, MD, PhD, is an
Fat digestion starts immediately with the activity
virtually unnoticeable due to the ingestion of all the associate professor of
of lipases secreted from the salivary glands and pediatrics in the Division of
milk. However, for the preterm or sick term infant
stomach. To digest these large globules of fat, Neonatal-Perinatal
where HM is pumped and stored, large variabil-
however, the membranes have to be broken down Medicine, University of
ity in fat content may be present. Using nonse- California San Diego, San
to allow access to the triglyceride core. Proper di-
quential delivery of milk may disadvantage an in- Diego, CA.
gestion of HM fat does require the presence of
fant to receive predominantly lower fat and thereby
bile acids, and therefore cholestatic infants may Elizabeth B. Froh, MS,
lower calorie milk. Nonsequential milk delivery is BSN, RN, is a pre-doctoral
not digest HM effectively. Once made accessible,
the delivery of stored milk without consideration of student in the School of
lipases found in the small bowel and secreted by Nursing, University of
matching the pumping sequence to the milk de-
the pancreas attack the free triglycerides. Pennsylvania, Philadelphia,
livery (Spatz, 2012).
PA.

JOGNN 2012; Vol. 41, Issue 1 123

IN FOCUS Nutritional and Immunobiological Properties of Human Milk

CNE
http://JournalsCNE.awhonn.org

Table 1: Nutritional and Immunobiological Components of Human Milk

Nutritional Components Bioactive factors

Proteins (PRO) Alpha-Lactalbumin Anti-infective Secretory IgA, IgM, IgG (PRO)

Beta-Lactoglobulin Lactoferrin (PRO)
Caseins Lysozyme (PRO)
Complement C3(PRO)
Bifidus Factor (CHO)
Antiviral Mucins, Glucosaminoglycans (CHO)
Oligosaccharides (CHO)
White Blood cells
Nucleotides (NPN)
Xanthine Oxidase (PRO)

Nonprotein nitrogen Alpha-amino nitrogen Anti-inflammatory Tumour Necrosis Factor (PRO)

(NPN) Creatine Interleukins (PRO)
Creatinine Interferon-gamma (PRO)
Glucosamine Prostaglandins Alpha-1 Antichymotrypsin (PRO)
Nucleotides Alpha-1 Antitrypsin (PRO)
Polyamines Platelet-Activating Factor Acetyl
Urea Hydrolase (PRO)
Uric Acid Glycopeptides (CHO)

Carbohydrates (CHO) Lactose Growth Factors Epidermal Growth Factor (PRO)

Glucose Nerve Growth Factor (PRO)
Insulin Growth Factor (PRO)
Insulin-Like Growth Factor (PRO)
Transforming Growth Factor (PRO)
Taurine (NPN)
Polyamines (NPN)
Gastrin (PRO)
Gastric Inhibitory Peptide (PRO)
Gastric Regulatory Peptide (PRO)
Neurotensin (PRO)
Peptide Histidine Methionine (PRO)
Peptide YY (PRO)

Lipids (LIP) Triglycerides

Fat-soluble Vitamins
(A, D, E, and K)
Carotenoids
Fatty Acids
Phospholipids

Sphingolipids Sterols Hormones Serotonin (PRO)

and Insulin (PRO)
Hydrocarbons Prolactin (PRO)
Thyroid Hormones (PRO)
Corticosteroids
ACTH (PRO)
Oxytocin (PRO)
Calcitonin (PRO)
Parathyroid Hormone (PRO)
Erythropoietin (PRO)
Progesterone
Estrogen

124 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x http://jognn.awhonn.org

Kim, J. H. and Froh, E. B. IN FOCUS
CNE
http://JournalsCNE.awhonn.org

Table 1: Continued

Nutritional Components Bioactive factors

Water-soluble Biotin, Choline, Folate, Enzymes Amylase (PRO)

vitamins Inositol, Niacin, Bile acid-stimulating lipase (PRO)
Panthenic Acid, Lipoprotein lipase (PRO)
Riboflavin, Thiamin, Proteases (PRO)
Vitamins B12, B6, Pancreatic Secretory Trypsin Inhibitor (PRO)
and C

Minerals Calcium Transporters Xanthine Oxidase (PRO)

Phosphate Glutathione Peroxidase (PRO)
Magnesium Alkaline Phosphatase (PRO)
Iron Folate Binder (PRO)
Cobalamin Binder (PRO)
IgF Binder (PRO)
Thyroxine Binder (PRO)
Corticosteroid Binder (PRO)

Ionic constituents Sodium, Chloride,

Potassium,
Bicarbonate, Citrate,
Sulfate

Trace minerals Chromium, Cobalt,

Copper, Fluoride,
Iodine, Manganese,
Molybdenum, Nickel,
Selenium, Zinc

Recognition of the physical properties of fresh HM
is important. With large fat globules, the fat por-
tion of freshly expressed HM will readily sepa-
rate within minutes of expression with the lipids
rising to form a top layer. This separation of fat
is important to consider when storing and deliv-
ering milk to preterm infants. Warming and gen-
tle shaking of milk are important to perform prior
to feeding. Storage of milk in short-term refriger-
ated state or longer term frozen state does not ad-
versely affect fat content, but freezing may frac-
ture membrane-bound globules (Vieira, Soares,
Pimenta, Abranches, & Moreira, 2011) (see
Table 2). Substantial losses of adherent fat and
nutrients can accumulate with multiple container
changes and long feeding tubes (Tacken et al.,
2009). Minimizing the number of transfers from
pumping to feeding is essential to prevent major
deterioration in milk quality.
Protein. The amino acid profile in HM proteins
is ideally balanced for the newborn. To achieve
this balance, numerous HM proteins are produced
during lactation. Human milk proteins contain 70%
whey and 30% casein fractions that can be sepa-
rated out by ultracentrifugation or acid precipita-
tion. The whey fraction of milk is digested better
than the casein fraction due to the faster transit
out of the stomach (Billeaud, Guillet, & Sandler,
1990). Bovine milk is casein dominant (> 80%),
but most infant formulas have been altered now
to contain a greater whey fraction to mimic HM.
Most of the bioactive factors in HM are in the
whey fraction. The major whey protein produced
by the mammary gland is -lactalbumin. Other
whey proteins that resist digestion and are im-
portant for host defense include proteins such as
lactoferrin, lysozyme, and secretory immunoglob-
ulin A (sIgA). The primary protein found in the ca-
sein fraction in HM, -casein, is highly phospho-
rylated enhancing its ability to bind calcium and
confer improved calcium solubility (Bouhallab &
Bougle, 2004). Free amino acids are present in
HM, the most abundant being glutamine, which
is not found in infant formulas because of prob-
lems with stability of free glutamine. Glutamine is
an important amino acid for cell growth, specifi-
cally intestinal epithelial growth, has a role in im-
mune function, and is a precursor in glutathione
synthesis.

JOGNN 2012; Vol. 41, Issue 1 125

IN FOCUS Nutritional and Immunobiological Properties of Human Milk

CNE
http://JournalsCNE.awhonn.org

Table 2: Effects of Treatment on Nutritional and Immunobiological Components of Human

Milk

Refrigeration Freezing Pasteurization Microwaving

Lactoferrin No change No significant Change Decreased

sIgA No change Decreased Decreased Decreased

WBCs Decreased Decreased Decreased

Antioxidant capacity Decreased

Lysozyme No change No change No change Decreased

C3 complement No change No change

Bifidus factor No change No change

Nutrients

Fat No change Fracture of fat globules No change

Otherwise no change

Protein No change No change Nutritional proteins

unaffected for
digestion

Carbohydrates No change No change No change

Oligosaccharides No change No change No change

Ca, Mg, P No change No change No change

Vitamins B1, B2, B6, folic acid, C Vit C Vit C, folate, Vit B6

Trace elements No change No change No change No change

Note. Based on Lawrence (1999) and Van Zoeren-Grobben et al. (1987).

