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Schulz EV, Wagner CL. Powdered to Liquid Human Milk Fortifiers in the Preterm Infant. Neoreviews 2021; 22:e360-e369. [PMID: 34074641 DOI: 10.1542/neo.22-6-e360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In preterm infants, the goal of aggressive extrauterine nutritional management is to mimic in utero growth and nutrient accretion. Over the latter half of the 20th century, nutritional optimization through the practice of fortifying human milk rose to practice with increased survival rates in preterm infants of younger gestational age. The quest for optimal preterm fortification and nutrition remains a contentious area of debate. This review aims to summarize the historical perspectives of human milk fortification as well as the current literature advocating for the use of liquid human milk fortifiers in enterally fed premature infants.
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Affiliation(s)
- Elizabeth V Schulz
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Carol L Wagner
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC
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Abstract
Human milk is the preferred enteral diet for preterm infants. It provides macronutrients, micronutrients, and bioactive factors that support physical growth and neurodevelopment. Challenges of the human milk diet include the variability in its composition and a need for fortification to mirror placental nutrient delivery and prevent extrauterine growth restriction. Various strategies exist to attain target nutrient provision and optimize growth, including leveraging new technology for point-of-care human milk analysis. When maternal milk is unavailable or in short supply, pasteurized donor human milk is the preferred alternative. Infants fed donor milk may have slower weight gain than those fed exclusively maternal milk or formula, whereas infants fed fortified maternal milk have similar weight gain to preterm formula-fed infants. Future directions include more rigorous characterization of the variation in human milk, further investigation of the clinical benefits of non-nutrient bioactive factors in milk, and novel approaches to optimize fortification.
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Affiliation(s)
- Margaret L Ong
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Grace E, Hilditch C, Gomersall J, Collins CT, Rumbold A, Keir AK. Safety and efficacy of human milk-based fortifier in enterally fed preterm and/or low birthweight infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2021; 106:137-142. [PMID: 32943531 DOI: 10.1136/archdischild-2020-319406] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/17/2020] [Accepted: 07/05/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of the efficacy and safety of fortification of human milk with human milk-based fortifier versus cow's milk-based fortifier for use in preterm and/or very low birthweight infants. DESIGN Randomised or quasi-randomised controlled trials comparing the effect of human milk fortification with human milk-based milk fortifier versus cow's milk-based fortifier in infants born <34 weeks' gestation and/or with birth weight <1500 g were identified by searching databases, clinical trial registries and reference lists until 5 November 2019. Two authors independently extracted data and assessed evidence quality. Meta-analyses were conducted using fixed or random effects models, as appropriate. MAIN OUTCOME MEASURES Necrotising enterocolitis (Bell's stage II or higher) and late-onset sepsis. RESULTS Of 863 unique records identified, 16 full-text trials were screened and 2 trials involving 334 infants were included. Primary outcome data were available for 332 infants. Use of human milk-based fortifier compared with cow's milk-based fortifier reduced the risk of necrotising enterocolitis (risk ratio 0.47, 95% CI 0.22 to 0.98). There was no clear evidence of an effect on late-onset sepsis or any other outcomes. The quality of evidence was low to very low due to imprecision and lack of blinding in one study. CONCLUSIONS Findings suggest that there is a reduction in the incidence of necrotising enterocolitis with human milk-based fortifiers compared with cow's milk-based fortifiers. The overall quality of evidence is low. Further appropriately powered trials are required before this intervention can be routinely recommended for preterm infants.
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Affiliation(s)
- Erin Grace
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Cathie Hilditch
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
| | - Judith Gomersall
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia.,School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Carmel T Collins
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia
| | - Alice Rumbold
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Amy K Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia .,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, North Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
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54
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Abstract
This review highlights clinical outcomes of human milk from infancy through adulthood. Human milk outcomes of both preterm and term infants, including critically ill term infants (such as infants with congenital heart disease and those requiring therapeutic hypothermia) are summarized. Several human milk diets are identified to reduce the risk of specific diseases. Emerging research of newly discovered components of human milk are also reviewed. Human milk has significant effects on the gut microbiome, somatic growth, and neurocognitive outcomes. Continued research promises to improve donor human milk and donor milk derived products to achieve better outcomes for infants who do not receive their own mother's milk. The promotion of human milk is well-founded on evidence from the previous half century.
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Affiliation(s)
- Katherine E Chetta
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States.
| | - Elizabeth V Schulz
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Uniformed Services University, United States
| | - Carol L Wagner
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive, MSC 915, Charleston, SC 29425, United States
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55
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Bushati C, Chan B, Harmeson Owen A, Woodbury A, Yang M, Fung C, Lechtenberg E, Rigby M, Baserga M. Challenges in Implementing Exclusive Human Milk Diet to Extremely Low-Birth-Weight Infants in a Level III Neonatal Intensive Care Unit. Nutr Clin Pract 2021; 36:1198-1206. [PMID: 33624353 DOI: 10.1002/ncp.10625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PROBLEM Extremely low-birth-weight (ELBW) infants require fortification of human milk (HM) to prevent growth failure. Bovine milk-based fortifiers (BOV-f) may be associated with feeding intolerance and necrotizing enterocolitis. Evidence suggests that an exclusive HM diet (EHMD) using HM-based fortifier (HM-f) may improve these outcomes. INTERVENTION EHMD was introduced as a quality improvement project to improve feeding tolerance in ELBW infants. METHOD Implementation included establishing EHMD feeding protocol and growth monitoring. We compared infants receiving HM with BOV-f (n = 49) with infants receiving an EHMD (n = 15). The primary outcome was a reduction of no oral intake days due to feeding intolerance. RESULTS The EHMD cohort had a more advanced GA (28 vs 26 weeks; P = .03), more males (66.7% vs 42.9%; P = .02), and higher incidence of SGA (40.0% vs 18.4%; P = .16) compared with the HM-f group. The EHMD cohort had fewer days with no oral intake (2 vs 5; P < .005), which is insignificant when adjusted for small for gestational age (SGA) (P = .26). The EHMD cohort vs. the HM-f cohort had a significant decrease in weight and length z-scores from birth to discharge (-1.09 vs -0.26 [P = .002]; -1.76 vs -0.83 [P = .02]). Inadequate weight gain persisted after adjustment for SGA. Interventions were performed to increase caloric intake and institute milk preparation changes. CONCLUSION EHMD improved feeding tolerance in our ELBW infants. Observed growth failure might be skewed by SGA prevalence. We highlight that implementation of EHMD requires close growth assessment, especially for SGA infants.
