Benefits of donor human milk for preterm infants: current evidence

Acceptability to donate human milk among postnatal mothers at St. Francis hospital Nsambya, Uganda: a mixed method study

BACKGROUND

The World Health Organization recommends the use of donated human milk (HM) as the second-best option for mothers who are temporarily unable to provide sufficient breast milk to meet the needs of their infants. However, HM donation is yet to become an accepted practice in Uganda. We assessed the level of, and factors associated with acceptability to donate HM among postnatal mothers at St. Francis Hospital Nsambya (SFHN).

METHODS

A cross-sectional sequential explanatory mixed method study was conducted between October 2018 and March 2019. A questionnaire on sociodemography, awareness and likely acceptability to donate HM was administered to 410 postnatal mothers at SFHN. Multivariate logistic regression analysis was undertaken to determine factors associated with acceptance of HM donation. Focus Group Discussions (4) and Key Informants Interviews (4) were used to explore factors influencing behaviours to donate human milk. Qualitative data were analysed using a content thematic approach.

RESULTS

Overall acceptance of donating the HM was 77.6%, and the significant factors were: willingness to express the HM (AOR 7.5; 95% CI 3.01, 18.68); wet-nursing knowledge (AOR 2.3; 95% CI 1.1, 5.0) and visit to under-5 years' clinic (AOR 21.3; 95% CI 2.3, 196.9). The major themes in relation to accepting to donate HM were wet nursing experience, and confidence in donating the HM, and its perceived effectiveness. There were concerns about the safety and adequacy of HM and fear of transmitting criminal behaviours and mental illness through human milk.

CONCLUSIONS

Acceptance to donate HM among postnatal mothers at St. Francis Hospital Nsambya was very high. Willingness to express and store human milk, prior knowledge about wet nursing and a visit to an under-five outpatient clinic were associated with acceptance. Thus, establishing a human milk bank is feasible in the study setting.

Acceptability of donated breast milk among pregnant women in selected hospitals in central Uganda: a cross-sectional study

BACKGROUND

Donated breast milk is considered beneficial to vulnerable infants. Thus, Uganda launched its first human milk bank in November 2021 to provide breast milk to preterm, low birthweight and sick babies. However, there is a scarcity of information on the acceptability of donated breast milk in Uganda. The study sought to assess the acceptability of using donated breast milk and associated factors among pregnant women at a private and a public hospital in central Uganda.

METHODS

This cross-sectional study enrolled pregnant women attending antenatal care at the selected hospitals between July and October 2020. All pregnant women recruited had already given birth to at least one child. Data were collected using a semi-structured questionnaire, and we recruited participants through systematic sampling. Used frequencies, percentages and means with standard deviations to summarize variables. Assessed the association between the acceptability of donated milk and selected factors by comparing their arithmetic means using a generalized linear model to allow for clustering at the health facility level. Used a normal distribution and an identity link and calculated the adjusted mean differences together with 95% CIs [generated using robust variance estimators to correct for model misspecification].

RESULTS

A total of 244 pregnant women with a mean age of 30 (± 5.25) years were enrolled. Sixty-one-point 5% (150/244) of the women reported that they would accept donated breast milk. Higher education (adjusted mean difference, technical versus primary level: 1.33; 95% CI 0.64, 2.02), being Muslim (adjusted mean difference, Muslim versus Christian: 1.24; 95% CI 0.77, 1.70), having heard of donated breast milk banking (adjusted mean difference, ever versus never: 0.62; 95% CI 0.18, 1.06) and presence of a serious medical condition (adjusted mean difference, preference of donated milk versus other feeds in a serious medical condition: 3.96; 95% CI, 3.28, 4.64) were associated with acceptability of donated breast milk.

CONCLUSIONS

The acceptability of using donated breast milk for infant feeding was high among pregnant women. Public sensitization and education campaigns are indispensable for the acceptability of donated milk. These programs should be designed to include women with lower education levels.

Donor Breast Milk Banking: Knowledge and Attitudes of Iranian Mothers

INTRODUCTION

Milk donation is allowed in Islam and considered a virtue, though according to Islam Sharia, feeding donated milk of other mothers leads to kinship between infants, complicating milk donation programs in Islamic countries. This study aimed to determine the knowledge and attitude of Iranian Muslim mothers regarding milk donation and milk banks.

METHODS

In this cross-sectional descriptive-analytic study, 634 mothers of infants below 1 year of age were recruited using cluster random sampling from health care centers in Tabriz, Iran. Data were collected by questionnaire.

RESULTS

The findings revealed a low level of knowledge but relatively positive attitudes. Knowledge predictors were education level, income, type of birth, breastfeeding experience, encouragement to donate milk, and hearing about milk donation (p ≤ .02). Predictors of attitude were knowledge score and encouragement to donate milk (p ≤ .001).

DISCUSSION

Comprehensive, culturally congruent education of mothers during pregnancy and post-pregnancy related to milk banks is recommended.

Prematüre Bebeği Olan Annelerin Anne Sütü Bankacılığı Konusunda Bilgi ve Görüşleri

