Maternal milk feedings reduce sepsis, necrotizing enterocolitis and improve outcomes of premature infants

Biomarker-based text messages to promote lactation success in mothers of critically Ill infants: a randomized controlled pilot study

OBJECTIVE

Infrequent breast pumping limits mother's own milk production in mothers of infants admitted to the neonatal intensive care unit. We aimed to determine the feasibility and benefit of biomarker-based personalized text messages on pumping frequency and milk sodium levels. A secondary aim examined lactation outcomes.

STUDY DESIGN

In this randomized controlled pilot study, 51 mothers were randomized to receive personalized text messages regarding pumping frequency or standard care.

RESULTS

There were no differences in pumped milk volume or sodium level, however, there was a trend towards the intervention group pumping more frequently, which was significant on day 5 (p = 0.035), and they lactated nearly 9 days longer. Post-hoc analysis found the intervention group tended to be more likely to pump ≥ 500 mL by day14 (p = 0.08), a marker of long-term lactation success.

CONCLUSION

Personalized biomarker-based text messages are feasible and may support lactation in mothers of critically ill 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.

Necrotizing Enterocolitis in Very Low Birth Weight Neonates: A Natural History Study

OBJECTIVE

We characterize the most recent natural history of necrotizing enterocolitis (NEC), as this is an essential first step in guiding the prevention and treatment of this disease in the present day.

STUDY DESIGN

We performed a retrospective cohort study of neonates who were born at 23 to 29 weeks' gestation and birth weight <1,500 g who received care from the Pediatrix Medical Group between 2004 and 2019. We assessed the incidence of medical and surgical NEC and the patterns of initial antibiotic treatment to develop a contemporary cohort for further analysis. Among patients discharged between 2015 and 2019, we characterized the stage-specific risk factors for patients diagnosed with medical or surgical NEC, as well as patterns of disease onset, progression, biomarkers, and outcomes. We used the same approach to characterize patients diagnosed with suspected NEC.

RESULTS

Among 34,032 patients in the contemporary cohort, 1,150 (3.4%) were diagnosed with medical NEC and 543 (1.6%) were diagnosed with surgical NEC. The temporal pattern of disease onset was different for medical and surgical NEC, with gestational age- and birth weight-specific risk disparities emerging earlier in surgical NEC. Thirty-day mortality was much greater among surgical NEC patients (medical NEC 16.4% vs. surgical NEC 43.0%), as were rates of various in-hospital and long-term outcomes. Suspected NEC was diagnosed in 1,256 (3.7%) patients, among whom risk factors and disease onset, progression, and outcomes closely resembled those of medical NEC.

CONCLUSION

Analyzing data from a contemporary cohort enabled us to characterize the current, stage-specific natural history of NEC, including novel insights into suspected NEC. Future studies could leverage this cohort to characterize how specific patient characteristics, care processes, or biomarkers may influence or predict disease outcomes.

KEY POINTS

· The incidence of NEC has reached a stable baseline in recent years.. · Risk factors for NEC vary in a stage-specific manner.. · The stage-specific onset and progression of NEC differ by gestational age and birth weight..

Breast-feeding as protective factor against bronchopulmonary dysplasia in preterm infants

Breast-feeding is associated with fewer comorbidities in very-low-birth-weight (VLBW) preterm infants. Bronchopulmonary dysplasia (BPD) of VLBW infants is a multifactorial pathology in which nutritional aspects may be of special importance. The aim of this study is to determine, in a cohort of VLBW infants, whether breast milk nutrition is associated with a reduced prevalence and severity of BPD. A retrospective study was conducted to record the intake of mother's own milk (MOM), pasteurised donor human milk or preterm formula milk in the first 2 weeks of postnatal life of 566 VLBW newborns at our hospital during the period January 2008-December 2021. After applying the relevant exclusion criteria, data for 489 VLBW infants were analysed; 195 developed some degree of BPD. Moderate or severe BPD is associated with less weight gain. Moreover, the preferential ingestion of breast milk in the first and second postnatal weeks had effects associated with lower OR for BPD, which were statistically demonstrable for mild (OR 0·16; 95 % CI 0·03, 0·71) and severe (OR 0·08; 95 % CI 0·009, 0·91) BPD. Breast-feeding during the first weeks of postnatal life is associated with a reduced prevalence of BPD, which is frequently associated with less weight gain as a result of greater respiratory effort with greater energy expenditure.

Neonatal enteroids absorb extracellular vesicles from human milk-fed infant digestive fluid

Human milk contains extracellular vesicles (HMEVs). Pre-clinical models suggest that HMEVs may enhance intestinal function and limit inflammation; however, it is unknown if HMEVs or their cargo survive neonatal human digestion. This limits the ability to leverage HMEV cargo as additives to infant nutrition or as therapeutics. This study aimed to develop an EV isolation pipeline from small volumes of human milk and neonatal intestinal contents after milk feeding (digesta) to address the hypothesis that HMEVs survive in vivo neonatal digestion to be taken up intestinal epithelial cells (IECs). Digesta was collected from nasoduodenal sampling tubes or ostomies. EVs were isolated from raw and pasteurized human milk and digesta by density-gradient ultracentrifugation following two-step skimming, acid precipitation of caseins, and multi-step filtration. EVs were validated by electron microscopy, western blotting, nanoparticle tracking analysis, resistive pulse sensing, and super-resolution microscopy. EV uptake was tested in human neonatal enteroids. HMEVs and digesta EVs (dEVs) show typical EV morphology and are enriched in CD81 and CD9, but depleted of β-casein and lactalbumin. HMEV and some dEV fractions contain mammary gland-derived protein BTN1A1. Neonatal human enteroids rapidly take up dEVs in part via clathrin-mediated endocytosis. Our data suggest that EVs can be isolated from digestive fluid and that these dEVs can be absorbed by IECs.

