Formula versus maternal breast milk for feeding preterm or low birth weight infants

A Systemic Review of the Difference Between Diets for Preterm Infants Containing Raw Mother's Own Milk and Frozen or Pasteurized Mother's Own Milk

BACKGROUND

Raw, never stored or pasteurized mother's own milk (MOM) is not always available to feed preterm infants; however, storage and pasteurization of MOM diminishes some bioactive components. It can be difficult to feed raw MOM to preterm infants due to transportation and storage of small volumes that might be pumped away from the infant, and a concern that they might harbor bacteria. However, the higher availability of bioactive components in raw MOM may provide benefits to preterm infants compared to frozen or pasteurized MOM.

RESEARCH AIM

To systematically review and summarize the results of studies on feeding raw MOM versus frozen or pasteurized MOM to preterm infants born at less than 37 weeks of gestation.

METHODS

Four databases were searched (Cochrane, Embase, Ovid MEDLINE, and Web of Science) for this systematic review. Of 542 studies identified, nine met inclusion criteria and were critically evaluated using the quality assessment tool for quantitative studies by the Effective Public Health Practice Project. Studies were organized using the Breastfeeding Challenges Facing Preterm Mother-Infant Dyads theoretical framework.

RESULTS

Included studies evaluated the outcomes of preterm infants fed raw versus pasteurized MOM (n = 7, 77.8%) or raw versus frozen MOM (n = 2, 22.2%). Researchers found that raw MOM did not increase infant infections and may have improved health and growth outcomes for study participants.

CONCLUSION

There is laboratory evidence supporting the safety and efficacy of the use of raw MOM for preterm infants. A raw MOM diet is recommended for preterm infants by professional organizations. Despite this, it may not be universally prioritized and could require purposeful implementation by each institution. Further research is needed to pursue the potential benefits of a raw MOM diet for preterm infants.

Defining postnatal growth failure among preterm infants in Indonesia

Background

Postnatal growth failure (PGF) frequently occurred among preterm infants with malnutrition. The decline in a weight-for-age z-score of ≥1.2 has been proposed to define PGF. It was unknown whether this indicator would be useful among Indonesian preterm infants.

Methods

Infants of <37 weeks of gestational age born between 2020 and 2021, both stable and unstable, were recruited for a prospective cohort study during hospitalization in the level III neonatal intensive care unit at the Cipto Mangunkusumo General Hospital, Jakarta, Indonesia. The prevalence of PGF as defined by a weight-for-age z-score of <−1.28 (<10th percentile) at discharge, a weight-for-age z-score of <−1.5 (<7th percentile) at discharge, or a decline in a weight-for-age z-score of ≥1.2 from birth till discharge was compared. The association between those PGF indicators with the preterm subcategory and weight gain was assessed. The association between the decline in a weight-for-age z-score of ≥1.2 with the duration to achieve full oral feeding and the time spent for total parenteral nutrition was analyzed.

Results

Data were collected from 650 preterm infants who survived and were discharged from the hospital. The weight-for-age z-score of <−1.28 or <−1.5 was found in 307 (47.2%) and 270 (41.5%) subjects with PGF, respectively. However, both indicators did not identify any issue of weight gain among subjects with PGF, questioning their reliability in identifying malnourished preterm infants. By contrast, the decline in a weight-for-age z-score of ≥1.2 was found in 51 (7.8%) subjects with PGF, in which this indicator revealed that subjects with PGF had an issue of weight gain. Next, a history of invasive ventilation was identified as a risk factor for preterm infants to contract PGF. Finally, the decline in a weight-for-age z-score of ≥1.2 confirmed that preterm infants with PGF took a longer time to be fully orally fed and a longer duration for total parenteral nutrition than the ones without PGF.

Conclusion

The decline in a weight-for-age z-score of ≥1.2 was useful to identify preterm infants with PGF within our cohort. This could reassure pediatricians in Indonesia to use this new indicator.