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Affiliation(s)
- Charity Bushati
- Women's and Children's Services, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Belinda Chan
- Neonatology Division, University of Utah, Salt Lake City, Utah, USA
| | | | - Anne Woodbury
- Nutrition Care Services, University of Utah, Salt Lake City, Utah, USA
| | - Michelle Yang
- Neonatology Division, University of Utah, Salt Lake City, Utah, USA
| | - Camille Fung
- Neonatology Division, University of Utah, Salt Lake City, Utah, USA
| | - Ellen Lechtenberg
- Lactation Service, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Marilyn Rigby
- Neonatology APC Group, Intermountain Health Care, Salt Lake City, Utah, USA
| | - Mariana Baserga
- Neonatology Division, University of Utah, Salt Lake City, Utah, USA
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56
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Kombo L, Smith J, Van Wyk L. Somatic Growth of Enteral-Only Fed Extremely Low Birth Weight Infants in a Resource-Restricted Setting. J Trop Pediatr 2021; 67:6054284. [PMID: 33370442 DOI: 10.1093/tropej/fmaa119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To determine the growth and prevalence of extrauterine growth restriction (EUGR) in extremely low birth weight (ELBW) infants receiving enteral-only nutrition in a resource-restricted (RR) environment. METHODS Information on nutritional intake, provided largely from fortified breastmilk, was collected retrospectively for 72 ELBW (<1000 g) infants admitted to Tygerberg Hospital, Cape Town, South Africa over a 1 year period. Anthropometric data for the first 49 postnatal days were compared to gender-specific INTERGROWTH-21st standards. RESULTS Full enteral feeds (150 ml/kg) were reached by Day 10-14 with energy >100 Kcal/kg/day from Day 10, and protein >3.5 mg/kg/day from Day 14, onwards. Growth velocity remained below 15 g/kg/day at Day 49. INTERGROWTH-21st Z-scores decreased from -0.8 ± 1.1 at birth to -2.4 ± 1.5 at Day 49. Adequate weight growth velocity (≥15 g/kg/day) was associated with maternal hypertension, completed antenatal steroids, caesarean section delivery and small for gestational age status. CONCLUSION This is the first study to evaluate growth of ELBW infants in a RR setting where enteral-only nutrition, principally from fortified breastmilk, was the primary feeding option. The incidence of EUGR, although high, was similar to the incidence in well-resourced settings, where total parenteral nutrition is routinely provided. Lay summaryExtra-uterine growth restriction (EUGR) is high in extremely low birth weight infants receiving enteral-only nutrition. However, EUGR rates are similar to infants receiving parenteral nutrition. Despite developmental immaturity, it is possible for these infants to achieve fetal growth rates. More aggressive feeding and fortification strategies may be necessary and will need to be balanced against the risk and fear of necrotizing enterocolitis. Enteral-only feeding regimens, especially in resource-restricted environments, should be audited regularly to ensure provision of feeds with the most optimal protein, and protein to energy ratios possible.
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Affiliation(s)
- Lena Kombo
- Department of Paediatrics & Child Health, Stellenbosch University, Tygerberg Hospital, Cape Town 7500, South Africa
| | - Johan Smith
- Department of Paediatrics & Child Health, Stellenbosch University, Tygerberg Hospital, Cape Town 7500, South Africa
| | - Lizelle Van Wyk
- Department of Paediatrics & Child Health, Stellenbosch University, Tygerberg Hospital, Cape Town 7500, South Africa
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Moschino L, Duci M, Fascetti Leon F, Bonadies L, Priante E, Baraldi E, Verlato G. Optimizing Nutritional Strategies to Prevent Necrotizing Enterocolitis and Growth Failure after Bowel Resection. Nutrients 2021; 13:nu13020340. [PMID: 33498880 PMCID: PMC7910892 DOI: 10.3390/nu13020340] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
Necrotizing enterocolitis (NEC), the first cause of short bowel syndrome (SBS) in the neonate, is a serious neonatal gastrointestinal disease with an incidence of up to 11% in preterm newborns less than 1500 g of birth weight. The rate of severe NEC requiring surgery remains high, and it is estimated between 20–50%. Newborns who develop SBS need prolonged parenteral nutrition (PN), experience nutrient deficiency, failure to thrive and are at risk of neurodevelopmental impairment. Prevention of NEC is therefore mandatory to avoid SBS and its associated morbidities. In this regard, nutritional practices seem to play a key role in early life. Individualized medical and surgical therapies, as well as intestinal rehabilitation programs, are fundamental in the achievement of enteral autonomy in infants with acquired SBS. In this descriptive review, we describe the most recent evidence on nutritional practices to prevent NEC, the available tools to early detect it, the surgical management to limit bowel resection and the best nutrition to sustain growth and intestinal function.
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MESH Headings
- Enterocolitis, Necrotizing/complications
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Failure to Thrive/prevention & control
- Humans
- Infant
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/surgery
- Intestines/surgery
- Short Bowel Syndrome/etiology
- Short Bowel Syndrome/prevention & control
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (M.D.); (F.F.L.)
| | - Luca Bonadies
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Elena Priante
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
| | - Giovanna Verlato
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University Hospital of Padova, 35128 Padova, Italy; (L.M.); (L.B.); (E.P.); (E.B.)
- Correspondence: ; Tel.: +39-0498211428
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58
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Rai S, Lofiego P, Samedi V. Severe feeding intolerance in extremely preterm neonates successfully treated with human milk derived human milk fortifier: A case series. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_210_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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59
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Effects of standardized feeding protocol on growth velocity and necrotizing enterocolitis in extremely low birth weight infants. J Perinatol 2021; 41:134-139. [PMID: 33281186 DOI: 10.1038/s41372-020-00892-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/26/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the effect of a standardized feeding protocol (SFP) on growth velocity (GV) and necrotizing enterocolitis (NEC) in extremely low birth weight infants. METHODS This single-study center retrospectively compared growth, nutritional, and gastrointestinal outcomes in two infant cohorts before (cohort 1; n = 145) and after (cohort 2; n = 69) SFP implementation. RESULTS Although weekly GV in the first 4 weeks of life did not differ between the two cohorts, median GV at 36 weeks' post-menstrual age (PMA) was higher in cohort 2 compared with cohort 1 (26.8 g/day [24.7, 28.9] vs 24.9 g/day [22.9, 28.3], p = 0.02). The odds of NEC were lower in cohort 2 by 63% after adjusting for birth weight, small-for-gestational-age, and gender (OR = 0.38, 95% CI 0.142-0.993, p = 0.047). CONCLUSION Our SFP was associated with improved GV at 36 weeks' PMA and a lower adjusted rate of NEC.
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60
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Lucas A, Abrams SA. Comment on "Human Milk-Derived Fortifiers Compared with Bovine Milk-Derived Fortifiers in Preterm Infants: A Systematic Review and Meta-Analysis". Adv Nutr 2020; 11:1712-1713. [PMID: 33191434 PMCID: PMC7666967 DOI: 10.1093/advances/nmaa098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Alan Lucas
- Institute of Child Health, University College, London, London, United Kingdom
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School, University of Texas, Austin, TX, USA
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61
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Ananthan A, Balasubramanian H, Rao S, Patole S. Response to comments by Prof Abrams and Prof Lucas on "Human Milk-Derived Fortifiers Compared with Bovine Milk-Derived Fortifiers in Preterm Infants: A Systematic Review and Meta-Analysis". Adv Nutr 2020; 11:1713-1715. [PMID: 33191433 PMCID: PMC7666968 DOI: 10.1093/advances/nmaa099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 07/25/2020] [Indexed: 01/27/2023] Open
Affiliation(s)
| | | | - Shripada Rao
- Department of Neonatal Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Sanjay Patole
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia,Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
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[Clinical guidelines for the diagnosis and treatment of feeding intolerance in preterm infants (2020)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 33059799 PMCID: PMC7568993 DOI: 10.7499/j.issn.1008-8830.2008132] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Feeding intolerance (FI) is one of the most common clinical problems in preterm infant and often leads to the delay in reaching total enteral nutrition and prolonged hospital stay. The prevention and treatment of FI are of great significance in improving the survival rate of preterm infants. With reference to current evidence in China and overseas, the clinical guidelines for the diagnosis and treatment of FI in preterm infants were developed based on Grading of Recommendations Assessment, Development and Evaluation (GRADE), so as to help neonatal pediatricians, nursing staff, and nutritionists with early identification and standard management of FI in preterm infants.