Effect of Neonatal Unit Interventions Designed to Increase Breastfeeding in Preterm Infants: An Overview of Systematic Reviews

INTRODUCTION

This overview aims to systematically review evidence regarding effects of interventions undertaken in neonatal units to increase breastfeeding in preterm infants.

METHODS

We followed Cochrane methodology. Systematic reviews published to October 31, 2022, reporting meta-analysis of effects from original studies on breastfeeding rates in preterm infants of neonatal unit interventions designed to increase breastfeeding were included.

RESULTS

Avoidance of bottles during breastfeed establishment (comparator breastfeeds with bottle-feeds) demonstrated clear evidence of benefit for any breastfeeding at discharge and exclusive breastfeeding 3 months post-discharge, and possible evidence of benefit for exclusive breastfeeding at discharge, and any breastfeeding post-discharge. Kangaroo mother care (KMC) (comparator usual care) demonstrated clear evidence of benefit for any and exclusive breastfeeding at discharge and possible benefit for any breastfeeding post-discharge. Quality improvement (QI) bundle(s) to enable breastfeeds (comparator conventional care) showed possible evidence of benefit for any breastfeeding at discharge. Cup feeding (comparator other supplemental enteral feeding forms) demonstrated possible evidence of benefit for exclusive breastfeeding at discharge and any breastfeeding 3 months after. Early onset KMC (commenced <24 h post-birth), oral stimulation, and oropharyngeal colostrum administration, showed no evidence of benefit. No meta-analyses reported pooled effects for gestational age or birthweight subgroups.

CONCLUSION

There is ample evidence to support investment in KMC, avoidance of bottles during breastfeed establishment, cup feeding, and QI bundles targeted at better supporting breastfeeding in neonatal units to increase prevalence of breastfeeding in preterm infants and promote equal access to breastmilk. Stratifying effects by relevant subgroups is a research priority.

A Gently Processed Skim Milk-Derived Whey Protein Concentrate for Infant Formula: Effects on Gut Development and Immunity in Preterm Pigs

SCOPE

Processing of whey protein concentrate (WPC) for infant formulas may induce protein modifications with severe consequences for preterm newborn development. The study investigates how conventional WPC and a gently processed skim milk-derived WPC (SPC) affect gut and immune development after birth.

METHODS AND RESULTS

Newborn, preterm pigs used as a model of preterm infants were fed formula containing WPC, SPC, extra heat-treated SPC (HT-SPC), or stored HT-SPC (HTS-SPC) for 5 days. SPC contained no protein aggregates and more native lactoferrin, and despite higher Maillard reaction product (MRP) formation, the clinical response and most gut and immune parameters are similar to WPC pigs. SPC feeding negatively impacts intestinal MRP accumulation, mucosa, and bacterial diversity. In contrast, circulating T-cells are decreased and oxidative stress- and inflammation-related genes are upregulated in WPC pigs. Protein aggregation and MRP formation increase in HTS-SPC, leading to reduced antibacterial activity, lactase/maltase ratio, circulating neutrophils, and cytotoxic T-cells besides increased gut MRP accumulation and expression of TNFAIP3.

CONCLUSION

The gently processed SPC has more native protein, but higher MRP levels than WPC, resulting in similar tolerability but subclinical adverse gut effects in preterm pigs. Additional heat treatment and storage further induce MRP formation, gut inflammation, and intestinal mucosal damage.

Mother's Own Milk Versus Donor Human Milk: What's the Difference?

Mother's own milk (MOM) is known to decrease complications in preterm infants and when unavailable, it is recommended that preterm very low-birth weight infants be fed donor human milk (DHM). Due to the pasteurization, processing, and lactation stage of donors, DHM does not contain the same nutritional, immunologic, and microbial components as MOM. This review summarizes the differences between MOM and DHM, the potential effects on health outcomes, and the clinical implications of these differences. Finally, implications for research and clinical practice are discussed.

Neonatal enteroids absorb extracellular vesicles from human milk-fed infant digestive fluid

Human milk contains extracellular vesicles (HMEVs). Pre-clinical models suggest that HMEVs may enhance intestinal function and limit inflammation; however, it is unknown if HMEVs or their cargo survive neonatal human digestion. This limits the ability to leverage HMEV cargo as additives to infant nutrition or as therapeutics. This study aimed to develop an EV isolation pipeline from small volumes of human milk and neonatal intestinal contents after milk feeding (digesta) to address the hypothesis that HMEVs survive in vivo neonatal digestion to be taken up intestinal epithelial cells (IECs). Digesta was collected from nasoduodenal sampling tubes or ostomies. EVs were isolated from raw and pasteurized human milk and digesta by density-gradient ultracentrifugation following two-step skimming, acid precipitation of caseins, and multi-step filtration. EVs were validated by electron microscopy, western blotting, nanoparticle tracking analysis, resistive pulse sensing, and super-resolution microscopy. EV uptake was tested in human neonatal enteroids. HMEVs and digesta EVs (dEVs) show typical EV morphology and are enriched in CD81 and CD9, but depleted of β-casein and lactalbumin. HMEV and some dEV fractions contain mammary gland-derived protein BTN1A1. Neonatal human enteroids rapidly take up dEVs in part via clathrin-mediated endocytosis. Our data suggest that EVs can be isolated from digestive fluid and that these dEVs can be absorbed by IECs.

Effects of human donor milk on gut barrier function and inflammation: in vitro study of the beneficial properties to the newborn

Introduction

The gastrointestinal and immune systems of premature infants are not fully developed, rendering them more vulnerable to severe complications like necrotizing enterocolitis. Human milk offers a rich array of bioactive factors that collectively contribute to reducing the incidence of gut infections and inflammatory conditions. When a mother's milk is unavailable, preterm infants are often provided with donor human milk processed in Human Milk Banks. However, it remains uncertain whether pasteurized milk confers the same level of risk reduction as unprocessed milk. This uncertainty may stem from the well-documented adverse effects of heat treatment on milk composition. Yet, our understanding of the comprehensive impact on protective mechanisms is limited.