A Systematic Review and Meta-Analysis of Human Milk Feeding and Short-Term Growth in Preterm and Very Low Birth Weight Infants

Human milk (HM) is the gold standard for feeding infants but has been associated with slower growth in preterm infants compared with preterm formula. This systematic review and meta-analysis summarises the post-1990 literature to examine the effect of HM feeding on growth during the neonatal admission of preterm infants with birth weight ≤1500 g and/or born ≤28 weeks' gestation. Medline, PubMed, CINAHL, and Scopus were searched, and comparisons were grouped as exclusive human milk (EHM) vs. exclusive preterm formula (EPTF), any HM vs. EPTF, and higher vs. lower doses of HM. We selected studies that used fortified HM and compared that with a PTF; studies comparing unfortified HM and term formula were excluded. Experimental and observational studies were pooled separately. The GRADE system was used to evaluate risk of bias and certainty of evidence. Forty-four studies were included with 37 (n = 9963 infants) included in the meta-analyses. In general, due to poor quality studies, evidence of the effect of any HM feeds or higher versus lower doses of HM was inconclusive. There was a possible effect that lower doses of HM compared with higher doses of HM improved weight gain during the hospital admission, and separately, a possible effect of increased head circumference growth in infants fed EPTF vs. any HM. The clinical significance of this is unclear. There was insufficient evidence to determine the effects of an exclusive HM diet on any outcomes.

Improving long-term health outcomes of preterm infants: how to implement the findings of nutritional intervention studies into daily clinical practice

Preterm-born children are at risk for later neurodevelopmental problems and cardiometabolic diseases; early-life growth restriction and suboptimal neonatal nutrition have been recognized as risk factors. Prevention of these long-term sequelae has been the focus of intervention studies. High supplies of protein and energy during the first weeks of life (i.e., energy > 100 kcal kg-1 day-1 and a protein-to-energy ratio > 3 g/100 kcal) were found to improve both early growth and later neurodevelopmental outcome. Discontinuation of this high-energy diet is advised beyond 32-34 weeks postconceptional age to prevent excess fat mass and possible later cardiometabolic diseases. After discharge, nutrition with a higher protein-to-energy ratio (i.e., > 2.5-3.0 g/100 kcal) may improve growth and body composition in the short term.Conclusion: Preterm infants in their first weeks of life require a high-protein high-energy diet, starting shortly after birth. Subsequent adjustments in nutritional composition, aimed at achieving optimal body composition and minimizing the long-term cardiometabolic risks without jeopardizing the developing brain, should be guided by the growth pattern. The long-term impact of this strategy needs to be studied. What is Known: • Preterm infants are at risk for nutritional deficiencies and extrauterine growth restriction. • Extrauterine growth restriction and suboptimal nutrition are risk factors for neurodevelopmental problems and cardiometabolic disease in later life. What is New: • Postnatally, a shorter duration of high-energy nutrition may prevent excess fat mass accretion and its associated cardiometabolic risks and an early switch to a protein-enriched diet should be considered from 32-34 weeks postconceptional age. • In case of formula feeding, re-evaluate the need for the continuation of a protein-enriched diet, based on the infant's growth pattern.

Risk Factors of Growth Retardation and Developmental Deficits in Very Preterm Infants in a German Tertiary Neonatal Unit

Over the last two decades, improvements in perinatology have led to increased survival rates of preterm infants. A large number of studies and meta-analyses have investigated of preterm infants and/or the influence of developmental care. However, the combined influence of the most frequent risk factors and developmental care on the long-term somatic, motor, and cognitive outcome of preterm infants remains unclear. This retrospective, single-center cohort study includes 256 children treated in a tertiary neonatal intensive care unit in Rostock, Germany, between 2008 and 2013. Follow-up examinations (somatic, psychomotor, and mental development) were performed at (corrected) 24 months using Bayley Scales of Infant Development II (BSID-II). Developmental care was carried out according to the legal framework and national guidelines (physiotherapy and/or early education). Bronchopulmonary dysplasia (BPD) and an exclusive formula feeding showed a 2.8–4.6-fold higher risk (95% Confidence Interval: Mental Developmental Index 1.73–7.58; Psychomotor Developmental Index 1.44–14.54; body length 1.20–6.41) for developmental deficits (mental and psychomotor developmental index; body length). Developmental care after discharge according to national guidelines did not prevent this. Since this is a retrospective pilot study, no recommendations can be made based on this analysis. Therefore, future research should evaluate whether standard developmental care should be extended by tailored measures depending on individual risk factors.