Protein digestion takes place through a series of
digestive steps beginning in the stomach where
acid-activated pepsin starts cleaving protein. In
the small bowel, the pancreatic juices are rich with
endopeptidases and carboxypeptidases. These
peptidases digest long polypeptides by hydrol-
ysis to tripeptides, dipeptides, and amino acids
that actively transport across the intestinal lumen
(Boudry et al., 2010). Maternal dietary protein may
also be present in minute amounts and in sensitive
infants lead to food protein sensitivity. This infant
sensitivity commonly occurs with bovine protein
intake in mothers (Solinas, Corpino, Maccioni, &
Pelosi, 2010; Wilson, Self, & Hamburger, 1990).
Many of the protein components, however, are bi-
ologically active, resistant to digestion, and func-
tion in a myriad of ways to improve gut function
through alterations in the gut immune, digestive,
and nervous system.
Proteins are not the only source for nitrogen in
HM. The total nitrogen content in HM represents
the sum of protein nitrogen and nonprotein nitro-
gen. Numerous nonprotein nitrogen sources are
found in HM and include compounds such as
peptides, urea, ammonia, free amino acids, cre-
atinine, creatine, nucleic acids, carnitine, amino
sugars, low molecular weight peptide hormones,
and growth factors. Furthermore, total protein con-
tent comprises both nutritional (digestible) and
nondigestible proteins, the latter being made up
of the many bioactive proteins found in HM. Test-
ing macronutrient content is tricky with protein be-
cause the fractions of nonprotein nitrogen may
contribute to the total nitrogen needs of the in-
dividual whereas the nondigestible bioactive fac-
tors do not add to the total nitrogen intake. Ref-
erence chemical analysis does not account for
the digestibility of these proteins but can separate
out true protein from nonprotein nitrogen. Infant
formulas, therefore, may have inadvertently over-
estimated the amount of nutritional protein that is
required (Hosoi et al., 2005).
Like fat, protein content in HM can vary consider-
ably over the lactation period. Most importantly is
a steady decline in protein content over the first
month of life (20%25%) with more gradual de-
clines (4%/month) over the subsequent months
(Saarela et al., 2005). This protein content change

126 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x http://jognn.awhonn.org