Methods

In this study, we conducted a comparative analysis of the effects of raw versus pasteurized milk and colostrum versus mature milk on cellular functions associated with the gut epithelial barrier and responses to inflammatory stimuli. We utilized THP-1 and HT-29 cell lines, representing monocyte/macrophages and gut epithelial cells, respectively.

Results

Our observations revealed that all milk types stimulated epithelial cell proliferation. However, only raw colostrum increased cell migration and interfered with the interaction between E. coli and epithelial cells. Furthermore, the response of epithelial and macrophage cells to lipopolysaccharide (LPS) was enhanced solely by raw colostrum, with a milder effect observed with mature milk. In contrast, both raw and pasteurized milk diminished the LPS induced response in monocytes. Lastly, we examined how milk affected the differentiation of monocytes into macrophages, finding that milk reduced the subsequent inflammatory response of macrophages to LPS.

Discussion

Our study sheds light on the impact of human milk on certain mechanisms that potentially account for its protective effects against necrotizing enterocolitis, highlighting the detrimental influence of pasteurization on some of these mechanisms. Our findings emphasize the urgency of developing alternative pasteurization methods to better preserve milk properties. Moreover, identifying the key components critically affected by these protective mechanisms could enable their inclusion in donor milk or formula, thereby enhancing immunological benefits for vulnerable newborns.

Perspectives and factors associated with informal human milk sharing: a mixed-methods systematic review protocol

Background

The practice of informal human milk sharing is a relatively new phenomenon and poses significant questions in the domain of infant feeding. Informal human milk sharing is a means of donating human milk from another lactating individual who is not the child's biological parent, in a casual manner, that is, without the involvement of health professionals or agencies. The advent of digital technology has facilitated the donation and receipt of human milk through digital online platforms and thus has amplified this modern practice. This research aims to comprehensively examine and synthesize evidence about the motivations, barriers, facilitators and experiences of individuals who both donate (donors) and the primary care givers of the infants who receive (recipients) human milk informally to provide to infants.

Methods

A mixed-methods systematic review will be undertaken. This review will consider qualitative, quantitative and primary mixed-methods studies which report on the factors associated with informal milk sharing, and on donors' and recipients' experiences of the practice. Primary mixed-method studies will be included if the individual qualitative and quantitative components can be extracted. Five databases will be searched for studies on informal human milk sharing published from inception of the database. Study quality will be evaluated using the standardized JBI critical appraisal tools, selected based on the methodology in each individual study. Data extraction will be conducted using the JBI mixed methods data extraction form followed by data transformation, synthesis and integration. This mixed-methods systematic review will follow a convergent integrated approach in accordance with JBI guidance.

Discussion

Informal human milk sharing is a novel practice in the domain of infant feeding. This review will enable a thorough understanding of this practice from both the donors and recipients' perspective and will have implications for healthcare professionals, policy and future clinical decision-making.

Protocol registration number

PROSPERO CRD42023405653.

Improving feeding skills and transition to breastfeeding in early preterm infants: a randomized controlled trial of oromotor intervention

Introduction

Oromotor therapy exercises used for preterm infants in the NICU might promote oral-motor skills and shorten discharge day. This study investigates the impact of an oral-motor therapy program on the successful transition to breastfeeding (BF) and the enhancement of feeding skills in preterm infants below 30 weeks of gestational age who experience feeding intolerance.

Methods

The intervention group received oral-motor therapy programme for one month, while the control group did not. The feeding skills were evaluated by Early Feeding Skills Assessment Tool (EFS) and Preterm Oral Feeding Readiness Scales (POFRAS).

Results

There was a significant difference in EFS and POFRAS scores, transition to bottle feeding at discharge and transition to BF after discharge between babies given oral-motor therapy programme and controls (p < 0.05). While the transition time to full enteral feeds did not vary significantly between the groups, noteworthy outcomes were observed in the intervention group, including differences in feeding type at discharge, the nature of feeds at discharge, and the success of transitioning to breastfeeding after discharge.

Discussion

We conclude that the oromotor therapy exercises in NICU improves the quality of sucking, contributes to better oromotor skills and promotes transition to enteral feeding and BF in preterm babies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05845684).

Nutrition for Infants with Congenital Heart Disease

Perioperative malnutrition in infants with congenital heart disease can lead to significant postnatal growth failure and poor short- and long-term outcomes. A standardized approach to nutrition is needed for the neonatal congenital heart disease population, taking into consideration the type of cardiac lesion, the preoperative and postoperative period, and prematurity. Early enteral feeding is beneficial and should be paired with parenteral nutrition to meet the fluid and nutrient needs of the infant.

The Association of Human Milk Proportion with the Clinical Outcomes of Necrotizing Enterocolitis in Preterm Infants: A Retrospective Study

Human milk (HM) has been associated with a lower risk of necrotizing enterocolitis (NEC). However, the association of precise HM proportion with the outcome of NEC remains unclear. A total of 77 cases and 154 matched controls were included in this study. The samples were divided into three groups based on the HM proportion of the total enteral intake before NEC onset: ≥70% (HHM), <70% (LHM), and 0% (NHM). The study cohort did not show a significant association between different HM proportions and NEC risk. The adjusted odds ratio (OR) for the highest versus the lowest intake was 0.599. In the prognosis of NEC, different HM proportions significantly affected weight gain, the timing of NEC onset, diagnosis time, hospitalization cost, and the severity of NEC (p < 0.05). Our findings support the beneficial effects of HM on reducing NEC in preterm infants, particularly when a greater proportion of HM of the total enteral intake is included in their feeding. Additionally, the study indicates that preterm infants fed with lower proportions of HM of the total enteral feeding are more prone to experiencing severe cases of NEC.