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Asbury MR, Butcher J, Copeland JK, Unger S, Bando N, Comelli EM, Forte V, Kiss A, LeMay-Nedjelski L, Sherman PM, Stintzi A, Tomlinson C, Wang PW, O'Connor DL. Mothers of Preterm Infants Have Individualized Breast Milk Microbiota that Changes Temporally Based on Maternal Characteristics. Cell Host Microbe 2020; 28:669-682.e4. [PMID: 32888417 DOI: 10.1016/j.chom.2020.08.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/01/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
Mother's milk contains complex microbial communities thought to be important for colonizing a preterm infant's gastrointestinal tract. However, little is known about the microbiota in the preterm mother's milk and factors influencing its composition. We characterized the temporal dynamics of microbial communities in 490 breast milk samples from 86 mothers of preterm infants (born <1,250g) over the first 8 weeks postpartum. Highly individualized microbial communities were identified in each mother's milk that changed temporally with notable alterations in predicted microbial functions. However, pre-pregnancy BMI, delivery mode, and antibiotics were associated with changes in these microbial dynamics. Individual classes of antibiotics and their duration of exposure during prenatal and postpartum periods showed unique relationships with microbial taxa abundance and diversity in mother's milk. These results highlight the temporal complexity of the preterm mother's milk microbiota and its relationship with maternal characteristics as well as the importance of discussing antibiotic stewardship for mothers.
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Affiliation(s)
- Michelle R Asbury
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - James Butcher
- Department of Biochemistry, Microbiology and Immunology and Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Julia K Copeland
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, ON M5S 3B2, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Rogers Hixon Ontario Human Milk Bank and the Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Nicole Bando
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Elena M Comelli
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Victoria Forte
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Alex Kiss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada; Evaluative and Clinical Sciences, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Lauren LeMay-Nedjelski
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Philip M Sherman
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Cell Biology Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Alain Stintzi
- Department of Biochemistry, Microbiology and Immunology and Ottawa Institute of Systems Biology, University of Ottawa, Ottawa, ON K1H 8M5, Canada
| | - Christopher Tomlinson
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Pauline W Wang
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, ON M5S 3B2, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Rogers Hixon Ontario Human Milk Bank and the Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada.
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Ananthan A, Balasubramanian H, Rao S, Patole S. Human Milk-Derived Fortifiers Compared with Bovine Milk-Derived Fortifiers in Preterm Infants: A Systematic Review and Meta-Analysis. Adv Nutr 2020; 11:1325-1333. [PMID: 32277813 PMCID: PMC7490161 DOI: 10.1093/advances/nmaa039] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/24/2020] [Accepted: 03/11/2020] [Indexed: 12/21/2022] Open
Abstract
This systematic review assessed outcomes after using human milk-derived fortifier (HMF) compared with bovine milk-derived fortifier (BMF) in preterm infants. Six randomized controlled trials (RCTs) were included. Meta-analysis using a random-effects model showed the following results: 1) lower risk of necrotizing enterocolitis (NEC; ≥Stage II) (RR: 0.38; 95% CI: 0.15, 0.95; P = 0.04, I2 = 9%; n = 334, 4 RCTs) and surgical NEC (RR: 0.13; 95% CI: 0.02, 0.67; P = 0.02, I2 = 0%; n = 209, 3 RCTs) in the HMF group; 2) no significant difference in mortality (RR: 0.40; 95% CI: 0.14, 1.15; P = 0.09, I2 = 0%; n = 334, 4 RCTs); 3) lower weight gain in the HMF group [mean difference (MD) = -1.08 g · kg-1 · d-1; 95% CI: -1.96, -0.21 g · kg-1 · d-1; P = 0.02, I2 = 0%; n = 241, 4 RCTs]; 4) no differences for length (MD = -0.11 cm/wk; 95% CI: -0.26, 0.04 cm/wk; P = 0.14, I2 = 68%) and head circumference (MD = -0.02 cm/wk; 95% CI: -0.08, 0.05 cm/wk; P = 0.59, I2 = 23%); and 5) no significant difference in late-onset sepsis (RR: 0.96; 95% CI: 0.56, 1.67; P = 0.90, I2 = 63%; n = 334, 4 RCTs). The beneficial effects of HMF for NEC were no longer significant in sensitivity analyses after excluding studies with high risk of bias. Quality of evidence as per Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis was low to very low, and hence the confidence in these results is low. In summary, fortification of milk in preterm infants with HMF compared with BMF decreased the risk of NEC but was associated with lower weight gain. Given the low quality of evidence, adequately powered and well-designed RCTs without the influence of industry are required in this field.
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Affiliation(s)
- Anitha Ananthan
- Department of Neonatology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | | | - Shripada Rao
- Department of Neonatal Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Sanjay Patole
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Neonatal Directorate, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
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65
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Abstract
This study reports on the human milk fortification session at the 2019 NEC Society Symposium, which included clinicians and parents discussing the evidence comparing fortification options such as efficacy, safety, cost effectiveness, and the need for parents to be informed about fortifier choice. With the current literature available and the varying standard of care practices for human milk fortification, further studies are needed to determine the most complete diet for preterm infants. The optimal diet would not only provide key nutrients and energy for growth and development, but also improve short- and long-term outcomes. Parents, as advocates and providers for their infant, should be informed, educated, and included in the discussion and decisions regarding fortification of human milk for their infant.
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66
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Burrin D, Sangild PT, Stoll B, Thymann T, Buddington R, Marini J, Olutoye O, Shulman RJ. Translational Advances in Pediatric Nutrition and Gastroenterology: New Insights from Pig Models. Annu Rev Anim Biosci 2020; 8:321-354. [PMID: 32069436 DOI: 10.1146/annurev-animal-020518-115142] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Pigs are increasingly important animals for modeling human pediatric nutrition and gastroenterology and complementing mechanistic studies in rodents. The comparative advantages in size and physiology of the neonatal pig have led to new translational and clinically relevant models of important diseases of the gastrointestinal tract and liver in premature infants. Studies in pigs have established the essential roles of prematurity, microbial colonization, and enteral nutrition in the pathogenesis of necrotizing enterocolitis. Studies in neonatal pigs have demonstrated the intestinal trophic effects of akey gut hormone, glucagon-like peptide 2 (GLP-2), and its role in the intestinal adaptation process and efficacy in the treatment of short bowel syndrome. Further, pigs have been instrumental in elucidating the physiology of parenteral nutrition-associated liver disease and the means by which phytosterols, fibroblast growth factor 19, and a new generation of lipid emulsions may modify disease. The premature pig will continue to be a valuable model in the development of optimal infant diets (donor human milk, colostrum), specific milk bioactives (arginine, growth factors), gut microbiota modifiers (pre-, pro-, and antibiotics), pharmaceutical drugs (GLP-2 analogs, FXR agonists), and novel diagnostic tools (near-infrared spectroscopy) to prevent and treat these pediatric diseases.