Kim, J. H. and Froh, E. B.
is particularly relevant when using donor HM that
is generally obtained from lactating donors sev-
eral months into their lactation period. Variabil-
ity in protein content seen between mothers is
poorly understood and is not well correlated with
daily diet. A study where mothers ingested ei-
ther very high- or low-protein diets found that
a high-protein diet increased nitrogen levels but
mostly due to increased urea (Forsum & Lon-
nerdal, 1980). For not fully understood reasons,
preterm milk contains more protein that term milk,
which is an advantage because preterm infants
require more protein to grow adequately.
Carbohydrates. The carbohydrate fraction of HM
comprises two major components, 90% to 95%
lactose and 5% to 10% HM oligosaccharides
(HMO). The lactose content of HM rises from
55 g/L in colostrum to 70 g/L in mature milk. Lac-
tose content correlates positively with milk volume
and negatively with whey protein content due to
its high osmotic properties. Besides providing an
abundant carbon source for energy, dietary lac-
tose also has been associated with increased min-
eral absorption (Klein, 2002). Digestion of lactose
into glucose and galactose occurs in the pres-
ence of intestinal lactase found on the brush bor-
der membrane of the intestinal mucosa. Galac-
tose is essential for the production of galacto-lipid
products like cerebrosides that are important in
central nervous system development. The pres-
ence of a small amount of lactose in the stool of
term infants is assumed a normal physiological
effect of feeding HM. A softer stool consistency,
more nonpathogenic bacterial fecal flora, and im-
proved absorption of minerals attribute to the pres-
ence of small quantities of unabsorbed lactose
in feces (Klein). The feeding of HM in premature
infants stimulates intestinal lactase activity com-
pared with no feeding or formula feeding and thus
permits early tolerance to lactose containing milk
(Shulman et al., 1998). Because of earlier con-
cerns regarding lactose utilization by premature
infants resulting in attempts to reduce the osmo-
lality of the milk, preterm formulas contain a large
proportion of carbohydrate as corn syrup solids or
glucose polymers (Klein). Human milk oligosac-
charides are resistant to digestion and likely have
mostly nonnutritional roles in the gut as discussed
in detail below.
Micronutrients
Calcium, Phosphorus, Magnesium. Bone health
of the newborn is dependent on an abundant sup-
ply of minerals. Human milk is well designed to
JOGNN 2012; Vol. 41, Issue 1
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
provide optimal mineral metabolism for the grow-
ing infant. Calcium (Ca) and phosphorus (P) ex-
ist in ionized and complex forms that are easily
absorbed. Preterm HM contains only minimally
higher amounts of Ca and P compared to term
HM (Bauer & Gerss, 2011). Due to the rapidity
of growth of the preterm infant compared to the
term infant, additional mineral supplementation is
required. The ratio of Ca and P increases over the
lactation period with gradually lower phosphorus
levels. Magnesium (Mg) is another essential com-
ponent of bone mass given that bone contains
approximately 60% of the bodys Mg. The absorp-
tion of Mg is significantly greater in unfortified HM
compared with formula and therefore additional
Mg is not required in HM feeding (Dorea, 2000).
Iron. Iron is an essential nutrient for normal cogni-
tive development. The iron in HM is found bound to
several different components including lipids, the
aqueous portion (20%30% with lactoferrin), and
casein (10%). The bioavailability of iron is fivefold
higher for HM as compared to infant formula milk.
The concentration of iron in HM declines through
lactation, from approximately 0.6 mg/L at 2 weeks
to 0.3 mg/L after 5 months of lactation (Siimes,
Vuori, & Kuitunen, 1979). Although the iron needs
are met with HM in the exclusively breastfed term
infant, preterm infants require additional supple-
mentation to maintain their iron stores (Agostoni
et al., 2010; Kleinman, 2009).
Vitamins. Good bone health requires adequate
mineral supply and vitamin D. The low content
of vitamin D in HM raises major health concerns
for the exclusively breastfed infant. Therefore,
the AAP recommends vitamin D supplementa-
tion for the exclusively breastfed infant. Interest-
ingly, the amount of vitamin D directly correlates
with maternal vitamin D stores. This correlation
raises the interesting hypothesis that greater ex-
posure to sunlight in human history led to much
higher amounts of vitamin D in maternal milk and
may not be a fixed deficiency of HM. Indeed,
high maternal supplementation has demonstrated
to improve milk vitamin D levels (Basile, Taylor,
Wagner, Horst, & Hollis, 2006). Fresh HM con-
tains ample amounts of water-soluble vitamins,
thiamin, riboflavin, niacin, vitamin B6, folate, vi-
tamin B12, pantothenic acid, biotin, and vitamin
C. These vitamins are not stored in the body, and
excess intakes are excreted in the urine or bile
(vitamin B12). However, some B vitamins and vi-
tamin C are more prone to degradation or ox-
idation with exposure to heat, light, or air (Van
127
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
Zoeren-Grobben, Schrijver, Van den Berg, &
Berger, 1987).
Trace Elements. Trace elements such as zinc
(Zn), copper (Cu), selenium (Se), manganese
(Mn), chromium (Cr), and cobalt (Co) are found
in adequate amounts in HM for the healthy term
infant. Zinc actively engages with different en-
zymes in catalytic, structural, and regulatory roles
that are essential for growth. Low maternal Zn sta-
tus can reduce Zn content of HM (de Figueiredo,
Palhares, Melnikov, da Cruz Montes Moura, & Dos
Santos, 2009). Copper has a catalytic role in re-
ducing molecular oxygen through its binding to
superoxide dismutase, a critical enzyme in antiox-
idant defense. Copper levels gradually reduce in
amount over the lactation period (Abdulrazzaq,
Osman, Nagelkerke, Kosanovic, & Adem, 2008).
Selenium is a key component in glutathione syn-
thetase and does not need to be supplemented
(Valent, Horvat, Mazej, Stibilj, & Barbone, 2011).
Manganese is essential for growth, development,
and maintenance of health, but recommendations
for Mn intake are poorly defined. Deficiencies in
Mn have not been described with exclusive HM
intake, and therefore the trace amounts of Mn in
HM are adequate for health. Chromium needs are
closely associated with insulin activity at the re-
ceptor level, and sufficient amounts of Cr can be
found in HM.
Content and Calorie Variability. Numerous factors
lead to changes in macronutrient content, and
many of these factors are not well understood.
Variability in nutritional content of HM is well known
and thought to be a result of differences between
pumping fraction (hindmilk vs. foremilk), time of
day, day of lactation, and degree of breast empty-
ing (Hale & Hartmann, 2007). Low-calorie foremilk
may contain as few as 12 kilocalories/ounce, and
high-calorie hind milk may contain as many as
30 kilocalories/ounce (Hosoi et al., 2005; Sauer &
Kim, 2011). The most variable component in HM is
fat, and because fat has the highest caloric den-
sity, great fluctuations in total energy has been
observed. Single daily pooling of pumped milk
eliminates the inherent variability in multiple daily
sampling. Individual samples can vary tremen-
dously for fat, protein, and carbohydrates.
Part of the problem with energy expenditure mea-
surements with calorimetry is that components of
HM that are resistant to digestion will be com-
busted alongside those that are absorbed. Use
of standard conversion tables to calculate total
128 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x
Nutritional and Immunobiological Properties of Human Milk
energy in HM may be erroneous due to the differ-
ences between bovine and HM. Calculated values
for energy may overestimate the caloric density of
HM by more than 10% (Hosoi et al., 2005). The im-
plications of this may be that formula may contain
excessive energy.
Mothers who continue lactation through to their
next pregnancy (called tandem nursing) may alter
their milk volumes and composition as a direct
result of the physiologic changes during preg-
nancy. The limited studies available suggest that
lactation has a variable response to a concur-
rent pregnancy (Marquis, Penny, Diaz, & Marin,
2002; Marquis, Penny, Zimmer, Diaz, & Marin,
2003; Merchant, Martorell, & Haas, 1990). One
may see a reduction or no effect on total milk vol-
ume, and infants may experience either a small
reduction or no effect in weight gain compared
to breastfed infants not fed by pregnant mothers.
Small changes in bioactive factors have also been
noted. Throughout the world, tandem nursing is
practiced safely, but further studies are required
to elaborate on the optimal feeding strategy with
multiple infants.
The Immunobiological Perspective. The immuno-
biological advantages associated with an exclu-
sive HM diet are critical for the healthy and the
preterm or vulnerable newborn. A diet of exclu-
sive HM will supply the infant with a multitude
of protective elements to establish critical host
defense systems (Piper, Berry, & Cregan, 2007;
Rodriguez, Miracle, & Meier, 2005; Wold & Adler-
berth, 2000). Human milk consists of specific el-
ements designed to enhance the newborns im-
mune system. The components of HM, such as
secretory IgA, lactoferrin, and lysozyme, are mul-
tifunctional and serve to protect the infant through
various interactions. Some of these advantages in-
clude an added immune defense by means of im-