Fecal pH and redox as functional markers in the premature infant gut microbiome

The infant gut microbiome is a crucial factor in health and development. In preterm infants, altered gut microbiome composition and function have been linked to serious neonatal complications such as necrotizing enterocolitis and sepsis, which can lead to long-term disability. Although many studies have described links between microbiome composition and disease risk, there is a need for biomarkers to identify infants at risk of these complications in practice. In this study, we obtained stool samples from preterm infant participants longitudinally during the first postnatal months, and measured pH and redox, as well as SCFA content and microbiome composition by 16S rRNA gene amplicon sequencing. These outcomes were compared to clinical data to better understand the role of pH and redox in infant gut microbiome development and overall health, and to assess the potential utility of pH and redox as biomarkers. We found that infants born earlier or exposed to antibiotics exhibited increased fecal pH, and that redox potential increased with postnatal age. These differences may be linked to changes in SCFA content, which was correlated with pH and increased with age. Microbiome composition was also related to birth weight, age, pH, and redox. Our findings suggest that pH and redox may serve as biomarkers of metabolic state in the preterm infant gut.

Stability and heterogeneity in the antimicrobiota reactivity of human milk-derived immunoglobulin A

Immunoglobulin A (IgA) is secreted into breast milk and is critical for both protecting against enteric pathogens and shaping the infant intestinal microbiota. The efficacy of breast milk-derived maternal IgA (BrmIgA) is dependent upon its specificity; however, heterogeneity in BrmIgA binding ability to the infant microbiota is not known. Using a flow cytometric array, we analyzed the reactivity of BrmIgA against bacteria common to the infant microbiota and discovered substantial heterogeneity between all donors, independent of preterm or term delivery. Surprisingly, we also observed intradonor variability in the BrmIgA response to closely related bacterial isolates. Conversely, longitudinal analysis showed that the antibacterial BrmIgA reactivity was relatively stable through time, even between sequential infants, indicating that mammary gland IgA responses are durable. Together, our study demonstrates that the antibacterial BrmIgA reactivity displays interindividual heterogeneity but intraindividual stability. These findings have important implications for how breast milk shapes the development of the preterm infant microbiota and protects against necrotizing enterocolitis.

Early-Life Nutrition in Preterm Infants and Risk of Respiratory Infections and Wheezing: A Scoping Review

INTRODUCTION

Preterm birth is a common early-life event that can lead to long-term consequences. The incidence of wheezing, asthma, and respiratory tract infections is higher in children born prematurely than in the general population. The purpose of this review was to synthesize the existing literature on the role of early-life nutrition in the later risk of respiratory morbidities.

METHODS

A scoping review of the literature was performed by searching three online databases. Inclusion criteria were: infants born <37 GWk, comparing human milk versus any other type of milk feeding formulation. Our primary outcomes were wheezing or asthma or respiratory tract infections after discharge. Two authors independently screened the results and extracted study characteristics using a predefined charting form.

RESULTS

Nine articles were included (eight cohort studies and one randomized trial). Four studies supported the protective effect of breastfeeding on wheezing or respiratory infections or both. Four studies did not confirm this association. One study confirmed the protective role of breastfeeding only on the subgroup of girls. There was a high heterogeneity among the included studies, in the type of milk feeding, outcomes, and age at follow-up.

CONCLUSIONS

The current evidence is conflicting. The high heterogeneity and methodological flaws could have influenced the results of the studies. Carefully designed studies are required to define the role of early-life nutrition among preterm infants on their long-term respiratory outcomes.

Protective and therapeutic potential of melatonin against intestinal diseases: updated review of current data based on molecular mechanisms

INTRODUCTION

Intestinal diseases, a leading global cause of mortality and morbidity, carry a substantial socioeconomic burden. Small and large intestines play pivotal roles in gastrointestinal physiology and food digestion. Pathological conditions, such as gut dysbiosis, inflammation, cancer, therapy-related complications, ulcers, and ischemia, necessitate the urgent exploration of safe and effective complementary therapeutic strategies for optimal intestinal health.

AREAS COVERED

This article evaluates the potential therapeutic effects of melatonin, a molecule with a wide range of physiological actions, on intestinal diseases including inflammatory bowel disease, irritable bowel syndrome, colon cancer, gastric/duodenal ulcers and other intestinal disorders.

EXPERT OPINION

Due to anti-inflammatory and antioxidant properties as well as various biological actions, melatonin could be a therapeutic option for improving digestive disorders. However, more researches are needed to fully understand the potential benefits and risks of using melatonin for digestive disorders.

Pasteurization of human milk affects the miRNA cargo of EVs decreasing its immunomodulatory activity

In this report, we evaluated the effect of the pasteurization (P) process of mother's own milk (MOM) on the miRNA content of extracellular vesicles (EVs) and its impact on innate immune responses. Differences in size or particle number were not observed upon pasteurization of MOM (PMOM). However, significant differences were observed in the EV membrane marker CD63 and miRNA profiles. miRNA sequencing identified 33 differentially enriched miRNAs between MOM_EV and PMOM_EV. These changes correlated with significant decreases in the ability of PMOM_EV to modulate IL-8 secretion in intestinal Caco2 cells where only MOM_EV were able to decrease IL-8 secretion in presence of TNFα. While EVs from MOM_EV and PMOM_EV were both able to induce a tolerogenic M2-like phenotype in THP-1 macrophages, a significant decrease in the transcript levels of IL-10 and RNA sensing genes was observed with PMOM_EV. Together, our data indicates that pasteurization of MOM impacts the integrity and functionality of MOM_EV, decreasing its EVs-mediated immunomodulatory activity. This data provides biomarkers that may be utilized during the optimization of milk processing to preserve its bioactivity.