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Affiliation(s)
- Douglas Burrin
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| | - Per Torp Sangild
- Comparative Pediatrics and Nutrition, University of Copenhagen, DK-1870 Frederiksberg C., Copenhagen, Denmark
| | - Barbara Stoll
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
| | - Thomas Thymann
- Comparative Pediatrics and Nutrition, University of Copenhagen, DK-1870 Frederiksberg C., Copenhagen, Denmark
| | - Randal Buddington
- College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
| | - Juan Marini
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA; .,Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Oluyinka Olutoye
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Robert J Shulman
- USDA-ARS Children's Nutrition Research Center, Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas 77030, USA;
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67
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Cattaneo S, Pica V, Stuknytė M, Masotti F, Mallardi D, Tabasso C, Roggero P, De Noni I. Effect of protein fortification on heat damage and occurrence of β-casomorphins in (un)digested donor human milk intended for nutrition of preterm infants. Food Chem 2020; 314:126176. [DOI: 10.1016/j.foodchem.2020.126176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/09/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
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68
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O'Connor DL, Kiss A, Unger S. Reply to A Lucas and SA Abrams. Am J Clin Nutr 2020; 111:1302-1303. [PMID: 32488258 PMCID: PMC7266681 DOI: 10.1093/ajcn/nqaa094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Deborah L O'Connor
- From the Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Department of Pediatrics, Sinai Health System, Toronto, Ontario, Canada,Address correspondence to DLOC (e-mail: )
| | - Alex Kiss
- Evaluative and Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Department of Pediatrics, Sinai Health System, Toronto, Ontario, Canada
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69
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Lucas A, Abrams SA. Human milk fortifiers: corrigenda. Am J Clin Nutr 2020; 111:1301-1302. [PMID: 32488256 DOI: 10.1093/ajcn/nqaa093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alan Lucas
- From the Institute of Child Health, University College, London, United Kingdom
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas, Austin, TX, USA
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70
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Premkumar MH, Massieu LA, Anderson DM, Gokulakrishnan G. Human Milk Supplements: Principles, Practices, and Current Controversies. Clin Perinatol 2020; 47:355-368. [PMID: 32439116 DOI: 10.1016/j.clp.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Human milk is the most optimal source of nutrition for preterm and term infants. However, in most preterm infants, breast milk fails to meet the energy needs of the newborn infant. Overwhelming evidence supports the fortification of breast milk in preterm infants to facilitate better short-term outcomes. Several single-nutrient and multinutrient breast milk supplements and fortifiers are used to improve the macronutrient and micronutrient content of breast milk. An individualized fortification strategy has the potential to offer better results compared with standard fortification strategies. Human milk-derived fortification is promising, but the benefits in exclusively human milk-fed preterm infants are unclear.
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Affiliation(s)
- Muralidhar H Premkumar
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | | | - Diane M Anderson
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Ganga Gokulakrishnan
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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71
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van Katwyk S, Ferretti E, Kumar S, Hutton B, Harrold J, Walker M, Forster AJ, Thavorn K. Economic Analysis of Exclusive Human Milk Diets for High-Risk Neonates, a Canadian Hospital Perspective. Breastfeed Med 2020; 15:377-386. [PMID: 32302511 DOI: 10.1089/bfm.2019.0273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: There is increasing evidence that premature newborns and infants with low birth weight can benefit substantially from an exclusive human milk-based diet (EHMD), consisting of human milk supplemented with a pasteurized donor human milk-derived fortifier. However, compared with the standard infant diet, EHMD also represents a significant added cost to the hospital and/or health system, thereby raising important questions about the economic feasibility of incorporating EHMD into newborn care. Design: We conducted a cost analysis and estimated the potential cost savings to a Canadian tertiary hospital based on the attributable complications averted from EHMD among low-weight neonates. A meta-analysis was performed to derive input parameters. A probabilistic analysis was conducted to determine the probability that EHMD is cost saving and 95% confidence interval (CI) around our estimates. Results: Our findings show that providing EHMD to preterm infants under 750 g at birth and at the highest risk of developing major complications is likely to be cost saving in the amount of $107,567 (95% CI: -145,229 to 360,362) per year. Extending EHMD to higher weight classes may be economically feasible depending on the pricing of the human milk-derived fortifier and the baseline risk of complications in the hospital setting. Conclusions: This comprehensive study provides critical insight for hospital-based decision makers to evaluate the potential gains and uncertainties associated with improved nutritional care for neonatal patients.
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Affiliation(s)
- Sasha van Katwyk
- Ottawa Hospital Research Institute, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Emanuela Ferretti
- Ottawa Hospital Research Institute, Ontario, Canada.,Division of Neonatology, The Ottawa Hospital General Campus, Ontario, Canada
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ontario, Canada
| | - JoAnn Harrold
- Ottawa Hospital Research Institute, Ontario, Canada.,Division of Neonatology, The Ottawa Hospital General Campus, Ontario, Canada
| | - Mark Walker
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada.,Division of Neonatology, The Ottawa Hospital General Campus, Ontario, Canada
| | - Alan J Forster
- Ottawa Hospital Research Institute, Ontario, Canada.,The Ottawa Hospital, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
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Bergner EM, Shypailo R, Visuthranukul C, Hagan J, O'Donnell AR, Hawthorne KM, Abrams SA, Hair AB. Growth, Body Composition, and Neurodevelopmental Outcomes at 2 Years Among Preterm Infants Fed an Exclusive Human Milk Diet in the Neonatal Intensive Care Unit: A Pilot Study. Breastfeed Med 2020; 15:304-311. [PMID: 32298596 PMCID: PMC7360515 DOI: 10.1089/bfm.2019.0210] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Long-term outcomes of preterm infants fed an exclusive human milk-based (EHM) diet using a donor human milk-based fortifier are not well defined. Materials and Methods: Infants ≤1,250 g birth weight (BW) were studied prospectively at two outpatient visits: 12-15 and 18-22 months corrected age (CA). Dual-energy X-ray absorptiometry and Bayley Scales of Infant and Toddler Development III (BSID-III) were performed at 18-22 months CA. Results: In this pilot study, 51 preterm infants (gestational age 27.8 ± 2.6 weeks and BW 893 ± 204 g) were evaluated. While anthropometric z-scores were significantly lower at discharge compared with birth, z-scores returned to birth levels by 12-15 months CA (length and head circumference [HC]) and 18-22 months CA (weight). Body composition at 2 years of age was similar to term-matched controls. Inpatient growth was significantly correlated with bone density, lean mass (LM), and fat-free mass at 18-22 months CA. Increased mother's own milk (MOM) was significantly correlated with decreased fat mass indices. BSID-III showed that 0% of cognitive composite scores were <70. Conclusions: In addition to returning to BW, length, and HC z-scores by 2 years of age, body composition analysis revealed that increase in body size was appropriate as reflected by LM and bone density similar to matched term controls without an increase in fat mass. No child had severe cognitive developmental delay using a cutoff score of 70. Inpatient growth and increased receipt of MOM correlated with favorable growth and body composition outcomes. Positive outcomes as shown in this study to confirm postdischarge safety of an EHM diet during hospitalization.
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Affiliation(s)
- Erynn M Bergner
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Section of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Roman Shypailo
- USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Chonnikant Visuthranukul
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.,USDA/ARS Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Department of Pediatrics, Section of Nutrition, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand.,Pediatric Nutrition STAR, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Joseph Hagan
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Andrea R O'Donnell
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Keli M Hawthorne
- Department of Pediatrics, Dell Medical School, Dell Pediatric Research Institute, University of Texas at Austin, Austin, Texas, USA
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School, Dell Pediatric Research Institute, University of Texas at Austin, Austin, Texas, USA
| | - Amy B Hair
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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73
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Lucas A, Boscardin J, Abrams SA. Preterm Infants Fed Cow's Milk-Derived Fortifier Had Adverse Outcomes Despite a Base Diet of Only Mother's Own Milk. Breastfeed Med 2020; 15:297-303. [PMID: 32239968 PMCID: PMC7232708 DOI: 10.1089/bfm.2019.0133] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: An increasingly common practice is to feed preterm infants a base diet comprising only human milk (HM), usually fortified with a cow's milk (CM)-derived fortifier (CMDF). We evaluated the safety of CMDF in a diet of 100% mother's own milk (MOM) against a HM-derived fortifier (HMDF). To date, this has received little research attention. Study Design: We reanalyzed a 12-center randomized trial, originally comparing exclusive HM feeding, including MOM, donor milk (DM), and HMDF, versus a CM exposed group fed MOM, preterm formula (PTF), and CMDF1. However, for the current study, we performed a subgroup analysis (n = 114) selecting only infants receiving 100% MOM base diet plus fortification, and fed no DM or PTF. This allowed for an isolated comparison of fortifier type: CMDF versus HMDF to evaluate the primary outcomes: necrotizing enterocolitis (NEC) and a severe morbidity index of NEC surgery or death; and several secondary outcomes. Results: CMDF and HMDF groups had similar baseline characteristics. CMDF was associated with higher risk of NEC; relative risk (RR) 4.2 (p = 0.038), NEC surgery or death (RR 5.1, p = 0.014); and reduced head circumference gain (p = 0.04). Conclusions: In neonates fed, as currently recommended with a MOM-based diet, the safety of CMDF when compared to HMDF has been little researched. We conclude that available evidence points to an increase in adverse outcomes with CMDF, including NEC and severe morbidity comprising NEC surgery or death.