munoglobulins, oligosaccharides, cytokines, and
glycoproteinsprotecting the newborn from in-
fective agents (Hosea Blewett, Cicalo, Holland,
& Field, 2008). Immune cells, long-chain polyun-
saturated fatty acids, cytokines, nucleotides, hor-
mones, and bioactive peptides also play a vital
role in aiding the immune system of the newborn
(Hosea Blewett et al.; Lawrence & Pane, 2007;
Newberg & Walker, 2007; Riordan & Wambach,
2010). Distinct advantages of the ingestion of HM
in the newborn period include improved gut bar-
rier protection, bacterial cell wall lysis, preven-
tion of inflammation, and the creation of an ideal
gut microflora (Niers, Stasse-Wolthuis, Rombouts,
http://jognn.awhonn.org
Kim, J. H. and Froh, E. B.
& Rijkers, 2007; Rodriguez et al.; Wold & Adler-
berth, 2000). The enteromammary pathway offers
the necessary passive immunity via maternal im-
munoglobulins in HM to provide prolonged im-
munological support needed in the newborn pe-
riod of life (Niers et al.). Next is a review of the
major categories of immunobiological properties
of HM including prebiotic, anti-infective, and anti-
inflammatory.
Prebiotics
Prebiotics are classified as food substances that
resist the acidity of the stomach and digestive
enzymes to reach the colon where they selec-
tively stimulate the growth and/or activity of mi-
croflora that result in benefits to hosts well-being
and health (Boehm et al., 2005; Coppa, Zampini,
Galeazzi, & Gavvrielli, 2006; Roberfroid, 2007).
The dominant prebiotic components in HM are
the HM oligosaccharides (HMOs). The other major
prebiotic in HM is lactoferrin. The gut microflora
is important to the health of the host. An essen-
tial determinant of the newborn gut microflora is
the type of enteral feeding introduced to the new-
born infant (Bullen, Tearle, & Willis, 1976; de La
Cochetiere et al., 2007; Harmsen et al., 2000).
The prebiotic factors in HM stimulate colonization
of bacteria throughout the gastrointestinal system
and have the potential to improve the overall health
of the newborn infant. Early observations docu-
mented differences in the gut microflora of infants
that were breastfed versus infants that were artifi-
cially fed with infant formula (Coppa et al., 2001;
Engfer, Stahl, Finke, Sawatzki, & Daniel, 2000;
German, Freeman, Lebrilla, & Mills, 2008). The
breastfed infant gut is dominated by a presence
of healthy bacteria, mostly bifidobacteria and lac-
tobacilli, whereas the microflora of the artificially
fed infant gut contains coliforms, enterococci, and
Bacteroides (de La Cochetiere et al., 2007). The
prebiotic effects of an exclusive HM diet originate
from the combination of several HM components
including glycans and lactoferrin. Successful dis-
tinction of the separate and specific roles of each
component has not yet been accomplished.
Oligosaccharides. Human milk oligosaccharides
(HMOs) protect the infant by stimulating the
growth of bifidobacteria and lactobacilli (healthy
microflora) in the colon (Coppa et al., 2001; Engfer
et al., 2000; German et al., 2008). Oligosaccha-
rides are carbohydrate substances that are com-
posed of between 3 and 10 monosaccharide
units. The concentration of oligosaccharides in
HM varies from 20 g/L in colostrum to 5g/L to
JOGNN 2012; Vol. 41, Issue 1
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
The number of white blood cells present in human milk is
dramatically reduced by storing, freezing, pasteurization,
microwaving, and sonification.
14 g/L in mature HM (Donovan, 2008). They are the
third most abundant component of HM following
lactose and lipids. They are only partially digested
in the small intestine and can reach the infant colon
where the oligosaccharides are able to selectively
stimulate the growth and development of bifido-
genic flora (Coppa et al., 2006). Roughly 90% of
oligosaccharides are found in the feces acting as
dietary fibers for the newborn infant (Bode, 2009).
Oligosaccharides are determined genetically, but
the biochemistry is still very poorly understood.
More than 200 different oligosaccharides have
been identified in HM. The structural diversity and
abundance of oligosaccharides in HM distinguish
HM from bovine infant formulas, as there are only
trace amounts of oligosaccharides present in ma-
ture bovine milk (Bode; Boehm et al., 2005; Coppa
et al.). Additionally, no natural alternative to the
oligosaccharides found in HM exists. Supplemen-
tations of alternatives to oligosaccharides in infant
formula have included alternative carbohydrate
substances not generally found in HM. In infant
formula, galacto-oligosaccharides (GOS), fructo-
oligosaccharides, and inulin have been used as
supplements (Coppa et al.). The limited diversity
of oligosaccharides in infant formula is unlikely to
mimic the biologic properties of HMOs.
In the case of a vulnerable newborn, the par-
ents of the infant need to understand the im-
portant role oligosaccharides play in supporting
the infants gastrointestinal development. Nurses
are obligated to educate mothers and fami-
lies about the importance of oligosaccharides in
the promotion of good bacterial growth that is
bifidus-predominant gut microflora. Emphasizing
the high concentration of oligosaccharides in hu-
man colostrum to the family is imperative. By feed-
ing the newborn infant maternal colostrum before
artificial means of nutrition, the mother is supply-
ing her infant with the factors needed to stimulate
the growth of oral healthy bacteria that serve as
protection against pathogens.
Lactoferrin. Lactoferrin, a major whey protein
in HM, has been shown to have prebiotic and
anti-infective characteristics. Found only in small
traces in bovine milk, lactoferrin is an essential
multifunctional component of HM. Approximately
129
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
6% to 10% of lactoferrin reaches the infant colon
undigested and could function as a prebiotic (Le
Huerou-Luron et al., 2010; Riordan & Wambach,
2010). From a rat model of necrotizing enterocol-
itis, Sherman Sherman, Bennett, Hwang, and Yu
(2004) introduced combinations of lactoferrin and
Lactobacillus GG (a probiotic) into rat pups that
typically do not ingest lactoferrin in their milk. They
showed the combined effect of lactoferrin and a
probiotic enhanced the rats defenses against in-
fective enteric pathogens such as Escherichia coli
in the small intestines. The primary mechanism
may be through the iron-binding capacity of lacto-
ferrin in removing accessible iron from the gut lu-
men preventing some pathogenic bacteria from
growing. Lactoferrin may act as a potent adjunct to
oligosaccharides in preventing bacterial disease
in infants (Sherman et al.).
Acknowledgment of the effects of temperature
such as during pasteurization on levels of lactofer-
rin in HM is important. Concentrations of lactoferrin
were 44% lower in pasteurized HM (P = .002) than
in fresh HM (Akinbi et al., 2010; Hosea Blewett
et al., 2008). However, no significant difference
in the concentrations of lactoferrin between fresh
and frozen HM was found (Akinbi et al.).
Anti-Infective Properties of HM. Numerous anti-
infective components of HM offer the infant robust
protection against infection (see Table 1). Human
milk consists of specific elements designed to
enhance the newborns immune system. Human
milk bioactive factors such as immune cells, long-
chain polyunsaturated fatty acids, cytokines, nu-
cleotides, hormones, and bioactive peptides play
a vital role in aiding the immune system of the
newborn (Hosea Blewett et al., 2008). The anti-
infective components of HM are effective against
pathogenic bacteria including Escherichia coli,
Vibrio cholerae, Campylobacter, Shigella, Giardia
lambia, and Pneumococcus as well as in the viral
defense against rotavirus, cytomegalovirus, in-
fluenza virus, and respiratory syncytial virus (Han-
cock et al., 2002; Hosea Blewett et al., 2008; Wold
& Adlerberth, 2000). Even partial daily feedings of
HM reduces the risk of nosocomial infections in
premature infants by 50% (Furman, Taylor, Minich,
& Hack, 2003; Rodriguez et al., 2005). Therefore,
HM confers to the newborn increased protection
from such infections as gastroenteritis, upper and
lower respiratory tract infections, urinary tract in-
fections, neonatal septicemia, necrotizing entero-
colitis, and acute otitis media (Wold & Adlerberth,
2000). Working in tandem with the newborns de-
130 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x
Nutritional and Immunobiological Properties of Human Milk
veloping immune system, HM offers the neces-
sary passive immunity (via maternal immunoglob-
ulins in HM) and prolonged immunological
support needed in the newborn period of life
(Niers et al., 2007).
Secretory Immunoglobulin A. Immunoglobulins or
antibodies are key anti-infective components of
HM. Immunoglobulins are proteins that are pro-
duced by plasma cells in response to a foreign
disease cell or particle. They identify and have the
ability to neutralize or act on particular antigens.
Although five immunoglobulins are present in HM,
the most important one is secretory immunoglobu-
lin A (IgA). Immunoglobulin A is responsible for the
prevention of bacteria and viruses from binding
to mucosal surfaces, neutralizing microbial tox-
ins, and increasing virus excretion in the newborn
(Hosea Blewett et al., 2008; Le Huerou-Luron et al.,
2010). Secretory IgA (sIgA) antibodies are synthe-
sized and stored in the maternal breast. Found in
highest concentration in the maternal colostrum
(10 g/L), sIgA is the major immune defense in the
newborns intestines and offers protection against