Relationship Between Human Milk Feeding Patterns and Growth in the First Year of Life in Infants with Congenital Heart Defects

The purpose of this study was to determine the relationship between patterning of human milk feeding and growth of infants with congenital heart defects in the first year of life. Inclusion criteria for this prospective cohort study included infants 0-21 days, who had undergone or had planned neonatal corrective or palliative surgery prior to hospital discharge, and whose mothers planned to feed human milk. Data on anthropometric measures (weight, length, head circumference) and infant milk type (human milk, formula, other) were collected at nine time points (0.5, 1, 2, 3, 4, 6, 8, 10, 12 months). Anthropometric data were converted to weight-for-age, length-for-age, head circumference-for-age, and weight-for-length Z-scores using World Health Organization growth reference data. Cluster analysis identified three milk type feeding patterns in the first year: Infants fed human milk only with no formula supplementation, infants fed human milk who then transitioned to a mix of human milk and formula, and infants who fed human milk and transitioned to formula only. General linear models assessed the effect of milk type feeding patterns on growth parameters over time. No effect of milk type pattern × time was found on longitudinal changes in weight-for-age (p for interaction = 0.228), length-for-age (p for interaction = 0.173), weight-for-length (p for interaction = 0.507), or head circumference-for-age (p for interaction = 0.311) Z-scores. In this cohort study, human milk alone or combined with infant formula supported age-appropriate growth in infants with congenital heart defects in the first year.

Stability and heterogeneity in the anti-microbiota reactivity of human milk-derived Immunoglobulin A

Immunoglobulin A (IgA) is secreted into breast milk and is critical to both protecting against enteric pathogens and shaping the infant intestinal microbiota. The efficacy of breast milk-derived maternal IgA (BrmIgA) is dependent upon its specificity, however heterogeneity in BrmIgA binding ability to the infant microbiota is not known. Using a flow cytometric array, we analyzed the reactivity of BrmIgA against bacteria common to the infant microbiota and discovered substantial heterogeneity between all donors, independent of preterm or term delivery. We also observed intra-donor variability in the BrmIgA response to closely related bacterial isolates. Conversely, longitudinal analysis showed that the anti-bacterial BrmIgA reactivity was relatively stable through time, even between sequential infants, indicating that mammary gland IgA responses are durable. Together, our study demonstrates that the anti-bacterial BrmIgA reactivity displays inter-individual heterogeneity but intra-individual stability. These findings have important implications for how breast milk shapes the development of the infant microbiota and protects against Necrotizing Enterocolitis.

SUMMARY

We analyze the ability of breast milk-derived Immunoglobulin A (IgA) antibodies to bind the infant intestinal microbiota. We discover that each mother secretes into their breast milk a distinct set of IgA antibodies that are stably maintained over time.

The Role of Coagulase-Negative Staphylococci Biofilms on Late-Onset Sepsis: Current Challenges and Emerging Diagnostics and Therapies

Infections are one of the most significant complications of neonates, especially those born preterm, with sepsis as one of the principal causes of mortality. Coagulase-negative staphylococci (CoNS), a group of staphylococcal species that naturally inhabit healthy human skin and mucosa, are the most common cause of late-onset sepsis, especially in preterms. One of the risk factors for the development of CoNS infections is the presence of implanted biomedical devices, which are frequently used for medications and/or nutrient delivery, as they serve as a scaffold for biofilm formation. The major concerns related to CoNS infections have to do with the increasing resistance to multiple antibiotics observed among this bacterial group and biofilm cells’ increased tolerance to antibiotics. As such, the treatment of CoNS biofilm-associated infections with antibiotics is increasingly challenging and considering that antibiotics remain the primary form of treatment, this issue will likely persist in upcoming years. For that reason, the development of innovative and efficient therapeutic measures is of utmost importance. This narrative review assesses the current challenges and emerging diagnostic tools and therapies for the treatment of CoNS biofilm-associated infections, with a special focus on late-onset sepsis.

State of the Science on the Benefits of Human Milk for Hospitalized, Vulnerable Neonates

Research on human milk has increased dramatically in recent years. The purpose of this review is to describe the literature on the health benefits of human milk for hospitalized, vulnerable neonates. PubMed, CINAHL, and Embase were searched for research articles reporting the health outcomes of hospitalized neonates who were exposed to human milk. Human milk, particularly a mother's own milk, has the potential to reduce the risk of death and the risk and severity of necrotizing enterocolitis, infection, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, kidney disease, and liver disease. Dose and timing of human milk is important, with more human milk and earlier introduction having a greater impact on health. When a mother's own milk is not available, donor human milk provides benefits over infant formula.

Impact of maternal factors, environmental factors, and race on necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a complex disease with a multifactorial etiology. As the leading cause of intestinal morbidity and mortality among premature infants, many resources are being dedicated to neonatal care and molecular targets in the newborn intestine. However, NEC is heavily influenced by maternal and perinatal factors as well. Given its nature, preventive approaches to NEC are more likely to improve outcomes than new treatment strategies. Therefore, this review focuses on maternal, environmental, and racial factors associated with the development of NEC, with an emphasis on those that may be modifiable to decrease the incidence of the disease.

Oral Application of Mother's Own Milk for Reducing Necrotizing Enterocolitis in Preterm Infants: An Updated Meta-Analysis of RCTs

Background

Necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) are the major contributors to mortality and morbidity in preterm infants. This updated meta-analysis was aimed to assess the effects of mother's milk on the incidence of NEC, LOS, and other clinical outcomes in preterm infants.

Methods

PubMed, Embase, and the Cochrane library were searched for papers published up to October 2022.

Results

A total of 13 RCTs with 1330 infants were included in the final analysis. Significant difference in NEC (stage 2 or 3) was found between the intervention group and the control group (RR = 0.508, 95% CI: 0.314-0.822, and P=0.008). The incidence of proven LOS (RR = 0.809, 95% CI: 0.610-1.071, and P=0.139) and death (RR = 0.800, 95% CI: 0.571-1.122, and P=0.196) was comparable between the two groups. Statistical differences in the incidence of proven or probable LOS (RR = 0.705, 95% CI: 0.577-0.862, and P=0.001) and length of hospitalization (WMD = -4.868, 95% CI: -6.608 to -3.128, and P < 0.001) between the intervention group and the control group were observed.