Giriş: Anne sütü bebeklerin sağlığı için çok önemlidir. Herhangi bir nedenle anne sütünü alamayan bebeklere donör süt önerilir. Bu nedenle anne sütü bankaları hem bebekler hem de anneler için çok önemli kurumlardır. Bu çalışmanın temel amacı prematüre bebeği olan annelerin anne sütü bankacılığı konusunda bilgi ve görüşlerini belirlemektir. Gereç ve Yöntem: Araştırma, bebeği prematüre ve yenidoğan yoğun bakım ünitesinde yatan annelerle yapıldı. Örneklemi anketi doldurmayı kabul eden 230 anne oluşturmuştur. Veriler, araştırmacı tarafından hazırlanan 39 sorudan oluşan anket ile toplanmıştır. Araştırmanın analiz aşamasında tanımlayıcı istatistikler ve ki-kare testi kullanılmıştır. Bulgular: Annelerin %86,1'inin anne sütü bankasını duymadığı, %90'ının bilmediği ve anne sütü bankasının kurulmasını isteme konusunda annelerin %43,9'unun kararsız olduğu saptanmıştır. Ülkemizde anne sütü bankası olması durumunda annelerin %41,3'ü süt bağışlamayacağını, %66,5'i süt bankasından süt talep etmeyeceğini ifade etmiştir. Annelerin %48,3'ü süt bankalarının din açısından herhangi bir sorun yaratıp yaratmayacağını bilmediklerini ifade etmiştir. Son olarak annelerin %58,3'ünün süt bankaları hakkında daha fazla bilgi talep ettiği görülmüştür.Annelerin eğitim düzeyi ile süt bankası ön bilgisi, süt bankası kurulmasına destek, süt bankasına ihtiyaç, süt bağışı ve süt talepleri arasında anlamlı bir istatistiksel oran bulunmuştur. Sonuç: Annelerin büyük bir çoğunluğunun anne sütü bankacılığı konusunda yeterli bilgiye sahip olmadığı saptanmıştır. Annelerin süt bankasının kurulmasını isteme konusunda çoğunlukla kararsız oldukları görülmüştür. Eğitim durumu arttıkça anne sütü bankasına karşı annelerin daha olumlu bir görüş içinde olduğu söylenebilir. Toplumun süt bankacılığı konusunda endişelerinin ortadan kaldırılıp ve bu konuda bilgilendirilmesi gerekmektedir.

Concentrating human milk: an innovative point-of-care device designed to increase human milk feeding options for preterm infants

OBJECTIVE

The purpose of this study was to determine whether a point-of-care osmotic device concentrates important human milk (HM) nutrients to support feeding neonates requiring high-nutrient, low-volume feedings.

STUDY DESIGN

Raw and pasteurized HM samples were concentrated to determine the effects of time and temperature on concentration. Concentrated samples were compared with matched baseline samples to measure changes in selected nutrient concentrations. Furthermore, changes in concentration of certain bioactive components of raw milk samples were measured.

RESULT

The device significantly increased the concentrations of the majority of the measured nutrient and bioactive levels (p < 0.05). Increasing temperature of HM from 4 to 37 °C increased the concentration rate >30%. In all cases, the concentration rate of pasteurized HM was greater than that of raw HM.

CONCLUSIONS

The osmotic concentration of HM is a promising option for neonatal nutrition. Further studies are needed to establish an evidence base for the practical applications of this point-of-care device.

Methods of mixing donor human milk during bottling results in fat differences between samples within a pool

The influence of milk-banking processes on nutrients in donor human milk (DHM) is largely unknown. Previous studies have measured nutrients between pools of DHM, but within-pool nutrient differences (between bottles from the same pool) have yet to be elucidated. The objective of this study was to gain a better understanding of the effect of different mixing characteristics on the distribution of fat, protein, IgA, and lysozyme in bottled, raw DHM. Pools of DHM were created in a laboratory setting according to published human milk-banking guidelines and assigned to a mixing treatment (mixing during bottling method, pooling container material, and refrigerated hold time). Four mixing protocols using glass pooling containers and a 1-h refrigerated hold time were tested: control (no mixing during bottling); manual-A (Man-A, hand swirl after pouring 3 bottles); manual-B (Man-B, hand swirl after pouring every bottle); and mechanical-G (Mech-G, continuous stirring with a magnet). As secondary objectives, we compared the effect of a glass and a plastic pooling container with mechanical mixing (mechanical-P, Mech-P), and compared refrigerated delays of 1 and 24 h before bottling with manual mixing (manual-A24, Man-A24). To control for differences in nutrient content, comparisons between treatments were made using absolute percent difference from the treatment-specific mean; and comparisons within a treatment were made using the ratio of fat content in a bottle to fat content in the first bottle of the same pool. We did not observe differences in nutrient distribution between Man-A, Man-B, and Mech-G in pools held for 1 h, but all were significantly different from the control for fat. There were no differences between glass or plastic pooling containers when mechanical mixing was used. Holding a pool in the refrigerator for 24 h before bottling created significantly greater fat distribution than holding a pool for 1 h. Outcomes were the result of controlled experiments. In summary, manual and mechanical mixing of 1,700-mL DHM pools produces similar fat and protein distributions when DHM is pooled and bottled after a 1-h hold time. When DHM is held for 24 h before bottling, more research is needed to determine the duration of initial mixing needed to reduce fat variability between bottles.

Strategies to Eliminate Mother-to-Child Transmission of HIV in Addis Ababa, Ethiopia (Qualitative Study)

OBJECTIVE

Globally, nearly 38 million people are living with HIV, and 1.8 million are children. Each day approximately 5600 people acquire HIV. Since the emerging of HIV, 78 million people have been infected and close to 39 million have died. In developing countries, from all new HIV infections, half are because of mother-to-child transmission (MTCT). The aim of this study is to evaluate the effect of option B+ prevention of mother-to-child HIV transmission (PMTCT) and to develop strategies that contribute to eliminate MTCT in Addis Ababa, Ethiopia.

METHODS

The study was conducted in three hospitals of Addis Ababa, Ethiopia, with a qualitative approach. Sixteen (16) in-depth interviews of HIV-positive mothers who had PMTCT follow-up and six focus group discussions with health professionals who work at a PMTCT unit were conducted. To analyse the data ATLAS.ti version 7 was used.

RESULTS

According to the findings of this study mother-to-child HIV transmission was associated with lack of HIV-discordant couples counselling guideline, lack of HIV disclosure strategy and counselling guidelines, unavailability of special PMTCT counselling guideline for HIV-positive commercial sex worker mothers and lack of HIV-free human breast milk (banked human breast milk) for PMTCT. Based on the study findings, a strategy that contributes to eliminate MTCT was developed.

CONCLUSION

Based on the research finding, the following four strategies were developed. Strategy 1: establish and use banked human breast milk for elimination of MTCT; Strategy 2: incorporate obligatory policy for discordant couple testing, counselling and disclosure with option B+ PMTCT; Strategy 3: develop disclosure policy and counselling guideline for PMTCT; and Strategy 4: formulate special PMTCT guideline for HIV-positive commercial sex worker mothers.