gastrointestinal infections (Chirico, Marzollo, Corti-
novis, Fonte, & Gasparoni, 2008; Thapa, 2005). In-
terestingly, mothers of critical or sick infants have
higher levels of sIgA in their breast milk (Feist,
Berger, & Speer, 2000). Along with lactoferrin, sIgA
resists digestion and finds its way into the intestinal
tract of the newborn (Niers et al., 2007). Together
these two elements make up approximately 30%
of proteins found in HM (Hosea Blewett et al.).
Although levels of sIgA remain stable in mature
HM, providing the infant with as much fresh HM as
possible to obtain maximum benefits is important.
The mean concentration of sIgA in HM is reduced
by approximately 51% when the HM is frozen, by
60% when the milk is pasteurized (P < 0.0001),
and by 98% when microwaved (Akinbi et al., 2010;
Lawrence, 1999; Tully, 2000).
Lactoferrin. Lactoferrin is an essential compo-
nent of the immune response (Coppa et al.,
2006; Le Huerou-Luron et al., 2010). Lactoferrin
has strong antimicrobial activity against multiple
pathogens including bacteria, fungi, viruses, and
protozoa. Lactoferrin can directly disrupt microbial
cell membranes and is an essential growth factor
for B- and T-lymphocytes (Riordan & Wambach,
2010). Lactoferrin also promotes epithelial growth
(Labbok, Clark, & Goldman, 2004). Lactoferrin has
strong affinity for iron and is thought to constrict the
available free iron in the gut away from pathogens.
http://jognn.awhonn.org
Kim, J. H. and Froh, E. B.
Lysozyme. Lysozyme is a major protein found
in HM with anti-infective and anti-inflammatory
properties. Lysozyme in tandem with lactofer-
rin has proven bactericidal effects (Lonnerdal,
2003; Newberg, 2005; Newberg, Ruiz-Palacios, &
Morrow, 2005). Through cell wall lysis, lysozyme
destroys such pathogenic bacteria including
Escherichia coli and Salmonella (Riordan &
Wambach, 2010). Concentrations of lysozyme
are higher in HM than bovine milk and progres-
sively increase with the duration of breastfeeding
and/or pumping (Hettinga et al., 2011; Riordan &
Wambach, 2010).
Oligosaccharides. One of the primary ways
oligosaccharides function is by counteracting the
ability of pathogens to bind to the newborns host
cell receptors (Niers et al., 2007). They are also re-
sistant to digestion and can therefore easily bind
to host cell receptors in the newborns gut (New-
berg et al., 2005). This action ensures protection
against some of the bacterial and viral pathogens
found in the gastrointestinal system. For example,
oligosaccharides have the ability to bind to the
intestinal mucosa and protect the breastfed new-
born from enteric pathogens that may lead to di-
arrhea (Morrow et al., 2004).
Human milk has a great diversity of glycan expres-
sion and differs in specific types of glycans due
to environmental as well maternal genetic factors
and stage of lactation (Newberg, 2008). This diver-
sity further distinguishes HM from other artificial
feeding alternatives.
White Blood Cells. Human milk contains numer-
ous different cellular components that contribute
to anti-infective defense. Approximately 90% of
the white blood cells found in HM are phagocytes
including macrophages and neutrophils (Riordan
& Wambach, 2010). Macrophages are large cells
that ingest pathogens and other cell debris. Upon
phagocytosis, the macrophage displays an anti-
gen, produced by the foreign substance, on its
cell surface for other cells to recognize. Addi-
tionally, macrophages, known to release the im-
munoglobulin IgA, are the chief antibody in the
membranes of the respiratory and gastrointesti-
nal tracts responsible for mucosal immunity (Rior-
dan & Wambach). However, the number of cells
present in HM is reduced dramatically by storing,
freezing, pasteurization, microwaving, and soni-
fication (Lawrence, 2001). Therefore, this reduc-
tion in the number of macrophage cells resulting
from HM processing is one of the strongest ra-
JOGNN 2012; Vol. 41, Issue 1
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
tionales for using fresh HM when possible to ob-
tain the benefits of its native phagocytes such as
macrophages and neutrophils.
The majority of leukocytes in HM are neu-
trophils (40%65% of total leukocytes), mono-
cytes/macrophages (35%55%), and either B- or
T-lymphocytes (Niers et al., 2007). B-lymphocytes
produce antibodies whereas T-lymphocytes are
part of the cell-mediated immune response (Niers
et al.). An integral component of the secretory im-
mune system, lymphocytes circulate through mu-
cosal lymphoid tissues becoming sensitized to
antigens found in the respiratory and gastrointesti-
nal tracts (Chirico et al., 2008). Most HM lympho-
cytes act locally within the gut to augment the in-
testinal immune system.
Pancreatic Secretory Trypsin Inhibitor. A recently
identified component of HM called pancreatic se-
cretory trypsin inhibitor (PSTI), a 56-amino acid
peptide, was found to be responsible for the pro-
tection of the pancreas from autodigestion, along
with having additional health benefits to the ani-
mal and human gut (Marchbank, Weaver, Nilsen-
Hamilton, & Playford, 2009). Found in highest
concentrations in maternal colostrum, PSTI is typ-
ically expressed in the mucus-producing cells of
the stomach and large intestine and secreted into
gastric juice where it protects the mucus layer form
excessive digestion (p. 697). This peptide stim-
ulates intestinal cell line migration; and through
a process of restitution, the surviving cells are
able to migrate over the wounded area. Using
an animal rat model, the authors compared rats
fed via gavage human breast milk to rats receiv-
ing a commercial formula feed. Gastric damage in
their model was reduced by 75% among rats fed
HM over the rats fed commercial formula. When
applied to a human population, the authors rec-
ommend that feeding neonates human colostrum
will aid in the establishment and maintenance of
human gut integrity (Marchbank et al.).
Xanthine Oxidase. Hancock et al. (2002) iden-
tified the connection between xanthine oxidase
(XO), an essential enzyme found in HM, and spec-
ified antimicrobial properties. The authors studied
the effects of bovine and HM on the metabolic
activity of Escherichia coli. Located on the outer
surfaces of fat globules, XO attracts pathogens
to bind to it therefore diverting bacteria away
from their target (inclusive of the digestive tract).
Found in highest concentrations in the maternal
colostrum, XO is a valuable protective component
131
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
The nurse is a key player in providing lactation support in the
form of education or direct facilitation of pumping and/or
breastfeeding.
of HM not found in commercial infant formulas
(Hancock et al., 2002).
Others. Other factors found to possess anti-
infective properties in HM not discussed in-
clude bifidus factor, free fatty acids, mucins, glu-
cosaminoglycans, and complement c3.
Anti-Inflammatory Properties of Human
Milk
The inflammatory response is a normal part of the
human immune system response. However, if un-
controlled the inflammatory process can poten-
tially damage healthy tissues. For example, infec-
tion caused by necrotizing enterocolitis is often
the result of tissue damage from an overactive
inflammatory response. Human milk has several
anti-inflammatory components that balance the in-
flammatory process and protect the infant from un-
necessary tissue damage (Claud, 2009). A frac-
tion of the anti-inflammatory agents in HM is
also resistant to the infants digestive enzymes
and therefore has lasting anti-inflammatory effects
(Hosea Blewett et al., 2008). The active compo-
nents of HM that have potential anti-inflammatory
properties include cytokines, antioxidants, and
antiproteases.
Cytokines. Cytokines are protein hormones that
mediate and regulate inflammatory responses
(Garofalo, 2010). The anti-inflammatory cytokines
present in HM work by inhibiting certain pro-
inflammatory cytokines. Interleukin-10 (IL-10),
transforming growth factor (TGF)-, IL-1 recep-
tor antagonist, and soluble tumor necrosis fac-
tor (TNF)-. All are anti-inflammatory cytokines
present in HM (Hosea Blewett et al., 2008). The
activity of anti-inflammatory cytokines is essential
to ensure a balanced inflammatory response.
Antioxidants. Antioxidants in HM are critical to
sustaining optimal health in the newborn. Dur-
ing the normal metabolic activity of cells, free
radicals/reactive oxygen species (ROS) are pro-
duced. These free radicals can lead to cell dam-
age and oxidative stress in the newborn infant.
Antioxidants are crucial to the newborn infant
as they can provide protection against ROS. If
levels of ROS become too high an infant can
132 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x
Nutritional and Immunobiological Properties of Human Milk
become compromised and experience oxidative
stress. It is believed that oxidative stress is asso-
ciated with the onset of bronchopulmonary dys-
plasia, retinopathy of prematurity, and necrotizing
enterocolitis (Hosea Blewett et al., 2008; Lee &
Davis, 2011; Szalagatys-Sidorkiewicz, Zagierski,
Renke, & Korzon, 2004). Identified antioxidants in
HM include vitamins A, C, and E; uric acid; -
carotene; cysteine; catalase; glutathione peroxi-
dase; and superoxide dismutase (Hosea Blewett
et al.; Zarban, Taheri, Chahkandi, Sharifzadeh, &
Khorashadizadeh, 2009). The level of total antiox-
idant capacity in maternal colostrum was found to
be significantly higher than in transitional or ma-
ture maternal milk and differed significantly from
the levels detected in the subsequent maternal