Conclusions

The results of this updated meta-analysis showed that compared to the placebo, mother's milk provides better effects in reducing the incidences of NEC, proven or probable LOS, and the length of stay, whereas no significant benefit of mother's milk was observed in reducing the incidence of proven LOS and death.

Breastfeeding and human milk bank in a neonatal intensive care unit: impact of the COVID-19 pandemic in an Italian cohort of very low birth weight infants

BACKGROUND

Parental stress in neonatal intensive care units (NICU) is well known, as is the stress induced by the COVID-19 pandemic. This combination might increase stress to the extent of affecting the availability of maternal expressed milk and the success of establishing breastfeeding. This is particularly relevant in very preterm infants.

METHODS

We conducted a single-centre retrospective analysis in two cohorts of very low birth weight infants born in a hospital in Italy. Babies born before the pandemic (September 2017 - December 2019) (n = 101) and during the pandemic (March 2020 - December 2021) (n = 67) were included in the analysis. We compared the rate of babies fed with maternal milk (both expressed and / or donated) at the achievement of full enteral feeding and the rate of those exclusively breastfed at discharge in the two groups. Then, we analysed the impact of donated human milk availability on infant formula use. We also compared mother's need for psychological support during NICU stay and the duration of psychological follow-up after discharge.

RESULTS

In our NICU the availability of expressed maternal milk significantly decreased during the COVID-19 pandemic (86.1% before the pandemic vs 44.8% during the pandemic, p < 0.001) at the time of full enteral feeding achievement. Thanks to the availability of donated human milk, the rate of formula-fed babies remained almost unchanged (13.9% vs 14.9%). At discharge, the rate of breastfeeding was similar (73.3% vs 72.7%). The maternal need for psychological support was significantly higher during the pandemic (33% vs 64%, p < 0.001), as well as the duration of follow-up > 6 months (1% vs 15%, p < 0.001). No differences in the main clinical outcomes were found.

CONCLUSION

Pandemic-induced stress had a significant impact on the availability of expressed maternal milk in NICU. However, the presence of human donated milk was fundamental in preventing increased use of infant formula during NICU stays. This underlines how strategies to implement the widespread establishment of donor milk banks on a national level are warranted. Further research is desirable to optimise the use of donated human milk banks during emergency situations.

Outcomes for necrotising enterocolitis (NEC) in babies born at the threshold of viability: a case-control study

BACKGROUND

The threshold for active management of babies born prematurely in the UK is currently 22 weeks. The optimal management strategy for necrotising enterocolitis (NEC) in babies born at or near this threshold remains unclear.

AIM

To review our institutional experience of babies born <24 weeks diagnosed with NEC, identify risk factors for NEC, and compare outcomes with a control cohort.

METHODS

All infants born <24 weeks gestation January 2015-December 2021 were identified. Babies diagnosed with NEC were defined as cases and babies with no NEC diagnosis as controls. Patient demographics, clinical features, complications and outcomes were extracted from the medical record and compared between cases and controls.

RESULTS

Of 56 babies, 31 (55.3%) were treated for NEC. There was no difference in NEC-specific risk factors between cases and controls. 17 babies (30.4%) underwent surgery, of these, 11/17 (64.7%) presented with a C reactive protein rise and 11/17 (64.7%) a fall in platelet count. Pneumatosis intestinalis (3/17 (17.7%)) or pneumoperitoneum (3/17 (17.7%)) were present in only a minority of cases. Abdominal ultrasound demonstrated intestinal perforation in 8/8 cases. The surgical complication rate was 5/17 (29.4%). There was no difference in the incidence of intraventricular haemorrhage, periventricular leukomalacia and survival to discharge between the groups.

CONCLUSIONS

The diagnosis of NEC in infants born <24 weeks gestation is challenging with inconsistent clinical and radiological features. Ultrasound scanning is a useful imaging modality. Mortality was comparable regardless of a diagnosis of NEC. Low gestational age is not a contraindication to surgical intervention in NEC.

The Association of Human Milk Feeding With Short-Term Health Outcomes Among Chinese Very/Extremely Low Birth Weight Infants

BACKGROUND

There is limited evidence about the influence of human milk feeding on short-term outcomes in a large preterm infant population.

RESEARCH AIMS

To explore the influences of human milk feeding on the primary outcome of necrotizing enterocolitis and secondarily sepsis, bronchial pulmonary dysplasia, severe retinopathy of prematurity, death, and the time to achieve full enteral feeding at discharge in very/extremely low-birth-weight infants.

METHODS

This study was a retrospective, longitudinal, observational two-group comparison cohort study. A total of 4470 very/extremely low-birth-weight infants from 25 neonatal intensive care units in China, between April 2015 and May 2018, were enrolled in this study. Exclusive human milk-fed and formula-fed participants were matched using propensity scores. After matching, human milk-fed participants (n = 1379) and formula-fed participants (n = 1378) were included in the analyses. The likelihood of necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, severe retinopathy of prematurity, death, and the time to achieve full enteral feeding were compared between the two groups.

RESULTS

Exclusive human milk feeding was associated with lower odds of necrotizing enterocolitis (2.90% vs. 8.42%, OR 0.33, 95% CI [0.22, 0.47]), bronchopulmonary dysplasia (15.74% vs. 20.26%, OR 0.69, 95% CI [0.56, 0.86]), severe retinopathy of prematurity (1.45% vs. 2.39%, OR 0.50, 95% CI [0.27, 0.93]), and death (6.02% vs. 10.38%, OR 0.44, 95% CI [0.32, 0.61]) compared with formula feeding. No significant differences in the time to achieve full enteral feeding or the odds of sepsis were found between the two groups.

CONCLUSION

Exclusive human milk feeding is associated with a reduction in necrotizing enterocolitis, bronchopulmonary dysplasia, severe retinopathy of prematurity, and mortality among very/extremely low-birth-weight infants.