Immunomodulatory Constituents of Human Donor Milk

Mother's own human milk is the best nutrition for infants, especially preterm very-low-birth-weight (VLBW) (≤1,500 g) infants, because of its immune-modulatory constituents that strengthen the infant's host defense, provide protection against infections, and decrease the risk of necrotizing enterocolitis (NEC). When mother's own milk is unavailable or insufficient, donor human milk is considered the best alternative, especially for preterm VLBW infants. However, to assure biological safety, donor milk must be pasteurized. This results in partial or complete inactivation of some of the immunomodulatory constituents of human milk, which confer host defense. This review summarizes the current evidence regarding the effects of pasteurization on the different immunological constituents of donor milk, and their clinical significance, especially in relation to prevention of NEC.

Exploring the barriers and facilitators to the acceptability of donor human milk in eastern Uganda - a qualitative study

BACKGROUND

Human milk is the best nutrition for all infants. When the mother's own milk is not available, the World Health Organization recommends the use of donated human milk and milk banking for neonates born prematurely or with medical problems. Donor human milk is rarely available in low-resource settings where both the rates of preterm birth and neonatal mortality are highest. The potential to reduce neonatal mortality through use of donated human milk is one that is yet to be fully explored in the African setting. For the introduction of any new health intervention to be successful, determining the barriers and facilitators to its acceptability is a vital first step. There are limited studies on this in sub-Saharan Africa.

METHODS

This qualitative study used focus group discussions and in-depth interviews to explore the potential barriers and facilitators to utilizing donated human milk for neonates in a hospital setting in eastern Uganda from the perspectives of caregivers (parents, grandparents) and healthcare workers.

RESULTS

Six focus group discussions involving 28 caregivers were conducted in a hospital setting in eastern Uganda. Four in-depth interviews were then also held with healthcare staff. Lack of knowledge of donated human milk emerged with discussants, and the barriers relating to transmission of infection (HIV) and poor hygiene. Common reasons which facilitated its acceptability were; a general knowledge and recognition that human milk is better than formula milk and a strong belief by caregivers in healthcare workers providing knowledgeable and safe care. Healthcare workers were supportive of introducing donor human milk but perceived a need for community and hospital education programs to enable this to be facilitated and scaled up.

CONCLUSIONS

This study shows that donor human milk can be acceptable to the caregivers of vulnerable babies in hospital settings in Uganda. Lack of awareness of donor human milk, its benefits and the methods of screening, acquisition and storage of donor milk are all barriers that could be addressed through improved education. This study advocates for national policies and programs that build capacity for effective and sustainable donor milk banking.

The Evolving Microbiome from Pregnancy to Early Infancy: A Comprehensive Review

Pregnancy induces a number of immunological, hormonal, and metabolic changes that are necessary for the mother to adapt her body to this new physiological situation. The microbiome of the mother, the placenta and the fetus influence the fetus growth and undoubtedly plays a major role in the adequate development of the newborn infant. Hence, the microbiome modulates the inflammatory mechanisms related to physiological and pathological processes that are involved in the perinatal progress through different mechanisms. The present review summarizes the actual knowledge related to physiological changes in the microbiota occurring in the mother, the fetus, and the child, both during neonatal period and beyond. In addition, we approach some specific pathological situations during the perinatal periods, as well as the influence of the type of delivery and feeding.

Human T-Cell Lymphotropic Virus Type 1 and associated diseases in Latin America

This narrative review, which is based on a systematic literature search following the PRISMA guidelines, provides a general overview of Human T-cell Lymphotropic Virus type 1 (HTLV-1) and associated diseases: Adult T-cell Leukaemia-Lymphoma (ATLL) and HTLV-1-Associated Myelopathy/Tropical Spastic Paraparesis (HAM/TSP) in Latin America, focusing on epidemiology and prevention. Using the published information on HTLV-1, ATLL and HAM/TSP prevalence, we present comprehensive and accurate maps and tables, and developed an algorithm to assist in the prevention of HTLV-1 transmission through breastfeeding while considering socio-economic status. Latin America is an interesting scenario to study HTLV-1 because of the diverse origin of its population. Apart from the expected high prevalence in inhabitants of African ancestry, the presence of endemic foci affecting indigenous populations is particularly striking. ATLL prevention is the biggest challenge in this field. Most ATLL cases are transmitted through breastfeeding; thus, prevention methods to avoid ATLL in endemic countries have to be focused on this. In view of the high inequality in most Latin American countries, reduction in breastfeeding duration, freezing/thawing and pasteurisation of breastmilk can be suitable interventions in poor settings, considering that avoiding the risk of malnutrition and infant mortality must be the priority.

The Effect of Deep Freezing on Human Milk Macronutrients Content

OBJECTIVES

Long-term storage of human milk (HM) requires freezing at low temperatures, the consequences of which upon macronutrients are unclear. The conflicting results of the few studies on freezing-induced changes on HM macronutrients led to different storage recommendations. We examined differences in macronutrients content of HM after long-term storage at -20°C compared with -80°C.

MATERIALS AND METHODS

Mature HM samples from 25 mothers of term and preterm infants were collected. Each sample was divided into six aliquots for storage at -20°C and -80°C for 4, 12, and 24 weeks. After thawing and homogenization, energy and macronutrients content were measured using an HM infrared spectroscopy analyzer.

RESULTS

A total of 150 HM samples were available for analysis. Thirteen samples were removed due to calibration errors. The final analysis was performed on 137 samples with validated results. Fat and energy content were consistently higher in the -80°C samples compared with the paired -20°C samples at each time point (p < 0.05). Comparison of the differences in macronutrients content over time (4 versus 24 weeks) revealed a significant loss of fat (0.3 g/100 mL [7.9%], p = 0.001) and energy (2.3 kcal/100 mL [3.3%], p = 0.03) in the -20°C group. Fat and protein were also significantly decreased over time in the -80°C group (by 0.14 g/100 mL [3%], p = 0.009, and 0.06 g/100 mL [6.4%], p = 0.02, respectively).