milk samples (Zarban et al.). Heat treatment of
HM produces an overall decrease in antioxidant
properties providing more justification for the use
of fresh milk (Silvestre et al., 2008).
Antiproteases. Inflammatory cells as well as some
pathogens produce proteases. Each protease dif-
fers in its ability to hydrolyze and break down
peptide bonds. In the inflammatory process, pro-
teases allow cells to enter into the affected area.
Human milk can counteract the pathogenic pro-
teases through the activity of protease inhibitors
that can protect the infant from the intrusion
of pathogenic proteases and aid in limiting an
overactive inflammatory response (Hosea Blewett
et al., 2008).
Conclusions and Implications
for Nursing Practice
Human milk should be recommended as the ex-
clusive choice for the term infant up to age 6
months. For the very low-birth-weight preterm in-
fant or other vulnerable infant, increasing evi-
dence exists that HM should be the only choice
for infant nutrition. Human milk provides the es-
sential nutritive and protective elements through
its unique complement of nutritional and immuno-
biological components. Human milk is a bioactive
liquid tissue that confers a myriad of health ben-
efits to the preterm and term infant. Ingestion of
HM will not only assist the newborns immature im-
mune system to ward off possible gastrointestinal
and non-enteric infections that she or he will un-
doubtedly encounter; it also has recognized pre-
biotic and anti-inflammatory effects. Additionally,
by supplying the newborn with HM as the first
nutritional source, susceptibility to inflammatory
http://jognn.awhonn.org
Kim, J. H. and Froh, E. B.
Table 3: Resources for Readers
Textbooks
Riordan, J., & Wambach, K. (Eds.). (2010). Breastfeeding
and human lactation. Sudbury, MA: Jones and Barlett.
Hale, T.W., & Hartmann, P.E. (Eds.). (2007). Textbook of
human lactation. Amarillo, TX: Hale Publishing.
Arnold, A. (2009). Human milk in the NICU: Policy into
practice. Sudbury, MA: Jones & Bartlett.
Wight, J., Moreton, J., & Kim, J. H. (2008). Best medicine:
Human milk in the NICU. Amarillo, TX: Hale Publishing.
Websites
Academy of Breastfeeding Medicine: http://www.bfmd.org
American Academy of Pediatrics (AAP), Section on
Breastfeeding: http://aappolicy.aappublications.org/
cgi/content/full/pediatrics;115/2/496
Breastfeeding Basics: http://www.BreastfeedingBasics.org
Center for Disease Control and Prevention, Section on
Breastfeeding: http://www.cdc.gov/breastfeeding
Human Milk Banking Association of North America:
http://www.hmbana.org
La Leche League International: http://www.
LaLecheLeague.org
U.S. Department of Health and Human Services, The
National Womens Health Information Center:
http://www.womenshealth.gov/breastfeeding
U.S. Department of Health and Human Services, Office of
the Surgeon General: http://www.surgeongeneral.gov/
topics/breastfeeding/index.html
Figure 1. Structure of human milk fat globule. From Michalski, M. C., Briard, V., Michel, F., Tasson, F., & Poulain, P. (2005). Size
distribution of fat globules in human colostrum, breast milk, and infant formula. Journal of Dairy Science, 88(6), 19271940.
Printed with permission from Elsevier.
JOGNN 2012; Vol. 41, Issue 1
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
stimuli and the systemic inflammatory response
may be decreased.
When parents are considering feeding options, the
nurse plays a critical role in this process. The bed-
side nurse should know not only the composition
of HM but also how those components interact
alone or in conjunction with each other to sup-
port newborn nutrition optimally. The nurse has a
responsibility to have the capacity to help moth-
ers and families to make an informed feeding de-
cision. This begins with direct patient education
at the bedside. With a sound knowledge base,
the nurse can provide parents with the information
needed to make an informed decision regarding
infant feeding and support the use of HM and
breastfeeding throughout the hospital stay. Sup-
porting the decision-making process for the fam-
ily of the newborn infant is the role of the nurse
who needs a strong HM knowledge base at the
bedside.
The nutritional and immunobiological components
of maternal colostrum are essential to the new-
born. The nurse can provide education to the fam-
ily and facilitate optimal use of human colostrum
that has a high concentration of sIgA, a needed
foundation for newborn nutrition. Even for those
infants not able to receive enteral feeds, oral care
can begin with the maternal colostrum. In do-
ing so, the infant will be able to benefit from the
recognized advantages of maternal colostrum via
absorption through the oral mucosa. Family ed-
ucation related to the benefits, handling, quality,
133
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
storage, and safety of HM throughout the hospital
stay is important.
Lactation support prior to delivery, immediately
postdelivery, throughout the duration of hospi-
talization, and postdischarge is important. As a
provider, the nurse is a key in supporting lactation,
through direct education or facilitation of pumping
and/or breastfeeding. Through advocacy of HM
as the primary means of nutrition, the nurse is pro-
moting the best possible form of infant nutrition for
his or her patient. Disseminating the research from
the bench to the bedside and educating providers
and patients, will translate into improved health
outcomes for the newborn population. For addi-
tional information see Table 3.
REFERENCES
Abdulrazzaq, Y. M., Osman, N., Nagelkerke, N., Kosanovic, M., &
Adem, A. (2008). Trace element composition of plasma and
breast milk of well-nourished women. Journal of Environmen-
tal Science and Health. Part A, Toxic/Hazardous Substances &
Environmental Engineering, 43 (3), 329334.
Academy of Breastfeeding Medicine. (2008). Position on breastfeed-
ing. Breastfeeding Medicine, 3 (4), 267270.
Agostoni, C., Braegger, C., Decsi, T., Kolacek, S., Koletzko, B.,
Michaelsen, K. F., . . . van Goudoever, J. (2009). Breast-feeding:
A commentary by the European Society of Paediatric Gastroen-
terology, Hepatology and Nutrition Committee on Nutrition. Jour-
nal of Pediatric Gastroenterology and Nutrition, 49 (1), 112125.
Agostoni, C., Buonocore, G., Carnielli, V. P., De Curtis, M., Darmaun,
D., Desci, T., . . . Ziegler, E. E. (2010). Enteral nutrient supply for
preterm infants: Commentary from the European Society of Pae-
diatric Gastroenterology, Hepatology and Nutrition Committee
on Nutrition. Journal of Pediatric Gastroenterology and Nutrition,
50 (1), 8591.
Akinbi, H., Meinzen-Derr, J., Auer, C., Ma, Y., Pullum, D., Kusano, R., . . .
Zimmerly, K. (2010). Alterations in the host defense properties
of human milk following prolonged storage or pasteurization.
Journal of Pediatric Gastroenterology and Nutrition, 51 (3), 347
352.
American Academy of Family Physicians. (2007). Family physicians
supporting breastfeeding. Leawood, KS: Author. Retrieved from
http://www.aafp.org/online/en/home/policy/policies/b/breastfee
dingpositionpaper.html
American College of Obstetricians and Gynecologists. (2005). Breast-
feeding handbook for physicians. Elk Grove Village, IL: American
College of Obstetrics and Gynecology & American Academy of
Pediatrics.
Basile, L. A., Taylor, S. N., Wagner, C. L., Horst, R. L., & Hollis, B.
W. (2006). The effect of high-dose vitamin D supplementation
on serum vitamin D levels and milk calcium concentration in
lactating women and their infants. Breastfeeding Medicine, 1
(1), 2735.
Bauer, J., & Gerss, J. (2011). Longitudinal analysis of macronutrients
and minerals in human milk produced by mothers of preterm
infants. Clinical Nutrition, 30 (2), 215220.
Billeaud, C., Guillet, J., & Sandler, B. (1990). Gastric emptying in infants
with or without gastro-oesophageal reflux according to the type
of milk. European Journal of Clinical Nutrition, 44 (8), 577583.
Bishara, R., Dunn, M. S., Merko, S. E., & Darling, P. (2008). Nutrient
134 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x
Nutritional and Immunobiological Properties of Human Milk
composition of hindmilk produced by mothers of very low birth
weight infants born at less than 28 weeks gestation. Journal of
Human Lactation, 24 (2), 159167.
Bode, L. (2009). Human milk oligosaccharides: Prebiotics and beyond.
Nutrition Reviews, 67 (2), S183S191.
Boehm, G., Stahl, B., Jelinek, J., Knol, J., Miniello, V., & Moro, G. E.
(2005). Prebiotic carbohydrates in human milk and formula. Acta
Paediatricia, 94 (Suppl 449), 1821.
Boland, M. (2005). Exclusive breastfeeding should continue to six
months. Paediatric Child Health, 10 (3), 148.
Bouhallab, S., & Bougle, D. (2004). Biopeptides of milk: Caseinophos-
phopeptides and mineral bioavailability. Reproductive Nutrition
and Development, 44 (5), 493498.
Boudry, G., David, E. S., Douard, V., Monteiro, I. M., Le Huerou-Luron, I.,
& Ferraris, R. P. (2010). Role of intestinal transporters in neonatal
nutrition: Carbohydrates, proteins, lipids, minerals, and vitamins.
Journal of Pediatric Gastroenterology and Nutrition, 51 (4), 380
401.
Bullen, C. L., Tearle, P. V., & Willis, A. T. (1976). Bifidobacteria in the
intestinal tract of infants: An in-vivo study. Journal of Medicinal
Microbiology, 9, 325333.
Chirico, G., Marzollo, R., Cortinovis, S., Fonte, C., & Gasparoni, A.
(2008). Antiinfective properties of human milk. Journal of Nutri-
tion, 138, 1801S1806S.
Claud, E. (2009). Neonatal necrotizing enterocolitisinflammation and
intestinal immaturity. Anti-Inflammatory & Anti-Allergy Agents in
Medicinal Chemistry, 8 (3), 248259.