TRIAL REGISTRATION

Clinicaltrials.gov on November 9, 2015 (NCT02600195).

Nutritional Considerations for the Neonate With Congenital Heart Disease

The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants &lt;6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.

Nurse-Driven Interventions for Improving ELBW Neurodevelopmental Outcomes

Survival rates for extremely low-birth-weight (ELBW) infants are improving as neurodevelopmental impairment (NDI) rates stay stable, thereby increasing the overall number of infants with NDI. Although there are many determinants of NDI in this population, nutritional factors are of interest because they are readily modifiable in the clinical setting. Nurses can influence nutritional factors such as improving access to human milk feeding, using growth monitoring, establishing feeding policies, implementing oral care with colostrum, facilitating kangaroo care, and providing lactation education for the mother. All of these measures assist in leading to a decrease in NDI rates among ELBW infants.

Short-term effects of fresh mother's own milk in very preterm infants

Fresh mother's own milk (MOM) can protect preterm infants from many complications. Often MOM is pasteurized for safety, which can deactivate cellular and bioactive components with protective benefits. Questions remain regarding whether pasteurized MOM provides the same benefits as fresh MOM. The aim of this study was to evaluate the association and feasibility of feeding very preterm infants with fresh MOM. This prospective cohort study included 157 very preterm infants born before 32 weeks' gestational age and with a birthweight below 1500 g. Of these, 82 infants were included in the fresh MOM without any processing group and 75 infants were included in the pasteurized never-frozen MOM (PNFMOM) group. The mortality rate, survival rate without severe complication, incidence of complications, feeding indexes and growth velocities were compared to assess the association and feasibility of feeding fresh MOM. Compared with the PNFMOM group, the fresh MOM group had a higher survival rate without severe complications (p = 0.014) and a lower incidence of bronchopulmonary dysplasia (p = 0.010) after adjustment for confounders. The fresh MOM group regained birthweight earlier (p = 0.021), reached total enteral feeding earlier (p = 0.024), and received total parenteral nutrition for less time (p = 0.045). No adverse events associated with fresh MOM feeding were recorded. Feeding fresh MOM may reduce the incidence of complications in very premature infants. Fresh MOM was shown to be a feasible feeding strategy to improve preterm infants' outcomes.

Emerging therapies for brain recovery after IVH in neonates: Cord blood derived Mesenchymal Stem Cells (MSC) and Unrestricted Somatic Stem Cells (USSC)

In this report, we summarize evidence on mechanisms of injury after intraventricular hemorrhage resulting in post-hemorrhagic white matter injury and hydrocephalus and correlate that with the possibility of cellular therapy. We describe how two stem cell lines (MSC & USSC) acting in a paracrine fashion offer promise for attenuating the magnitude of injury in animal models and for improved functional recovery by: lowering the magnitude of apoptosis and neuronal cell death, reducing inflammation, and thus, mitigating white matter injury that culminates in improved motor and neurocognitive outcomes. Animal models of IVH are analyzed for their similarity to the human condition and we discuss merits of each approach. Studies on stem cell therapy for IVH in human neonates is described. Lastly, we offer suggestions on what future studies are needed to better understand mechanisms of injury and recovery and argue that human trials need to be expanded in parallel to animal research.

Digested Human Colostrum Reduces Interleukin-8 Production in Induced Human Intestinal Epithelial Cells

Little is known about the impact of human colostrum on infant intestinal health following digestion. The aim of this study was to compare the effect of digested versus undigested human colostrum on inflammation and cytotoxicity in human intestinal epithelial cells (Caco2BBe) stimulated with lipopolysaccharides (LPS) or tumor necrosis factor (TNF). Colostrum samples (days 2–8 postpartum) from ten mothers of preterm infant were applied. Caco2BBe cells were pretreated by digested or undigested colostrum before stimulation with LPS or TNF. The inflammatory response was determined by measuring the production of interleukin-8 (IL-8) from cells using enzyme linked immunosorbent assay (ELISA). Cytotoxicity was examined by measuring the release of lactate dehydrogenase (LDH) from the cells. Digested colostrum significantly reduced IL-8 production under LPS and TNF stimulation compared with undigested colostrum. Individual colostrum samples exhibited wide variance in the ability to suppress IL-8 production and cytotoxicity in Caco2BBe cells. In vitro-digested human colostrum suppressed an inflammatory response more than undigested human colostrum in an induced intestinal cell culture model.

Milk Volume Outcomes in Pump-Dependent Mothers of Critically Ill Infants

INTRODUCTION

Mother's own milk improves health outcomes in infants of all gestational ages. Although pump-dependent mothers of extremely premature infants are at risk of insufficient milk production, whether mother's milk production is impacted by gestational age and pump dependency in mothers of more mature critically ill infants is unknown.

PURPOSE

To determine whether there is a relationship between gestational age, milk production, and time to secretory activation in mothers delivering a critically ill infant.

METHODS

A convenience sample of 136 pump-dependent mothers whose infants were admitted to the neonatal intensive care unit was enrolled between 2013 and 2016 as part of a quality improvement project. Group 1 (early preterm) delivered infants at 30 to 33 weeks of gestation (n = 41), group 2 (late preterm) 34 to 36 weeks (n = 48), and group 3 (term) 37 weeks and more (n = 47). Milk volume on days 1 to 7 was measured by weighing each vial of expressed milk and compared using general linear mixed-model analysis. Time to the onset of secretory activation was compared using censored regression analysis.

RESULTS

Main effect for gestational age controlling for day was statistically significant (P = .0234). The early preterm group produced more milk over the 7-day study than the term (P = .01) and late preterm (P = .02) groups. The early preterm group achieved secretory activation earlier than the late preterm group (adjusted P = .039).

IMPLICATIONS FOR PRACTICE

Pump-dependent mothers of all infants admitted to the neonatal intensive care unit may be at risk of inadequate milk production and delayed secretory activation and may therefore benefit from early milk production monitoring and lactation support.