CONCLUSIONS

Long-term storage of HM at -80°C is associated with better fat and energy preservation compared with storage at -20°C. These results may help construct evidence-based recommendations and guidelines for optimal HM storage.

The availability of probiotics and donor human milk is associated with improved survival in very preterm infants

BACKGROUND

To determine whether the introduction of pasteurized donor human milk and probiotics for infants born < 32 weeks gestational age or < 1500 g birthweight is associated with a reduction in mortality and the incidence of necrotising enterocolitis (NEC) and sepsis.

METHODS

We performed a retrospective analysis of two cohorts: before and after the introduction of probiotics and pasteurised donor human milk. Univariate analysis of primary and secondary outcomes was performed; variables impacting outcomes were assessed using multivariate logistic regression.

RESULTS

There were 1791 infants: 1334 in the pre-donor milk/probiotic cohort and 457 in the post-donor milk/probiotic cohort. On univariate analysis, mortality (7.6 vs. 2.4%, P < 0.001) and incidence of sepsis (6.2 vs. 3.5%, P = 0.028) were statistically significantly lower in the post-donor milk/probiotic group. NEC (2.8 vs. 1.5%, P = 0.14) and non-NEC associated gastrointestinal perforation (1.6 vs. 0.4%, P = 0.052) were lower in the post-donor milk/probiotics cohort, but these were not statistically significant. The difference in mortality remained statistically significant on multivariate analysis in the post-donor milk/probiotic cohort compared to those in the pre-donor milk/probiotic cohort (odds ratio 0.31, 95% confidence interval 0.16-0.61). The decrease in the incidence of NEC was consistent with previous observational studies but the difference was not statistically significant.

CONCLUSION

The availability of probiotics and pasteurised donor human milk is associated with a reduction in mortality in very preterm infants.

Preterm Gut Microbiome Depending on Feeding Type: Significance of Donor Human Milk

Preterm microbial colonization is affected by gestational age, antibiotic treatment, type of birth, but also by type of feeding. Breast milk has been acknowledged as the gold standard for human nutrition. In preterm infants breast milk has been associated with improved growth and cognitive development and a reduced risk of necrotizing enterocolitis and late onset sepsis. In the absence of their mother's own milk (MOM), pasteurized donor human milk (DHM) could be the best available alternative due to its similarity to the former. However, little is known about the effect of DHM upon preterm microbiota and potential biological implications. Our objective was to determine the impact of DHM upon preterm gut microbiota admitted in a referral neonatal intensive care unit (NICU). A prospective observational cohort study in NICU of 69 neonates <32 weeks of gestation and with a birth weight ≤1,500 g was conducted. Neonates were classified in three groups according to feeding practices consisting in their MOM, DHM, or formula. Fecal samples were collected when full enteral feeding (defined as ≥150 cc/kg/day) was achieved. Gut microbiota composition was analyzed by 16S rRNA gene sequencing. Despite the higher variability, no differences in microbial diversity and richness were found, although feeding type significantly influenced the preterm microbiota composition and predictive functional profiles. Preterm infants fed MOM showed a significant greater presence of Bifidobacteriaceae and lower of Staphylococcaceae, Clostridiaceae, and Pasteurellaceae compared to preterm fed DHM. Formula fed microbial profile was different to those observed in preterm fed MOM. Remarkably, preterm infants fed DHM showed closer microbial profiles to preterm fed their MOM. Inferred metagenomic analyses showed higher presence of Bifidobacterium genus in mother's milk group was related to enrichment in the Glycan biosynthesis and metabolism pathway that was not identified in the DHM or in the formula fed groups. In conclusion, DHM favors an intestinal microbiome more similar to MOM than formula despite the differences between MOM and DHM. This may have potential beneficial long-term effects on intestinal functionality, immune system, and metabolic activities.

Donor Human Milk Protects against Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis

Bronchopulmonary dysplasia (BPD) is the most common complication after preterm birth. Pasteurized donor human milk (DHM) has increasingly become the standard of care for very preterm infants over the use of preterm formula (PF) if the mother's own milk (MOM) is unavailable. Studies have reported beneficial effects of DHM on BPD. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies on the effects of DHM on BPD and other respiratory outcomes. Eighteen studies met the inclusion criteria. Meta-analysis of RCTs could not demonstrate that supplementation of MOM with DHM reduced BPD when compared to PF (three studies, risk ratio (RR) 0.89, 95% confidence interval (CI) 0.60-1.32). However, meta-analysis of observational studies showed that DHM supplementation reduced BPD (8 studies, RR 0.78, 95% CI 0.67-0.90). An exclusive human milk diet reduced the risk of BPD, compared to a diet with PF and/or bovine milk-based fortifier (three studies, RR 0.80, 95% CI 0.68-0.95). Feeding raw MOM, compared to feeding pasteurized MOM, protected against BPD (two studies, RR 0.77, 95% CI 0.62-0.96). In conclusion, our data suggest that DHM protects against BPD in very preterm infants.

A retrospective study on the effects of exclusive donor human milk feeding in a short period after birth on morbidity and growth of preterm infants during hospitalization

The risks and benefits of feeding preterm formula (PF) versus donor human milk (DHM) in preterm infants are uncertain, and studies evaluating the efficacy of DHM to the morbidities and growth of preterm infants in the neonatal intensive care unit are confused by the need for milk fortification. We aimed to determine and compare the outcome of short-term morbidities in neonatal intensive care unit and growth between premature infants fed exclusively DHM only until a volume of 130 mL/kg/d of enteral feeding was achieved and infants fed with a PF mix after birth. The data of 132 infants with low birth weight of <1500 g and gestational age of less than 32 weeks were considered. Ninety infants were analyzed, of which 86 were discharged alive. The DHM group (n = 36) was made up of infants who were fed exclusively with DHM, whereas the PF group (n = 54) consisted of infants who were fed with a combination of PF and either DHM or human milk, until a volume of 130 mL/kg/d of enteral feeding was achieved. Once feeding in the DHM group progressed to volumes greater than 130 mL/kg/d, infants were fed fortified DHM and PF alternately. One infant (2.8%) in the DHM group had late-onset sepsis or necrotizing enterocolitis compared with 21 (38.9%) in the PF group (adjusted odds ratio 0.05, 95% confidence interval 0.01-0.41); 13 (36.1%) infants in the DHM group had bronchopulmonary dysplasia compared with 38 (70.4%) in the PF group (odds ratio 0.18, 95% confidence interval 0.05-0.41). Although the DHM group demonstrated a comparatively lower rate of weight gain, head circumference increment, and height increment from birth to the age at which an enteral feeding volume of 130 mL/kg/d was achieved, there were no significant differences in these values at 36 weeks' postmenstrual age between both groups.