Coppa, G., Pierani, P., Zampini, L., Bruni, S., Carloni, I., & Gabrielli, O.
(2001). Characterization of oligosaccharides in milk and faeces
of breast-fed infants by high-performance anion-exchange chro-
matography. Advances in Experimental Medical Biology, 501,
307314.
Coppa, G., Zampini, L., Galeazzi, T., & Gavvrielli, O. (2006). Prebiotics
in human milk: A review. Digestive and Liver Disease, 38 (2),
S291-S294.
de Figueiredo, C S., Palhares, D. B., Melnikov, P., da Cruz Montes
Moura, A. J., & Dos Santos, S. C. (2009). Zinc and copper con-
centrations in human preterm milk. Biology of Trace Elements
Research, 136 (1), 17.
de La Cochetiere, M., Rouge, C., Darmaun, D., Roze, J., Potel, G., &
Leguen, C. (2007). Intestinal microbiota in neonates and preterm
infants: A review. Current Pediatric Reviews, 3 (1), 2134.
Donovan, S. M. (2008). Human milk oligosaccharides-the plot thickens.
British Journal of Nutrition, 101 (9), 12671269.
Dorea, J. G. (2000). Magnesium in human milk. Journal of American
College of Nutrition, 19 (2), 210219.
Engfer, M., Stahl, B., Finke, B., Sawatzki, G., & Daniel, H. (2000).
Human milk oligosaccharides are resistant to enzymatic hydrol-
ysis in the upper gastrointestinal tract. American Journal of Clin-
ical Nutrition, 71 (6), 15891596.
Feist, N., Berger, D., & Speer, C. (2000). Anti-endotoxin antibodies
in human milk: Correlation with infection of the newborn. Acta
Paediatrica, 89 (9), 10871092.
Forsum, E., & Lonnerdal, B. (1980). Effect of protein intake on protein
and nitrogen composition of breast milk. American Journal of
Clinical Nutrition, 33 (8), 18091813.
Friesen, R., & Innis, S. M. (2006). Trans fatty acids in human milk in
Canada declined with the introduction of trans fat food labeling.
Journal of Nutrition, 136 (10), 25582561.
Furman, L., Taylor, G., Minich, N., & Hack, M. (2003). The effect of ma-
ternal milk on neonatal morbidity of very low-birth-weight infants.
Archives of Pediatrics & Adolescent Medicine, 157 (1), 6671.
Garofalo, R. (2010). Cytokines in human milk. Journal of Pediatrics, 156
(Suppl), S36S40.
http://jognn.awhonn.org
Kim, J. H. and Froh, E. B.
Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., OHare, D.,
. . . Eidelman, A. I. (2005). Breastfeeding and the use of human
milk. Pediatrics, 115 (2), 496506.
German, J. B., Freeman, S. L., Lebrilla, C. B., & Mills, D. A.
(2008). Human milk oligosaccharides: Evolution, structures and
bioselectivity as substrates for intestinal bacteria. Nestle Nutri-
tion Institute Workshop Series: Pediatric Program, 62, 205222.
Hale, T., & Hartmann, P. (2007). Textbook of human lactation. Amarillo,
TX: Hale Publishing.
Hancock, J. T., Salisbury, V., Ovejero-Boglione, M. C., Cherry, R., Hoare,
C., Eisenthal, R., . . . Harrison, R. (2002). Antimicrobial proper-
ties of milk: Dependence on presence of xanthine oxidase and
nitrate. Antimicrobial Agents and Chemotherapy, 46 (10), 3308
3310.
Harmsen, H., Wildeboer-Veloo, A., Raangs, G., Wagendorp, A., Klijn,
N., Bindels, J. G., . . . Wellig, G. (2000). Analysis of intestinal
flora development in breast-fed and formula-fed infants by us-
ing molecular identification and detection methods. Journal of
Pediatric Gastroenterology and Nutrition, 30 (1), 6167.
Hettinga, K., van Valenberd, H., de Vries, S., Boeren, S., van Hooijdonk,
T., van Arendonk, J., . . . Vervoort, J. (2011). The host defense
proteome of human and bovine milk. PLoS One, 6 (4), 28.
Hosea Blewett, H. J., Cicalo, M. C., Holland, C. D., & Field, C. J. (2008).
The immunological components of human milk. Advances in
Food and Nutrition Research, 54, 4580.
Hosoi, S., Honma, K., Daimatsu, T., Kiyokawa, M., Aikawa, T., &
Watanabe, S. (2005). Lower energy content of human milk than
calculated using conversion factors. Pediatrics International, 47
(1), 79.
Klein, C. J. (2002). Nutrient requirements for preterm infant formulas.
Journal of Nutrition, 132 (6 Suppl 1), 1395S1577S.
Kleinman, R. E. (2009). Pediatric nutrition handbook (6th ed.). Elk Grove
Village, IL: American Academy of Pediatrics.
Koo, W. W., Hockman, E. M., & Dow, M. (2006). Palm olein in the fat
blend of infant formulas: Effect on the intestinal absorption of
calcium and fat, and bone mineralization. Journal of American
College of Nutrition, 25 (2), 117122.
Labbok, M. H., Clark, D., & Goldman, A. S. (2004). Breastfeeding:
Maintaining an irreplaceable immunological resource. Nature
Reviews Immunology, 4 (7), 565572.
Lauritzen, L., & Carlson, S. E. (2011). Maternal fatty acid status dur-
ing pregnancy and lactation and relation to newborn and infant
status. Maternal & Child Nutrition, 7 (Suppl 2), 4158.
Lawrence, R. A. (1999). Storage of human milk and the influence of
procedures on immunological components of human milk. Acta
Paediatrica, 88 (Suppl 430), 1418.
Lawrence, R. (2001). Milk banking: The influence of storage procedures
and subsequent processing on immunologic components of
human milk. Advances in Nutritional Research, 10, 389404.
Lawrence, R. M., & Pane, C. A. (2007). Human breast milk: Current con-
cepts of immunology and infections diseases. Current Problems
in Pediatric and Adolescent Health Care, 37 (1), 736.
Lee, J., & Davis, J. (2011). Future applications of antioxidants in pre-
mature infants. Current Opinion in Pediatrics, 23 (2), 161166.
Le Huerou-Luron, I., Blat, S., & Boudry, G. (2010). Breast v. formula-
feeding: Impacts on the digestive tract and immediate and long-
term health effects. Nutrition Research Reviews, 23 (1), 2336.
Lindquist, S., & Hernell, O. (2010). Lipid digestion and absorption in
early life: An update. Current Opinion in Clinical Nutrition and
Metabolic Care, 13 (3), 314320.
Lonnerdal, B. (2003). Nutritional and physiologic significance of
human milk proteins. American Journal of Clinical Nutrition, 77
(6), 1537515435.
Marquis, G. S., Penny, M. E., Diaz, J. M., & Marin, R. M. (2002). Post-
JOGNN 2012; Vol. 41, Issue 1
IN FOCUS
CNE
http://JournalsCNE.awhonn.org
partum consequences of an overlap of breastfeeding and preg-
nancy: Reduced breast milk intake and growth during early in-
fancy. Pediatrics, 109 (4), e56.
Marquis, G. S., Penny, M. E., Zimmer, J. P., Diaz, J. M., & Marin, R.
M. (2003). An overlap of breastfeeding during late pregnancy is
associated with subsequent changes in colostrum composition
and morbidity rates among Peruvian infants and their mothers.
Journal of Nutrition, 133 (8), 25852591.
Marchbank, T., Weaver, G., Nilsen-Hamilton, M., & Playford, R. J.
(2009). Pancreatic secretory trypsin inhibitor is a major moto-
genic and protective factor in human breast milk. American Jour-
nal of Physiology. Gastrointestinal and Liver Physiology, 296,
G697-G703.
Merchant, K., Martorell, R., & Haas, J. (1990). Maternal and fetal re-
sponses to the stresses of lactation concurrent with pregnancy
and of short recuperative intervals. American Journal of Clinical
Nutrition, 52 (2), 280288.
Michalski, M. C., Briard, V., Michel, F., Tasson, F., & Poulain, P. (2005).
Size distribution of fat globules in human colostrum, breast milk,
and infant formula. Journal of Dairy Science, 88 (6), 19271940.
Morrow, A. L., Ruiz-Palacios, G. M., Altaye, M., Jiang, X., Guerrero,
L., Meinzen-Derr, J. K., . . . Newburg, D. S. (2004). Human milk
oligosaccharides are associated with protection against diar-
rhea in breast-fed infants. Journal of Pediatrics, 145 (3), 297
303.
Newberg, D. S. (2005). Innate immunity and human milk. Journal of
Nutrition, 135 (5), 13081312.
Newberg, D. S. (2008). Neonatal protection by an innate immune sys-
tem of human milk consisting of oligosaccharides and glycans.
Journal of Animal Science, 87 (Suppl 13), 2634.
Newberg, D. S., Ruiz-Palacios, G. M., & Morrow, A. L. (2005). Human
milk glycans protect infants against enteric pathogens. Annual
Review of Nutrition, 25, 3758.
Newberg, D. S., & Walker, W. A. (2007). Protection of the neonate by
the innate immune system of developing gut and human milk.
Pediatric Research, 61 (1), 28.
Niers, L., Stasse-Wolthuis, M., Rombouts, F. M., & Rijkers, G. T. (2007).
Nutritional support for the infants immune system. Nutrition Re-
views, 65 (8), 347360.
Olsen, S. F., Osterdal, M. L., Salvig, J. D., Mortensen, L. M., Rytter,
D., Secher, N. J., . . . Henriksen, T. B. (2008). Fish oil intake
compared with olive oil intake in late pregnancy and asthma in
the offspring: 16 y of registry-based follow-up from a randomized
controlled trial. American Journal of Clinical Nutrition, 88 (1),
167175.
Piper, K., Berry, C., & Cregan, M. (2007). The bioactive nature of human
breastmilk. Breastfeeding Review, 15 (3), 510.
Riordan, J., & Wambach, K. (Eds.). (2010). Breastfeeding and human
lactation. Sudbury, MA: Jones and Bartlett.
Roberfroid, M. (2007). Prebiotics: The concept revisited. Journal of
Nutrition, 137 (Suppl), 830S837S.
Rodriguez, N., Miracle, D., & Meier, P. (2005). Sharing the science
on human milk feedings with mothers of very-low-birth-weight
infants. Journal of Obstetric, Gynecologic, & Neonatal Nursing,
34 (1), 109119.
Saarela, T., Kokkonen, J., & Koivisto, M. (2005). Macronutrient and en-
ergy contents of human milk fractions during the first six months
of lactation. Acta Paediatrica, 94 (9), 11761181.
Sauer, C. W., & Kim, J. H. (2011). Human milk macronutrient analysis
using point-of-care near-infrared spectrophotometry. Journal of
Perinatology, 31 (5), 339343.
Sherman, M., Bennett, S., Hwang, F., & Yu, C. (2004). Neonatal small
bowel epithelia: Enhancing anti-bacterial defense with lactoferrin
and Lactobacillus GG. Biometals, 17 (3), 285289.
135
IN FOCUS Nutritional and Immunobiological Properties of Human Milk