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Affiliation(s)
- Alan Lucas
- Institute of Child Health, University College, London, United Kingdom
| | - John Boscardin
- Department of Medicine and University of California, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, USA
| | - Steven A. Abrams
- Department of Pediatrics, Dell Medical School, The University of Texas, Austin, Texas, USA
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74
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Rigo J, Hascoët J, Picaud JC, Mosca F, Rubio A, Saliba E, Radkë M, Simeoni U, Guillois B, Hays NP, Hartweg M, Billeaud C, Spalinger J. Comparative study of preterm infants fed new and existing human milk fortifiers showed favourable markers of gastrointestinal status. Acta Paediatr 2020; 109:527-533. [PMID: 31435957 PMCID: PMC7028100 DOI: 10.1111/apa.14981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022]
Abstract
AIM This study examined the influence of different human milk fortifiers on biomarkers of gastrointestinal immaturity and inflammation in preterm infants. METHODS We report secondary outcomes from a controlled, double-blind, randomised, parallel group study conducted from 2011 to 2014 in neonatal intensive care units at 11 metropolitan hospitals in France, Belgium, Germany, Switzerland and Italy. Preterm infants born at up to 32 weeks or weighing up to 1500 g were randomised to a new powdered human milk fortifier (n = 77) or a control fortifier (n = 76) for a minimum of 21 days. We analysed faecal markers of gut inflammation, namely alpha-1 antitrypsin and calprotectin, and maturity, namely elastase-1. RESULTS Faecal alpha-1 antitrypsin was slightly lower in the new than control fortifier group after 21 days of full enteral feeding, with a geometric mean and standard deviation of 1.52 ± 1.32 vs 1.82 ± 1.44 mg/g stools (P = .01). There was no significant difference in faecal calprotectin (median [Q1-Q3] of 296 [136-565] μg/g stools in both groups combined at study day 21). Faecal elastase-1 was lower in the new fortifier than control fortifier group (202.5 ± 1.6 vs 257.7 ± 1.5 μg/g stools, P = .016). CONCLUSION Mean values for each parameter were within the ranges in healthy term infants, indicating favourable markers of gastrointestinal status in both groups. In addition, for faecal calprotectin, the relatively high concentration observed in preterm infants fed fortified human milk suggests that the threshold level for detecting necrotising enterocolitis should be revised.
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Affiliation(s)
- Jacques Rigo
- Department of NeonatologyCHR CitadelleUniversity of LiègeLiègeBelgium
| | | | | | - Fabio Mosca
- Neonatal Intensive Care UnitDepartment of Clinical Science and Community HealthFondazione IRCCS “Ca' Granda” Ospedale Maggiore PoliclinicoUniversity of MilanMilanoItaly
| | | | | | | | - Umberto Simeoni
- Centre Hospitalier Universitaire VaudoisUniversity of LausanneLausanneSwitzerland
| | | | - Nicholas P. Hays
- Nestlé Product Technology Center – NutritionLa Tour‐de‐PeilzSwitzerland
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75
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Schulz EV, Wagner CL. History, epidemiology and prevalence of neonatal bone mineral metabolic disorders. Semin Fetal Neonatal Med 2020; 25:101069. [PMID: 31952927 DOI: 10.1016/j.siny.2019.101069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The evolutionary patterns of human migration and historical pre/post-industrial revolution have changed the face of bone metabolic disease through past centuries. Cultural, religious, and lifestyle practices continue to alter nutritional recommendations for this expanding diagnosis. Likewise, modern advancements in the field of neonatology and, more specifically, aggressive nutritional management of premature infants have shaped the epidemiology of neonatal bone metabolism over the past two decades. Decreased use of long-term parenteral nutrition, early fortification of enteral nutrition, and stringent American Academy of Pediatrics (AAP) practice guidelines instituting early supplementation of vitamin D have attributed to improved bone mineralization outcomes in both term and preterm infants. Nevertheless, neonatal bone mineral metabolic disorders remain prevalent. In this review, we provide an in-depth look at the diagnoses, therapeutics, and subset populations-both genetic and non-genetic-affected by neonatal bone mineral metabolic disorders.
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Affiliation(s)
- Elizabeth V Schulz
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Avenue, MSC 917, Charleston, SC, 29425, USA.
| | - Carol L Wagner
- Department of Pediatrics, Medical University of South Carolina, 165 Ashley Avenue, MSC 917, Charleston, SC, 29425, USA.
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76
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Bührer C, Fischer HS, Wellmann S. Nutritional interventions to reduce rates of infection, necrotizing enterocolitis and mortality in very preterm infants. Pediatr Res 2020; 87:371-377. [PMID: 31645057 DOI: 10.1038/s41390-019-0630-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
Observational studies demonstrating reduced rates of infections, necrotizing enterocolitis (NEC), and mortality in preterm infants fed their own mother's milk, as opposed to formula, have prompted endeavors to achieve similar effects with the right choice of food and food additives. In a systematic review of meta-analyses and randomized controlled trials (RCTs), we considered nutritional interventions aimed at reducing the rates of infections, NEC, or mortality in very preterm infants. The overall effects of particular interventions were presented as risk ratios with 95% confidence intervals. In RCTs, pasteurized human donor milk, as opposed to formula, reduced NEC but not infections or mortality. No differences emerged between infants receiving human or bovine milk-based fortifiers. Pooled data of small trials and a recent large RCT suggested that bovine lactoferrin reduced rates of fungal sepsis without impact on other infections, NEC, or mortality. Pooled data of RCTs assessing the use of prebiotic oligosaccharides found reduced infection but not mortality. Enteral L-glutamine (six RCTs) lowered infection rates, and enteral L-arginine (three RCTs) reduced NEC. A meta-analysis sensitivity approach found multiple-strain (but not single-strain) probiotics to be highly effective in reducing NEC and mortality. Thus, selected food components may help to improve outcomes in preterm infants.