Deep sequencing of the 16S ribosomal RNA of the neonatal oral microbiome: a comparison of breast-fed and formula-fed infants

In utero and upon delivery, neonates are exposed to a wide array of microorganisms from various sources, including maternal bacteria. Prior studies have proposed that the mode of feeding shapes the gut microbiota and, subsequently the child’s health. However, the effect of the mode of feeding and its influence on the development of the neonatal oral microbiota in early infancy has not yet been reported. The aim of this study was to compare the oral microbiota of healthy infants that were exclusively breast-fed or formula-fed using 16S-rRNA gene sequencing. We demonstrated that the oral bacterial communities were dominated by the phylum Firmicutes, in both groups. There was a higher prevalence of the phylum Bacteroidetes in the mouths of formula-fed infants than in breast-fed infants (p = 0.01), but in contrast Actinobacteria were more prevalent in breast-fed babies; Proteobacteria was more prevalent in saliva of breast-fed babies than in formula-fed neonates (p = 0.04). We also found evidence suggesting that the oral microbiota composition changed over time, particularly Streptococcus species, which had an increasing trend between 4–8 weeks in both groups. This study findings confirmed that the mode of feeding influences the development of oral microbiota, and this may have implications for long-term human health.

Micronucleated Erythrocytes in Peripheral Blood from Neonate Rats Exposed by Breastfeeding to Cyclophosphamide, Colchicine, or Cytosine-Arabinoside

Genotoxic exposure to chemical substances is common, and nursing mothers could transmit harmful substances or their metabolites to their offspring through breast milk. We explored the possibility of determining genotoxic effects in the erythrocytes of breastfeeding rat pups whose mothers received a genotoxic compound while nursing. Ten groups of female rats and five pups per dam were studied. The control group received sterile water, and the experimental groups received one of three different doses of cyclophosphamide, colchicine, or cytosine-arabinoside. Blood smears were prepared from samples taken from each dam and pup every 24 h for six days. There were increased numbers of micronucleated erythrocytes (MNEs) and micronucleated polychromatic erythrocytes (MNPCEs) in the samples from pups in the experimental groups (P < 0.02) and increased MNPCE frequencies in the samples from the dams (P < 0.05). These results demonstrate the vertical transmission of the genotoxic effect of the compounds tested. In conclusion, assessing MNEs in breastfeeding neonate rats to assess DNA damage may be a useful approach for identifying genotoxic compounds and/or cytotoxic effects. This strategy could help in screening for therapeutic approaches that are genotoxic during the lactation stage and these assessments might also be helpful for developing preventive strategies to counteract harmful effects.

The Experience of Human Milk Banking for 8 Years: Korean Perspective

Human milk banks are a solution for mothers who cannot supply their own breast milk to their sick or hospitalized infants; premature infants, in particular, are unable to receive a full volume of breast milk for numerous reasons. As of December 2015, there was only one milk bank in a university hospital in Korea. We reviewed the basic characteristics of donors and recipients, and the amounts and contamination of breast milk donated at the Human Milk Bank in Kyung Hee University Hospital at Gangdong in Korea from 2008 to 2015. The donor pool consisted of 463 first-time donors and 452 repeat donors who made 1,724 donations. A total of 10,820 L of breast milk was collected, and 9,541.6 L were processed. Detectable bacteria grew in 12.6% after pasteurization and 52.5% had cytomegalovirus DNA before pasteurization in donated milk. There were 836 infant and 25 adult recipients; among new infant recipients, 48.5% were preterm; the groups received 8,009 and 165.7 L of donor milk, respectively. There was an increase in the percentage of preterm infants among new infant recipients in 2015 (93.1%) compared to 2008 (8.5%). Based on the number of premature infants in Korea, the number of potential recipients is not likely to diminish anytime soon, despite efforts to improve the breastfeeding rate. Sustainability and quality improvement of the milk bank need long-term financial support by health authorities and a nationwide network similar to blood banking will further contribute to the progress of milk banking.

The effect of pasteurization on trace elements in donor breast milk

OBJECTIVE

Premature infants often receive pasteurized donor human milk when mothers are unable to provide their own milk. This study aims to establish the effect of the pasteurization process on a range of trace elements in donor milk.

STUDY DESIGN

Breast milk was collected from 16 mothers donating to the milk bank at the Royal Brisbane and Women's Hospital. Samples were divided into pre- and post-pasteurization aliquots and were Holder pasteurized. Inductively coupled plasma mass spectrometry was used to analyze the trace elements zinc (Zn), copper (Cu), selenium (Se), manganese (Mn), iodine (I), iron (Fe), molybdenum (Mo) and bromine (Br). Differences in trace elements pre- and post-pasteurization were analyzed.

RESULTS

No significant differences were found between the trace elements tested pre- and post-pasteurization, except for Fe (P<0.05). The median (interquartile range, 25 to 75%; μg l(-1)) of trace elements for pre- and post- pasteurization aliquots were-Zn: 1639 (888-4508), 1743 (878-4143), Cu: 360 (258-571), 367 (253-531), Se: 12.34 (11.73-17.60), 12.62 (11.94-16.64), Mn: (1.48 (1.01-1.75), 1.49 (1.11-1.75), I (153 (94-189), 158 (93-183), Fe (211 (171-277), 194 (153-253), Mo (1.46 (0.37-2.99), 1.42 (0.29-3.73) and Br (1066 (834-1443), 989 (902-1396).