CNE
http://JournalsCNE.awhonn.org

Shulman, R. J., Schanler, R. J., Lau, C., Heitkemper, M., Ou, C. N., Continuing Nursing Education
& Smith, E. O. (1998). Early feeding, feeding tolerance, and
To take the test and complete the evaluation, please visit
lactase activity in preterm infants. Journal of Pediatrics, 133 (5),
http://JournalsCNE.awhonn.org.
645649.
Siimes, M. A., Vuori, E., & Kuitunen, P. (1979). Breast milk irona de-
Certificates of completion will be issued on receipt of
clining concentration during the course of lactation. Acta Paedi-
the completed evaluation form, application and process-
atrica Scandinavica, 68 (1), 2931.
ing fees. Note: Accredited status does not imply en-
Silvestre, D., Miranda, M., Muriach, M., Almansa, I., Jareno, E., &
dorsement by AWHONN or ANCC of any commercial
Romero, F. J. (2008). Antioxidant capacity of human milk: Effect
products displayed or discussed in conjunction with this
of thermal conditions for the pasteurization. Acta Paediatrica, 97
activity.
(8), 10701074.
Smithers, L. G., Gibson, R. A., McPhee, A., & Makrides, M. (2008).
Higher dose of docosahexaenoic acid in the neonatal period Learning Objectives
improves visual acuity of preterm infants: Results of a random-
ized controlled trial. American Journal of Clinical Nutrition, 88 Upon completion of this activity, participants will be able
(4), 10491056. to
Solinas, C., Corpino, M., Maccioni, R., & Pelosi, U. (2010). Cows milk
protein allergy. Journal of Maternal Fetal Neonatal Medicine, 23 1. Describe the unique qualities and health benefits
(Suppl 3), 7679. of the macronutrient and micronutrient contents of
Spatz, D. (2012). Innovations in the provision of human milk and breast- human milk.
feeding for infants requiring intensive care. Journal of Obstet- 2. Identify the major immunobiological factors found in
ric, Gynecologic, & Neonatal Nursing, 41 (1), in press. DOI: human milk and detail their mechanisms of action.
10.1111/j.1552-6909.2011.01315.x. 3. Integrate how the nutritional and biologic properties
Szalagatys-Sidorkiewicz, A., Zagierski, M., Renke, J., & Korzon, M. of human milk confer positive health outcomes for
(2004). Antioxidative properties of human milk. Medycyna Wieku the healthy and sick term and preterm newborn.
Rozwojowego, 8 (2), 353358.
Tacken, K. J., Vogelsang, A., van Lingen, R. A., Slootstra, J., Dikkeschei,
B. D., & van Zoeren-Grobben, D. (2009). Loss of triglycerides Questions
and carotenoids in human milk after processing. Archives of 1. The anti-inflammatory properties of human
Disease in Childhood: Fetal Neonatal Edition, 94 (6), F447F450.
milk (HM) include
Thapa, B. R. (2005). Health factors in colostrum. Indian Journal of
Pediatrics, 72 (7), 579581. a. cytokines.
Tully, M. (2000). Recommendations for handling of mothers own milk.
b. fats.
Journal of Human Lactation, 16 (2), 149151.
c. xanthine oxidase.
United Nations Childrens Fund. (2003). Global strategy for infant and
young child feeding. Geneva, Switzerland: World Health Orga- 2. The concentration of oligosaccharides in HM
nization.
varies from _____ in colostrum to _____ in ma-
Valent, F., Horvat, M., Mazej, D., Stibilj, V., & Barbone, F. (2011). Maternal
ture HM.
diet and selenium concentration in human milk from an Italian
population. Journal of Epidemiology, 21 (4), 285292. a. 10 g/L; 514 g/L
Van Zoeren-Grobben, D., Schrijver, J., Van den Berg, H., & Berger,
b. 20 g/L; 2024 g/L
H. M. (1987). Human milk vitamin content after pasteurisation,
storage, or tube feeding. Archives of Disease in Childhood, 62
c. 20 g/L; 514 g/L
(2), 161165.
3. When comparing levels of lactoferrin be-
Vieira, A. A., Soares, F. V., Pimenta, H. P., Abranches, A. D., & Moreira,
tween fresh, heat-treated, and frozen human
M. E. (2011). Analysis of the influence of pasteurization, freez-
ing/thawing, and offer processes on human milks macronutrient
milk, the following statement is true:
concentrations. Early Human Development, 87 (8), 577580.
a. Levels of lactoferrin remain consistent re-
Wilson, N. W., Self, T. W., & Hamburger, R. N. (1990). Severe cows milk
gardless of treatment.
induced colitis in an exclusively breast-fed neonate. Case report
and clinical review of cows milk allergy. Clinical Pediatrics, 29
b. No significant difference exists in the con-
(2), 7780. centrations of lactoferrin between fresh
Wold, A. E., & Adlerberth, I. (2000). Breast feeding and the intestinal and frozen HM.
microflora of the infant implications for protection against infec- c. No significant difference exists in the con-
tious disease. Advances in Experimental Medicine and Biology, centrations of lactoferrin between fresh
478, 7793.
and heat-treated HM.
World Health Organization. (2001). The optimal duration of exclusive
breastfeeding: A systematic review. Retrieved from http:// 4. Lysozyme, a major protein in human milk,
www.who.int/child_adolescent_health/documents/nhd_01_09/
is responsible for cell wall lysis. Effects of
en/index.html
lysozyme have been proved on bacterial
Zarban, A., Taheri, F., Chahkandi, T., Sharifzadeh, G., & Kho-
rashadizadeh, M. (2009). Antioxidant and radical scavenging
strains including
activity of human colostrum, transitional and mature milk. Jour-
a. Escherichia coli and Salmonella.
nal of Clinical Biochemistry and Nutrition, 45 (2), 150154.

136 JOGNN, 41, 122-137; 2012. DOI: 10.1111/j.1552-6909.2011.01314.x http://jognn.awhonn.org

Kim, J. H. and Froh, E. B. IN FOCUS
CNE
http://JournalsCNE.awhonn.org

b. Salmonella and Shigella. 10. The mechanisms of fat digestion available to

c. Shigella and Escherichia coli. the newborn include which of the following:

5. Human milk as proven prebiotic, anti- a. bile salt dependent lipase.

infective, and anti-inflammatory properties. b. cholesterol esterase.
Lactoferrin is a component of HM that is mul- c. pancreatic amylase.
tifunctional. However, as a bactericidal com-
11. Which of the following is a human milk pro-
ponent, lactoferrin is responsible for
tein?
a. disrupting cell wall membranes.
a. Beta-casein
b. phagocytosis of pathogens.
b. Cholesterol
c. the attraction of pathogens.
c. Glycosaminoglycan
6. Zarban and colleagues (2009) studied the
12. Which of the following enhances calcium ab-
antioxidant capacity in human milk, and their
sorption?
conclusions emphasized the importance of
a HM diet for the newborn infant. Reflecting a. Beta-casein
on total antioxidant capacity, it is important to b. Glucose
remember that antioxidant levels are highest c. Magnesium
in maternal
13. The low content of vitamin D in human milk is
a. colostrum. due to
b. foremilk.
a. changes in diet that have altered the vita-
c. mature milk.
min D content of human milk.
7. As a prebiotic, human milk oligosaccha- b. humans need less vitamin D than in the
rides past.
c. less exposure to sunlight now than earlier
a. protect the infant by stimulating the growth
in human history, according to one hypoth-
of bifidobacteria and lactobacilli in the
esis.
colon.
b. protect the infant gut by stimulating epithe- 14. Nutritional quality of HM is most affected by
lial cells.
a. freezing milk at 20 C.
c. protect the infant via the identification of
b. pasteurization.
foreign pathogenic bacteria.
c. vigorous shaking at room temperature.
8. Infants who consume a majority of human
15. The nurse plays a crucial role in support-
milk are shown to have decreased incidence
ing HM feeding of the newborn. It is im-
of
portant for the nurse to do which of the
a. bone fractures. following?
b. desaturations.
a. Ensure all very low-birth-weight preterm in-
c. respiratory infections.
fants are fed HM.
9. The most variable component in human milk b. Persuade all of the women they care for to
is exclusively breastfeed.
c. Support womens decision making about
a. calcium.
infant feeding by conveying a solid under-
b. fat.
standing of the benefits of HM.
c. iron.

JOGNN 2012; Vol. 41, Issue 1 137