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Affiliation(s)
- Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Hendrik S Fischer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sven Wellmann
- Division of Neonatology, University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany
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77
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Scholz SM, Greiner W. An exclusive human milk diet for very low birth weight newborns-A cost-effectiveness and EVPI study for Germany. PLoS One 2019; 14:e0226496. [PMID: 31887150 PMCID: PMC6936873 DOI: 10.1371/journal.pone.0226496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/27/2019] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Human milk-based fortifiers have shown a protective effect on major complications for very low birth weight newborns. The current study aimed to estimate the cost-effectiveness of an exclusive human milk diet (EHMD) compared to the current approach using cow's milk-based fortifiers in very low birth weight newborns. METHODS A decision tree model using the health states of necrotising enterocolitis (NEC), sepsis, NEC + sepsis and no complication was used to calculate the cost-effectiveness of an EHMD. For each health state, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (RoP) and neurodevelopmental problems were included as possible complications; additionally, short-bowel syndrome (SBS) was included as a complication for surgical treatment of NEC. The model was stratified into birth weight categories. Costs for inpatient treatment and long-term consequences were considered from a third party payer perspective for the reference year 2017. Deterministic and probabilistic sensitivity analyses were performed, including a societal perspective, discounting rate and all input parameter-values. RESULTS In the base case, the EHMD was estimated to be cost-effective compared to the current nutrition for very low birth weight newborns with an incremental cost-effectiveness ratio (ICER) of €28,325 per Life-Year-Gained (LYG). From a societal perspective, the ICER is €27,494/LYG using a friction cost approach and €16,112/LYG using a human capital approach. Deterministic sensitivity analyses demonstrated that the estimate was robust against changes in the input parameters and probabilistic sensitivity analysis suggested that the probability EHMD was cost-effective at a threshold of €45,790/LYG was 94.8 percent. CONCLUSION Adopting EHMD as the standard approach to nutrition is a cost-effective intervention for very low birth weight newborns in Germany.
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Affiliation(s)
- Stefan Michael Scholz
- Department of Health Economics and Health Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wolfgang Greiner
- Department of Health Economics and Health Management, School of Public Health, Bielefeld University, Bielefeld, Germany
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78
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Hopperton KE, O'Connor DL, Bando N, Conway AM, Ng DVY, Kiss A, Jackson J, Ly L, Unger SL. Nutrient Enrichment of Human Milk with Human and Bovine Milk-Based Fortifiers for Infants Born <1250 g: 18-Month Neurodevelopment Follow-Up of a Randomized Clinical Trial. Curr Dev Nutr 2019; 3:nzz129. [PMID: 32154499 PMCID: PMC7053578 DOI: 10.1093/cdn/nzz129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Bovine milk-based fortifiers (BMBF) have been standard of care for nutrient fortification of feeds for very low birth weight (VLBW) infants, however, there is increasing use of human milk-based fortifiers (HMBF) in neonatal care despite additional costs and limited supporting data. No randomized clinical trial has followed infants fed these fortifiers after initial hospitalization. OBJECTIVE To compare neurodevelopment in infants born weighing <1250 g fed maternal milk with supplemental donor milk and either a HMBF or BMBF. METHODS This is a follow-up of a completed pragmatic, triple-blind, parallel group randomized clinical trial conducted in Southern Ontario between August 2014 and March 2016 (NCT02137473) with feeding tolerance as the primary outcome. Infants weighing <1250 g at birth were block randomized by an online third-party service to receive either HMBF (n = 64) or BMBF (n = 63) added to maternal milk with supplemental donor milk during hospitalization. Neurodevelopment was assessed at 18-mo corrected age using the Bayley Scales of Infant and Toddler Development, Third Edition. Follow-up was completed in October 2017. RESULTS Of the 127 infants randomized, 109 returned for neurodevelopmental assessment. No statistically significant differences between fortifiers were identified for cognitive composite scores [adjusted mean scores 94.7 in the HMBF group and 95.9 in the BMBF group; fully adjusted mean difference, -1.1 (95% CI: -6.5 to 4.4)], language composite scores [adjusted scores 92.4 in the HMBF group and 93.1 in the BMBF; fully adjusted mean difference, -1.2 (-7.5 to 5.1)], or motor composite scores [adjusted scores 95.6 in the HMBF group and 97.7 in the BMBF; fully adjusted mean difference, -1.1 (-6.3 to 4.2)]. There was no difference in the proportion of participants that died or had neurodevelopmental impairment or disability between groups. CONCLUSIONS Providing HMBF compared with BMBF does not improve neurodevelopmental scores at 18-mo corrected age in infants born <1250 g otherwise fed a human milk diet. This trial was registered at clinicaltrials.gov as NCT02137473.
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Affiliation(s)
- Kathryn E Hopperton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Deborah L O'Connor
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | - Nicole Bando
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Aisling M Conway
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Dawn V Y Ng
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Alex Kiss
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada
- Evaluative and Clinical Sciences, Sunnybrook Research Institute and the Institute of Health Policy, Toronto, Canada
| | | | - Linh Ly
- Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | | | - Sharon L Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
- Department of Paediatrics, Sinai Health System, Toronto, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
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Premkumar MH, Pammi M, Suresh G. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Cochrane Database Syst Rev 2019; 2019:CD013145. [PMID: 31697857 PMCID: PMC6837687 DOI: 10.1002/14651858.cd013145.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Preterm infants who are fed breast milk in comparison to infant formula have decreased morbidity such as necrotizing enterocolitis. Multi-nutrient fortifiers used to increase the nutritional content of the breast milk are commonly derived from bovine milk. Human milk-derived multi-nutrient fortifier is now available, but it is not clear if it improves outcomes in preterm infants fed with breast milk. OBJECTIVES To determine whether the fortification of breast milk feeds with human milk-derived fortifier in preterm infants reduces mortality, morbidity, and promotes growth and development compared to bovine milk-derived fortifier. SEARCH METHODS We searched the following databases for relevant trials in September 2018. Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, Issue 9), electronic journal reference databases including MEDLINE (1980 to 20 September 2018), PREMEDLINE, Embase (1974 to 20 September 2018), CINAHL (1982 to 20 September 2018), biological abstracts in the database BIOSIS and conference abstracts from 'Proceedings First' (from 1992 to 2011). We also included the following clinical trials registries for ongoing or recently completed trials: ClinicalTrials.gov (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP; www.whoint/ictrp/search/en/) and the ISRCTN Registry (www.isrctn.com/), and abstracts of conferences: proceedings of Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research and European Society for Paediatric Research) from 1990 in the 'Pediatric Research' journal and 'Abstracts online' (2000 to 2017). SELECTION CRITERIA We included randomized and quasi-randomized controlled trials that compared preterm infants fed breast milk fortified with human milk-derived fortifier versus those fed with breast milk fortified with bovine milk-derived fortifier. DATA COLLECTION AND ANALYSIS The data were collected using the standard methods of Cochrane Neonatal. Two authors evaluated trial quality of the studies and extracted data. We reported dichotomous data using risk ratios (RRs), risk differences (RDs), number needed to treat (NNT) where applicable, and continuous data using mean differences (MDs). We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS One randomized trial with 127 infants met the eligibility criteria and had low risk of bias. Human milk-based fortifier did not decrease the risk of necrotizing enterocolitis in exclusively breast milk-fed preterm infants (RR 0.95, 95% CI 0.2 to 4.54; 1 study, 125 infants, low certainty of evidence). Human milk-derived fortifiers did not improve growth, decrease feeding intolerance, late-onset sepsis, or death. AUTHORS' CONCLUSIONS There is insufficient evidence evaluating human milk-derived fortifier with bovine milk-derived fortifier in exclusively breast milk-fed preterm infants. Low-certainty evidence from one study suggests that in exclusively breast milk-fed preterm infants human milk-derived fortifiers in comparison with bovine milk-derived fortifier may not change the risk of necrotizing enterocolitis, mortality, feeding intolerance, infection, or improve growth. Well-designed randomized controlled trials are needed to evaluate short-term and long-term outcomes.