CONCLUSIONS

Pasteurization had minimal effect on several trace elements in donor breast milk but high levels of inter-donor variability of trace elements were observed. The observed decrease in the iron content of pasteurized donor milk is, however, unlikely to be clinically relevant.

TO INVESTIGATE THE EFFECT OF THE PASTEURISATION PROCESS ON TRACE ELEMENTS IN DONOR BREAST MILK

AIM

To investigate the effect of the pasteurisation process on trace elements in donor breast milk.

METHOD

Premature infants often receive donor breast milk when the mother is unable to produce sufficient breast milk. It is widely accepted that donor milk has considerable advantages over formula milk.1 The Royal Brisbane and Women's Hospital (RBWH) has a milk bank that receives milk donated by women which undergoes a pasteurisation process.2 This study investigated the effect of pasteurisation on a range of trace elements in donor milk.A total of 14 participants who donated to the milk bank were recruited in this study. A 2 ml sample was collected pre- and post- pasteurisation, and frozen at -80 °C. Post-natal age of the milk was documented. Inductively-coupled plasma mass-spectrometry was used to analyse the following trace elements - zinc (Zn), copper (Cu), selenium (Se), manganese (Mn), iodine (I), iron (Fe), molybdenum (Mo) and bromine (Br). The study received ethical approval from RBWH and The University of Queensland Ethics Committee.

RESULTS

No significant difference was found between the levels of any of the trace elements tested pre- and post-pasteurisation. The following p-values were calculated - Zn (0.82), Cu (0.80), Se (0.97), Mn (0.63), I (0.99), Fe (0.05), Mo (0.41), Br (0.59). The following ranges in mcg/L of trace elements were calculated - Zn (365.4-5460.0), Cu (157.6-820.5), Se (10.6-23.7), Mn (0.55-3.24), I (66.4-215.3), Fe (101.5-473.1), Mo (0.20-5.45), Br (704.9-3379.0). Spearman's rank correlation analysis showed significant correlations between post-natal age of milk and trace elements - Zn (ρ=-0.578), Se (ρ=-0.627). Fe (ρ=-0.704), and Mo (ρ=-0.534). No significant correlation was found for Cu, Mn, I, and Br.

CONCLUSION

This study found that the pasteurisation process had minimal effect on trace element levels in donor breast milk. However, it was noted that there was a correlation between post-natal age of donor milk and Zn, Se, Fe and Mo. Further work is needed to establish factors that may influence levels of trace elements in donor milk such as post-natal age.

Implementation of a Donor Milk Program Is Associated with Greater Consumption of Mothers' Own Milk among VLBW Infants in a US, Level 3 NICU

BACKGROUND

It is unclear whether use of donor milk (DM) changes the provision of mothers' own milk (MOM) to very low birth weight (VLBW) infants in the neonatal intensive care unit (NICU).

OBJECTIVES

To determine whether (1) the rates of any MOM and human milk consumption at feeding initiation and discharge and (2) the proportion of VLBW infants who stopped consuming any MOM and human milk during hospitalization changed in the 2 years after versus before implementation of a DM program in a US, inner-city, level 3 NICU.

METHODS

We studied VLBW infants admitted to Boston Medical Center in the 2 years before (n = 74) and after (n = 80) implementation of a DM program (June 2011). We used multivariable logistic regression to compare milk consumption at feeding initiation and discharge and Cox proportional hazards to compare the proportion of infants that stopped consuming milk during the hospitalization pre and post our DM program.

RESULTS

After adjustment for maternal race, age, insurance, delivery type, gestational age, and birth weight, we found a 6.0-fold increased odds (95% CI, 2.0-17.7) of consuming MOM at discharge and a 49% reduction in the cessation of MOM consumption during hospitalization (hazard ratio [HR], 0.51; 95% CI, 0.28-0.93) in the 2 years after versus before our DM program.

CONCLUSION

Implementation of a DM program was associated with greater consumption of MOM throughout hospitalization and at discharge among VLBW infants. Implementation of DM programs may augment support of mothers to provide breast milk in level 3 NICUs.

Nutritional support for premature infants in the neonatal intensive care unit

Nutritional support for premature infants in the neonatal intensive care unit setting is complex. Such infants have conditions unique to this period of the lifespan requiring specialized care management, both of which may impede the provision of adequate nutrition to support basal metabolic needs. Premature infants require optimum nutritional intake to support rapid growth during a time when they are not fully capable of tolerating it. This article reviews developmental anatomy, physiology, and the effect of premature delivery by systems; the challenges of providing adequate nutrition; and current evidence-based strategies to provide nutrition for premature infants during hospitalization.

Patterns and predictors of donor human milk non-consent in the neonatal ICU

BACKGROUND

Previous research has not evaluated predictors of donor human milk (DHM) non-consent status in a neonatal intensive care unit (ICU) setting within the United States. The purpose of this study is to identify and describe maternal and infant factors associated with DHM consent status in a Level IV inner-city neonatal ICU.

MATERIALS AND METHODS

Demographics and additional maternal/infant data were stratified by DHM consent and compared with the appropriate parametric/nonparametric hypothesis testing statistic. A predictive multivariable logistic regression model was constructed, adjusted for independent predictors identified in the bivariate analysis (p≤0.2) using a backwards selection process (retention threshold p≤0.1). The adjusted odds ratios generated from the multivariable model identified predictors independently associated with DHM non-consent.

RESULTS

Data were analyzed for 113 mother-infant dyads from the first 18 months of a DHM program, with 65 mothers consenting to DHM and 48 not consenting. Race, ethnicity, marital status, education, delivery mode, and presence of a breastfeeding duration goal qualified for inclusion into the multivariable model. Only race and marital status were retained in the final model. In this sample, black race, other race, and being married are all independent predictors for DHM non-consent.

CONCLUSIONS

Black race, other race, and marital status statistically predicted DHM non-consent in a Level IV inner-city neonatal ICU. These results are relevant to all neonatal ICUs who use DHM and to those who are developing DHM programs.