Effect on splanchnic oxygenation of breast milk, fortified breast milk, and formula milk in preterm infants

BACKGROUND

Enteral feeding induces mesenteric hemodynamic changes in preterm infants, which may vary according to the milk used. Our aim in this study was to evaluate changes of splanchnic regional oxygenation (rSO₂S) measured by near-infrared spectroscopy (NIRS) in infants fed with mother's own milk (MOM), fortified human milk (FHM), or preterm formula (PTF).

METHODS

Infants born at 25-31 weeks of gestational age (n = 54) received a bolus of MOM, FHM, or PTF. rSO₂S and splanchnic fractional oxygen extraction ratio (FOES) were recorded 60 min before (T₀), and 30 min (T₁) and 120 min (T₂) after the beginning of bolus feeding.

RESULTS

In the MOM group, rSO₂S and FOES did not change during the study period. In the FBM group, rSO₂S decreased from T₀ to T₁ and increased from T₁ to T₂, while FOES changed in reverse. In the PTF group, rSO₂S decreased from T₀ to T₁ and from T₁ to T₂, while FOES changed in reverse.

CONCLUSIONS

Splanchnic oxygenation was not affected by MOM feeding, was transiently decreased by FBM feeding, and was persistently decreased by PTF. These results suggest that preterm infants who received PTF has higher splanchnic tissue oxygen extraction compared to those who received MOM or FBM.

IMPACT

Human milk feeding is associated to a lower splanchnic energy expenditure than preterm formula feeding. Fortified human milk transiently increases splanchnic energy expenditure. Preterm formula should be used only in the absence of human milk.

Essential and toxic elements in human milk concentrate with human milk lyophilizate: A preclinical study

Concentrated human milk (HM-concentrate) can be obtained from the simple and inexpensive method of donated breast milk direct lyophilization. A previous study reported that HM-concentrate contains the adequate amount of main macro- and micronutrients for use as a nutritional resource for preterm infants with very low birth weight admitted to neonatal intensive care units. However, further details need to be elucidated about HM-concentrate composition, particularly its content of essential and potentially toxic trace elements. Therefore, this study aimed to determine the concentration of essential and toxic elements in human milk considered baseline (HM-baseline) and HM-concentrate, as well as to quantify changes in concentration of these elements after the HM concentration process. The concentration of Aluminum, Arsenic, Cadmium, Chromium, Iron, Mercury, Manganese, Nickel, Lead, Selenium, Tin, and Thallium was analyzed by inductively coupled plasma-mass spectrometry (ICP-MS). Moreover, Bayesian linear mixed effect models were applied to estimate the mean difference between HM-baseline and HM-concentrate samples. After comparison (HM-concentrate versus HM-baseline), a significant increase in concentration was observed only for Manganese (0.80 μg/L; 95% CrI [0.16; 1.43]) and Selenium (6.74 μg/L; 95% CrI [4.66; 8.86]), while Lead concentration (-6.13 μg/L; 95% CrI [-8.63; -3.61]) decreased. This study provides latest and reliable information about HM composition. After milk concentration by lyophilization, there was a significant increase only in the essential elements Manganese and Selenium. The essential micronutrient content in HM-concentrate was similar or higher than that in preterm mothers' milk, which suggests it is viable for nutritional support of preterm infants. In addition, the low concentrations of potentially toxic elements in HM-concentrate indicates that it is safe for consumption by premature newborns.