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Affiliation(s)
- Muralidhar H Premkumar
- Baylor College of MedicineSection of Neonatology, Department of PediatricsHoustonTexasUSA
| | - Mohan Pammi
- Baylor College of MedicineSection of Neonatology, Department of PediatricsHoustonTexasUSA
| | - Gautham Suresh
- Baylor College of MedicineSection of Neonatology, Department of PediatricsHoustonTexasUSA
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80
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Hartmann BT. Benefit by design: Determining the 'value' of donor human milk and medical products derived from human milk in NICU. Semin Perinatol 2019; 43:151157. [PMID: 31383367 DOI: 10.1053/j.semperi.2019.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The use of donor human milk to provide therapeutic benefit to infants should only proceed where there is positive 'value'. This can be determined through an assessment of the benefit and the known risks. The emergence of new products derived from human milk requires new value assessments. The known hazards in human milk are modified by differences in the donor selection, processing methods and intended use and result in a unique risk assessment where any of these factors vary. The human source of the raw product requires high ethical standards in the design of these services with care taken to protect donors and recipients from harm. Any supplement to maternal milk should be provided cautiously to avoid displacement of maternal lactation.
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Affiliation(s)
- Ben T Hartmann
- Perron Rotary Express Milk Bank, Neonatology Clinical Care Unit, 1st Floor Block A, King Edward Memorial Hospital, Bagot Rd, Subiaco, Western Australia 6008, Australia; Centre for Neonatal Research and Education, The University of Western Australia (M550), 35 Stirling Highway Crawley, Perth, Western Australia 6009, Australia.
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81
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Abstract
Human milk provides not only ideal nutrition for infant development but also immunologic factors to protect from infection and inflammation. For the newborn preterm infant, the natural delivery of milk is not attainable, and instead pumped maternal milk, donor human milk, and human milk fortification are mainstays of clinical care. Current research demonstrates a decreased risk of necrotizing enterocolitis with maternal milk and donor human milk when individually compared to formula and with a complete human milk diet of maternal milk supplemented with donor human milk. The incidence of severe retinopathy of prematurity is decreased with an exclusive human milk diet, and this decrease is more pronounced with human milk-based compared to bovine milk-based human milk fortifier. The incidence of other morbidities such as late-onset sepsis and bronchopulmonary dysplasia is decreased with higher dose of human milk though significant differences are not apparent in exclusive human milk diet studies.
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Affiliation(s)
- Sarah N Taylor
- Yale School of Medicine, PO Box 208064, New Haven, Connecticut, 06520-8064, USA.
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82
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Adams M, Bassler D, Darlow BA, Lui K, Reichman B, Hakansson S, Norman M, Lee SK, Helenius KK, Lehtonen L, San Feliciano L, Vento M, Moroni M, Beltempo M, Yang J, Shah PS. Preventive strategies and factors associated with surgically treated necrotising enterocolitis in extremely preterm infants: an international unit survey linked with retrospective cohort data analysis. BMJ Open 2019; 9:e031086. [PMID: 31615799 PMCID: PMC6797308 DOI: 10.1136/bmjopen-2019-031086] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To compare necrotising enterocolitis (NEC) prevention practices and NEC associated factors between units from eight countries of the International Network for Evaluation of Outcomes of Neonates, and to assess their association with surgical NEC rates. DESIGN Prospective unit-level survey combined with retrospective cohort study. SETTING Neonatal intensive care units in Australia/New Zealand, Canada, Finland, Israel, Spain, Sweden, Switzerland and Tuscany (Italy). PATIENTS Extremely preterm infants born between 240 to 286 weeks' gestation, with birth weights<1500 g, and admitted between 2014-2015. EXPOSURES NEC prevention practices (probiotics, feeding, donor milk) using responses of an on-line pre-piloted questionnaire containing 10 questions and factors associated with NEC in literature (antenatal steroids, c-section, indomethacin treated patent ductus arteriosus and sepsis) using cohort data. OUTCOME MEASURES Surgical NEC rates and death following NEC using cohort data. RESULTS The survey response rate was 91% (153 units). Both probiotic provision and donor milk availability varied between 0%-100% among networks whereas feeding initiation and advancement rates were similar in most networks. The 9792 infants included in the cohort study to link survey results and cohort outcomes, revealed similar baseline characteristics but considerable differences in factors associated with NEC between networks. 397 (4.1%) neonates underwent NEC surgery, ranging from 2.4%-8.4% between networks. Standardised ratios for surgical NEC were lower for Australia/New Zealand, higher for Spain, and comparable for the remaining six networks. CONCLUSIONS The variation in implementation of NEC prevention practices and in factors associated with NEC in literature could not be associated with the variation in surgical NEC incidence. This corroborates the current lack of consensus surrounding the use of preventive strategies for NEC and emphasises the need for research.
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MESH Headings
- Cause of Death
- Cohort Studies
- Data Analysis
- Databases, Factual
- Enterocolitis, Necrotizing/mortality
- Enterocolitis, Necrotizing/prevention & control
- Enterocolitis, Necrotizing/surgery
- Female
- Hospital Mortality/trends
- Humans
- Infant, Extremely Premature
- Infant, Newborn
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/surgery
- Intensive Care Units, Neonatal
- Internationality
- Male
- Primary Prevention/methods
- Probiotics/administration & dosage
- Prognosis
- Retrospective Studies
- Risk Factors
- Surveys and Questionnaires
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- Mark Adams
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Brian A Darlow
- Department of Paediatrics, University of Otago, Christchurch, Otago, New Zealand
| | - Kei Lui
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Brian Reichman
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Centre, Tel Hashomer, Israel
| | - Stellan Hakansson
- Department of Clinical Sciences/Pediatrics, Umeå University Hospital, Umeå, Sweden
| | - Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Shoo K Lee
- Department of Paediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Kjell K Helenius
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Liisa Lehtonen
- Department of Pediatrics, University of Turku, Turku, Finland
| | | | - Maximo Vento
- Division of Neonatology and Health Research Institute La Fe, University of Valencia, Valencia, Spain
| | - Marco Moroni
- Neonatal Intensive Care Unit, Anna Meyer Children's University Hospital, Florence, Italy
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, Québec, Canada
| | - Junmin Yang
- Department of Paediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
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83
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Growth, Feeding Tolerance and Metabolism in Extreme Preterm Infants under an Exclusive Human Milk Diet. Nutrients 2019; 11:nu11071443. [PMID: 31248006 PMCID: PMC6683272 DOI: 10.3390/nu11071443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND For preterm infants, human milk (HM) has to be fortified to cover their enhanced nutritional requirements and establish adequate growth. Most HM fortifiers are based on bovine protein sources (BMF). An HM fortifier based on human protein sources (HMF) has become available in the last few years. The aim of this study is to investigate the impact of an HMF versus BMF on growth in extremely low birth weight (ELBW, <1000 g) infants. METHODS This was a retrospective, controlled, multicenter cohort study in infants with a birthweight below 1000 g. The HMF group received an exclusive HM diet up to 32+0 weeks of gestation and was changed to BMF afterwards. The BMF group received HM+BMF from fortifier introduction up to 37+0 weeks. RESULTS 192 extremely low birth weight (ELBW)-infants were included (HMF n = 96, BMF n = 96) in the study. After the introduction of fortification, growth velocity up to 32+0 weeks was significantly lower in the HMF group (16.5 g/kg/day) in comparison to the BMF group (18.9 g/kg/day, p = 0.009) whereas all other growth parameters did not differ from birth up to 37+0 weeks. Necrotizing enterocolitis (NEC) incidence was 10% in the HMF and 8% in the BMF group. CONCLUSION Results from this study do not support the superiority of HFM over BMF in ELBW infants.