Variability of Criteria for Pasteurized Donor Human Milk Use: A Survey of U.S. Neonatal Intensive Care Unit Medical Directors

BACKGROUND

Use of donor human milk (DHM) is increasing, but criteria for its use are not well defined.

MATERIALS AND METHODS

We conducted a 34-question Internet-based survey of medical directors of U.S. level 3 and level 4 neonatal intensive care units (NICUs), with the goal of describing specifics of policies developed to guide DHM use in U.S. NICUs. Respondents reported NICU characteristics and details of policies concerning DHM use. Policy-specified criteria for DHM use, if any, were described. Bivariate and multivariate analyses were used to identify NICU characteristics associated with DHM use.

RESULTS

Respondents returned 153 (33%) surveys, with use of DHM reported by 91 (59%). Donor human milk use was more likely with more than 100 annual admissions <1500 g at birth (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.7) and with Vermont-Oxford Network participants (OR, 4.6; 95% CI, 1.8-11.6). Among 72 NICUs reporting a written policy, criteria for providing DHM required birth weights varying from <1000 to <1800 g and/or gestational ages from <28 to <34 completed weeks, but criteria were reportedly waived in many circumstances. Policies regarding duration of DHM therapy were similarly varied.

CONCLUSIONS

Criteria for initiating and continuing DHM vary widely among U.S. level 3 and level 4 NICUs. Donor human milk use is more frequent in NICUs with many very low-birth-weight admissions and among Vermont-Oxford Network participants. Further research is needed to define short- and long-term outcomes and cost benefits of DHM use in subgroups of NICU patients, particularly for uses other than necrotizing enterocolitis prevention.

Influence of prolonged storage process, pasteurization, and heat treatment on biologically-active human milk proteins

OBJECTIVES

The bioactive proteins in human milk may be influenced by prolonged storage process, pasteurization, and heat treatment. This study was conducted to evaluate the effects of these procedures.

MATERIALS AND METHODS

Three forms of human milk - freshly expressed, frozen at -20°C for a prolonged duration, and pasteurized milk - were collected from 14 healthy lactating mothers and a milk bank. The concentrations of major bioactive proteins (secretory immunoglobulin A, lactoferrin, lysozyme, and leptin) were quantified using enzyme-linked immunosorbent assay kits. Changes in these proteins by heat treatment at 40°C or 60°C for 30 minutes were further evaluated.

RESULTS

The mean concentrations of lactoferrin and secretory immunoglobulin A were significantly reduced by 66% and 25.9%, respectively, in pasteurized milk compared with those in freshly-expressed milk. Heat treatment at 40°C or 60°C did not cause significant changes in lactoferrin and secretory immunoglobulin A, but there was an apparent increase in lysozyme (p = 0.016). There were no significant differences in leptin level among these three forms of milk prior to (p = 0.153) or after heat treatment (p = 0.053).

CONCLUSION

Various freezing/heating/pasteurization processes applied to human milk prior to delivery to neonates could affect the concentration of immunomodulatory proteins, especially lactoferrin, secretory immunoglobulin A, and lysozyme. Leptin was unaffected by the various handling processes tested. Fresh milk was found to be the best food for neonates. Further studies are warranted to evaluate the functional activity of these proteins and their effects on infants' immunological status.

"Lost milk?": Counting the economic value of breast milk in gross domestic product

BACKGROUND

The contribution of breastfeeding and mothers milk to the economy is invisible in economic statistics.

OBJECTIVE

This article demonstrates how the economic value of human milk production can be included in economic statistics such as gross domestic product (GDP) and provides estimates for Australia, the United States, and Norway.

METHODS

The contribution of human milk and lactation to GDP in these countries is estimated using United Nations (System of National Accounting) guidelines and conventional economic valuation approaches to measuring production in GDP.

RESULTS

In Australia, current human milk production levels exceed $3 billion annually. The United States has the potential to produce human milk worth more than US$110 billion a year, but currently nearly two thirds of this value is lost due to premature weaning. In Norway, production valued at US$907 million annually is 60% of its potential value.

CONCLUSIONS

The potential loss of economic value from not protecting women's lactation and milk production from competing market pressures is large. Failure to account for mothers' milk production in GDP and other economic data has important consequences for public policy. The invisibility of human milk reduces the perceived importance of programs and regulations that protect and support women to breastfeed. The value of human milk can be measured using accepted international guidelines for calculating national income and production. It is quantitatively nontrivial and should be counted in GDP.

Establishment, operation and development of a donor human milk bank

Human milk is very valuable in premature infant nutrition. The collection, screening, processing and distribution of donor human milk are described in this report. These activities take place in the Donor Human Milk Bank (DHMB) of the Large Romagna Area (LRA) in Italy, the development of which is also described here. Over the years, the activities of this bank, which is located in Cesena Hospital, in the center of the LRA, have developed from an informal and domestic-level activity to become a multistep controlled process designed to prevent the possibility of disease transmission. This little food-supply industry, run by a multi-disciplinary team with strict rules and diverse responsibilities, complies with the Hazards Analysis and Critical Control Points (HACCP) system.

Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals

OBJECTIVE

To determine acceptance of donor human milk (DM) for feeding preterm infants and whether offering DM, alters mothers' milk (MM) feeding.

STUDY DESIGN

Infant feeding data were collected from medical records of 650 very preterm infants enrolled between 2006-2011 in two hospital level III neonatal intensive care units (NICUs) in Cincinnati, Ohio. The study was conducted during the implementation of a program offering 14 days of DM.

RESULT

From 2006-2011, any DM use increased from 8 to 77% of infants, largely replacing formula for the first 2 weeks of life; provision of MM did not change. DM was more likely to be given in the first 2 weeks of life, if infants never received MM or were >1000 g birth weight, but DM use did not differ by sociodemographic factors.

CONCLUSION

Offering DM dramatically increased human milk feeding and decreased formula use, but did not alter MM feeding in hospital.

Similar efficacy of human banked milk and bovine colostrum to decrease incidence of necrotizing enterocolitis in preterm piglets

Preterm birth and formula feeding predispose to necrotizing enterocolitis (NEC) in infants. As mother's milk is often absent following preterm delivery, infant formula (IF) and human donor milk (HM) are frequently used as alternatives. We have previously shown that porcine and bovine colostrum (BC) provide similar NEC protection in preterm piglets relative to IF. We hypothesized that HM exerts similar effects and that this effect is partly species-independent. Preterm piglets (n = 40) received 2 days of total parenteral nutrition, followed by a rapid transition to full enteral feeding (15 ml·kg(-1)·2 h(-1)) for 2 days using BC (n = 13), HM (n = 13), or IF (n = 14). Intestinal passage time and hexose absorption were tested in vivo. Body and organ weights were recorded on day 5, and macroscopic NEC lesions in the gastrointestinal tract were assessed. Intestinal samples were collected for determination of histomorphology, histopathology, tissue IL-6 and IL-8, organic acids, bacterial adherence by fluorescence in situ hybridization score, and digestive enzyme activities. Relative to IF, pigs from BC and HM showed longer intestinal passage time; higher weight gain, hexose absorptive capacity, mucosal proportion, and enzyme activities; lower NEC incidence, organic acid concentration, and IL-8 concentration; and reduced histopathology lesions. Tissue IL-6 concentration and bacterial adherence score were lower for HM, relative to both BC and IF groups. We conclude that BC and HM are both superior to IF in stimulating gut structure, function, and NEC resistance in preterm piglets. BC may be a relevant alternative to HM when mother's milk is unavailable during the first week after preterm birth.

Mothers' knowledge of and attitudes toward human milk banking in South Australia: a qualitative study

BACKGROUND

The beneficial effects of breastfeeding for mothers and babies are well recognized. When maternal breast milk is not available in sufficient quantity, donor breast milk is recommended as an alternate source of nutrition, particularly in preterm and other high-risk infants. Australia lags behind the rest of the developed world in establishing and promoting human milk banks; there is no human milk bank in South Australia and little is known concerning mothers' perceptions of using human milk banks in that state.

OBJECTIVE

This study explored mothers' knowledge of and attitudes toward human milk banks, to inform the development of human milk banking policies and guidelines in South Australia should a milk bank be established.

METHODS

In-depth semistructured interviews were conducted with 12 mothers who were breastfeeding and/or had preterm or sick babies. In addition, 2 focus groups were conducted-1 with breastfeeding mothers as potential donors (n = 5) and the other with mothers of preterm or high-risk infants (n = 4)-to answer questions raised by early analysis of the individual interview data.

RESULTS

Breastfeeding mothers, as potential donors, unanimously supported donating their breast milk to a human milk bank, provided it would be easy (especially if required to drop off milk) and not overly time consuming. Mothers of preterm or sick infants would use a human milk bank if they were assured the milk was safe and appropriate for their babies.

CONCLUSION

Study participants would welcome having access to a human milk bank for both donating and receiving milk in South Australia.

Impact of pasteurization on the antibacterial properties of human milk

Growing evidence favours the use of human milk for the feeding of preterm newborns based on its many beneficial effects. Despite the many benefits, human milk has been associated as a possible vehicle of transmission for a number of infections. Although pasteurization of human milk can diminish the risk of neonatal infection, it also significantly reduces the concentrations of immunological components in human milk due to thermal damage. In order to evaluate the impact of pasteurization on the antibacterial properties of human milk, we aimed to compare the capacity of raw and pasteurized human milk to inhibit bacterial proliferation. Therefore, a single milk sample was collected from ten healthy lactating mothers. Each sample was divided into two aliquots; one aliquot was pasteurized, while the other was kept raw. Both aliquots were inoculated either with Escherichia coli or Staphylococcus aureus and incubated at 37 °C during 8 h. Viable colony counts from the inoculated samples were performed at regular time points to compare the bacterial growth in both forms of breast milk. Relative to the tryptic soy broth control sample, both raw and pasteurized milk samples exhibited an inhibitory effect on the growth of E. coli and S. aureus. Compared with the raw portion, growth inhibition was significantly lower in the pasteurized milk at every time point beyond T0 (after 2, 4 and 8 h of incubation) (p = 0.0003 for E. coli and p < 0.0001 for S. aureus).

CONCLUSION

Our study shows that pasteurization adversely affects the antibacterial properties of human milk.

Acceptability of donated breast milk in a resource limited South African setting

Background

The importance of breast milk for infants' growth, development and overall health is widely recognized. In situations where women are not able to provide their infants with sufficient amounts of their own breast milk, donor breast milk is the next preferred option. Although there is considerable research on the safety and scientific aspects of donor milk, and the motivations and experiences of donors, there is limited research addressing the attitudes and experiences of the women and families whose infants receive this milk. This study therefore examined attitudes towards donated breast milk among mothers, families and healthcare providers of potential recipient infants.

Methods

The study was conducted at a public hospital and nearby clinic in Durban, South Africa. The qualitative data was derived from eight focus group discussions which included four groups with mothers; one with male partners; and one with grandmothers, investigating attitudes towards receiving donated breast milk for infants. There was also one group each with nurses and doctors about their attitudes towards donated breast milk and its use in the hospital. The focus groups were conducted in September and October 2009 and each group had between four and eleven participants, leading to a total of 48 participants.

Results

Although breast milk was seen as important to child health there were concerns about undermining of breast milk because of concerns about HIV and marketing and promotion of formula milks. In addition there were concerns about the safety of donor breast milk and discomfort about using another mother's milk. Participants believed that education on the importance of breast milk and transparency on the processes involved in sourcing and preparing donor milk would improve the acceptability.

Conclusions

This study has shown that there are obstacles to the acceptability of donor milk, mainly stemming from lack of awareness/familiarity with the processes around donor breast milk and that these could be readily addressed through education. Even the more psychological concerns would also likely be reduced over time as these educational efforts progress. With government and health care worker endorsement and commitment, breast milk donation could have a promising role in improving child health.