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84
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Ahnfeldt AM, Hyldig N, Li Y, Kappel SS, Aunsholdt L, Sangild PT, Zachariassen G. FortiColos - a multicentre study using bovine colostrum as a fortifier to human milk in very preterm infants: study protocol for a randomised controlled pilot trial. Trials 2019; 20:279. [PMID: 31118098 PMCID: PMC6530095 DOI: 10.1186/s13063-019-3367-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Very preterm infants (< 32 weeks gestation) have a relatively high nutrient requirement for growth and development. The composition of human milk is often inadequate to ensure optimal growth so it is common to fortify human milk for very preterm infants with nutrient fortifiers based on bovine milk. However, there are concerns that bovine milk-based fortifiers may increase the risk of feeding intolerance, necrotizing enterocolitis and late-onset sepsis. We hypothesize that a bovine colostrum-based product is a suitable alternative to bovine milk-based products when used as a fortifier to human milk in very preterm infants. METHODS/DESIGN In an open-label multicentre randomised controlled pilot trial, 200 very preterm infants (26 + 0 to 30 + 6 weeks gestation at birth) will be randomly allocated to a bovine colostrum-based or a bovine milk-based fortifier added to mother's own milk and/or human donor milk. Outcomes are growth rate, incidence of necrotizing enterocolitis and late-onset sepsis, a series of paraclinical endpoints, and practical feasibility of using the novel fortifier for very preterm infants. DISCUSSION The optimal enteral diet and feeding regimen for very preterm infants remain debated; this clinical trial will document the feasibility, safety and preliminary efficacy of using bovine colostrum, rich in nutrients and bioactive factors, as a novel fortifier for human milk to very preterm infants. Data on infant growth, metabolism, gut function and immunity will be assessed from clinical data as well as blood and stool samples. TRIAL REGISTRATION Registered retrospectively 25 May 2018 at ClinicalTrials.gov: NCT03537365 .
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Affiliation(s)
- Agnethe M. Ahnfeldt
- Section of Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Frederiksberg, Denmark
| | - Nana Hyldig
- University of Southern Denmark, Odense, Denmark
- OPEN Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Yanqi Li
- Section of Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Frederiksberg, Denmark
| | - Susanne Soendergaard Kappel
- Section of Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Frederiksberg, Denmark
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
| | - Lise Aunsholdt
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
| | - Per T. Sangild
- Section of Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Frederiksberg, Denmark
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Gitte Zachariassen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
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85
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Arslanoglu S, Boquien CY, King C, Lamireau D, Tonetto P, Barnett D, Bertino E, Gaya A, Gebauer C, Grovslien A, Moro GE, Weaver G, Wesolowska AM, Picaud JC. Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification. Front Pediatr 2019; 7:76. [PMID: 30968003 PMCID: PMC6439523 DOI: 10.3389/fped.2019.00076] [Citation(s) in RCA: 139] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/25/2019] [Indexed: 01/03/2023] Open
Abstract
Evidence indicates that human milk (HM) is the best form of nutrition uniquely suited not only to term but also to preterm infants conferring health benefits in both the short and long-term. However, HM does not provide sufficient nutrition for the very low birth weight (VLBW) infant when fed at the usual feeding volumes leading to slow growth with the risk of neurocognitive impairment and other poor health outcomes such as retinopathy and bronchopulmonary dysplasia. HM should be supplemented (fortified) with the nutrients in short supply, particularly with protein, calcium, and phosphate to meet the high requirements of this group of babies. In this paper the European Milk Bank Association (EMBA) Working Group on HM Fortification discusses the existing evidence in this field, gives an overview of different fortification approaches and definitions, outlines the gaps in knowledge and gives recommendations for practice and suggestions for future research. EMBA recognizes that "Standard Fortification," which is currently the most utilized regimen in neonatal intensive care units, still falls short in supplying sufficient protein for some VLBW infants. EMBA encourages the use of "Individualized Fortification" to optimize nutrient intake. "Adjustable Fortification" and "Targeted Fortification" are 2 methods of individualized fortification. The quality and source of human milk fortifiers constitute another important topic. There is work looking at human milk derived fortifiers, but it is still too early to draw precise conclusions about their use. The pros and cons are discussed in this Commentary in addition to the evidence around use of fortifiers post discharge.
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Affiliation(s)
- Sertac Arslanoglu
- Division of Neonatology, Department of Pediatrics, Istanbul Medeniyet University, Istanbul, Turkey
| | - Clair-Yves Boquien
- PhAN, Institut National de la Recherche Agronomique (INRA), Université de Nantes, CRNH-Ouest, Nantes, France
| | - Caroline King
- Department of Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Delphine Lamireau
- Lactariums de Bordeaux-Marmande, Pôle Pédiatrique, Centre Hospitalo-Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Paola Tonetto
- Neonatal Unit of Turin University, City of Health and Science of Turin, Turin, Italy
| | - Debbie Barnett
- Greater Glasgow and Clyde Donor Milk Bank, Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - Enrico Bertino
- Neonatal Unit of Turin University, City of Health and Science of Turin, Turin, Italy
| | - Antoni Gaya
- Banc de Teixits, Fundaciò Banc Sang i Teixits de les Illes Balears, Palma de Mallorca, Spain
| | - Corinna Gebauer
- Abteilung Neonatologie Klinik und Poliklinik für Kinder und Jugendliche, Leipzig, Germany
| | - Anne Grovslien
- Neonatal Unit, Milk Bank, Oslo University Hospital, Oslo, Norway
| | - Guido E. Moro
- Associazione Italiana Banche del Latte Umano Donato (AIBLUD), Milan, Italy
| | - Gillian Weaver
- Hearts Milk Bank, Rothamsted Research Institute, Harpenden, United Kingdom
| | | | - Jean-Charles Picaud
- CarMeN Unit, INSERM U1060, INRA U1397, Claude Bernard University Lyon 1, Pierre Bénite, France
- Division of Neonatology, Hôpital de la Croix-Rousse, Lyon, France
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86
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Walsh V, McGuire W. Immunonutrition for Preterm Infants. Neonatology 2019; 115:398-405. [PMID: 30974431 DOI: 10.1159/000497332] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/19/2022]
Abstract
Care and outcomes for very preterm infants continue to improve, but important causes of mortality and acute and long-term morbidity associated with prolonged hospitalisation remain. Necrotising enterocolitis (NEC) and late-onset infection have emerged as the major causes of death beyond the early neonatal period and of neurodisability in very preterm infants. Although the pathogenesis of these conditions is incompletely understood, it appears to be related to the content and mode of delivery of the enteral diet, particularly the impact of immunonutrients from human breast milk on the microbial and metabolic balance within the immature intestine. Evidence exists to support investment in measures to help mothers to express breast milk as the primary source of nutrition for their very preterm infants. In the absence of maternal milk, pasteurised donor breast milk provides protection against NEC, but its nutritive adequacy is not clear and its cost-effectiveness is uncertain. Supplementation with individual immunonutrients, including immunoglobulins and lactoferrin, has not been shown to be effective in preventing NEC or infection in randomised controlled trials. The evidence base for prebiotics and probiotics is stronger, but concerns exist about the choice, safety and availability of formulations. Other strategies - including avoidance of drugs such as gastric acid suppressants that compromise innate immunity, as well as evidence-based progressive feeding strategies that reduce exposure to invasive interventions - are emerging as key components of care packages to reduce the burden of NEC, infection and associated growth and developmental faltering for very preterm infants.
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Affiliation(s)
- Verena Walsh
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, United Kingdom,
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