IMPLICATIONS FOR RESEARCH

Further studies should examine targeted interventions to increase milk production in pump-dependent mothers.

A Comparison of the Timing of Hand Expressing of Human Milk With Breast Massage to Standard Care for Mothers of Preterm Infants: An Exploratory Pilot Using a Randomized Controlled Design

BACKGROUND

Globally, 10% of all births are preterm. Access to human milk via manual breast expression is required to reduce the incidence of adverse outcomes related to prematurity. However, there is little evidence to recommend optimum timing to commence breast expression in mothers of preterm infants or the most effective method.

RESEARCH AIMS

(1) To test feasibility of recruitment and compliance to the protocol and (2) to determine influence of using hand expressing and breast massage on milk production, engorgement, mastitis, and breastfeeding status at 3 months.

METHODS

This study was an exploratory parallel two-group, pilot randomized controlled trial. Mothers of preterm infants at a metropolitan maternity hospital in Queensland Australia (N = 31) were randomized to receive either hand expressing and breast massage within the 1st hr of birth or standard care, hand expressing within 6 hr of birth, to determine the influence on milk production, engorgement, mastitis, and breastfeeding status at 3 months.

RESULTS

Feasibility targets were not met; however, valuable learning from this trial uncovered barriers facing midwives in the birth suite to commencing expressing in the 1st hr of birth. There was no difference in occurrence of secondary outcomes, although trends support future study.

CONCLUSIONS

Overall, unpredictability of preterm birth influenced our ability to recruit participants. Important directions for future study design would benefit from incorporating expressing times up to 6 hr with a replicable breast massage.

Health of the Newborn and Breastfeeding during the COVID-19 Pandemic: A Literature Review

OBJECTIVE

 The present article presents a literature review concerning the microbiota of breast milk and the influence of epigenetics in the susceptibility to COVID-19.

METHODS

 A literature review.

RESULTS

 Breastfeeding transfers microbiota, nutrients, diverse white blood cells, prebiotics, hormones, and antibodies to the baby, which provide short- and long-term immunological protection against several infectious, gastrointestinal, and respiratory illnesses. The little evidence available shows that breast milk very rarely carries the SARS-CoV-2 virus, and even in those cases, it has been discarded as the source of contagion.

CONCLUSION

 The reviewed studies show evidence of a beneficial effect of breastfeeding and highlights its importance on the current pandemic due to the immune reinforcement that it provides. Breastfed individuals showed better clinical response due to the influence on the microbiota and to the nutritional and immune contribution provided by breast milk, compared with those who were not breastfed.

A prospective cohort study on lactation status and breastfeeding challenges in mothers giving birth to preterm infants

Background

Mothers of preterm infants face many challenges in breastfeeding, especially regarding lactation. This study aimed to investigate the lactation status and challenges in breastfeeding faced by preterm infants’ mothers.

Methods

We approached 124 mothers who gave birth to preterm infants between 26 May and 31 October 2018 in a tertiary hospital in China. Lactation status and challenges in breastfeeding on day 7 postpartum, at discharge of infants, 2 weeks post-discharge, and 3 months of corrected age were collected using questionnaires. The area under the receiver operating characteristic (ROC) curve for expressed milk volume on day 7 postpartum for predicting expressed milk volume ≥ 300 mL/d at discharge was calculated. Logistic regression analyses were performed to identify factors associated with delayed lactogenesis II onset and continuation of breastfeeding at 3 months of corrected age.

Results

Seventy mothers were enrolled, and 51.4% had delayed lactogenesis II. Multivariate logistic regression analysis revealed that older maternal age (aOR = 1.19; 95% CI: 1.01, 1.40) and first live birth (aOR = 4.81; 95% CI 1.43, 16.18) were significant independent predictors of delayed lactogenesis II. Mothers with delayed lactogenesis II had significantly lower expressed milk volume (day 7 postpartum: 160.0 mL vs. 300.0 mL, U = 328.50, p = 0.001; at discharge: 425.0 mL vs. 612.5 mL, U = 372.00, p = 0.005), with a lower proportion of exclusive breastfeeding in their infants (at discharge: 33.3% vs. 69.8%, χ² = 12.39, df = 1, p < 0.001; 3 months of corrected age: 17.8% vs. 52.8%, χ² = 11.03, df = 1, p = 0.001). The ROC showed that expressed milk volume > 190 mL/d on day 7 postpartum significantly predicted expressed milk volume ≥ 300 mL/d at discharge. Insufficient human milk was the main reason for breastfeeding discontinuation at 3 months of corrected age. Twins were less likely to continue breastfeeding at 3 months of corrected age (aOR = 0.27; 95% CI 0.09, 0.86). In singleton infants, mother’s own milk ≥50% of total milk uptake at 2 weeks post-discharge (aOR = 32.66; 95% CI 3.00, 355.25) was an independent predictor of continuous breastfeeding at 3 months of corrected age. Feeding complications in infants, poor breastfeeding technique, and low milk output are the main challenges in breastfeeding.

Conclusion

Interventions to improve early postpartum lactation and breastfeeding techniques may increase breastfeeding adoption in mothers of preterm infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00447-4.

Risk Factors for Periventricular Leukomalacia in Preterm Infants: A Systematic Review, Meta-analysis, and GRADE-Based Assessment of Certainty of Evidence

BACKGROUND

We analyzed the certainty of evidence (CoE) for risk factors of periventricular leukomalacia (PVL) in preterm neonates, a common morbidity of prematurity.

METHODS

Medline, CENTRAL, Embase, and CINAHL were searched. Cohort and case-control studies and randomised randomized controlled trials were included. Data extraction was performed in duplicate. A random random-effects meta-analysis was utilizedused. CoE was evaluated as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

One hundred eighty-six studies evaluating 95 risk factors for PVL were included. Of the 2,509,507 neonates assessed, 16,569 were diagnosed with PVL. Intraventricular hemorrhage [adjusted odds ratio: 3.22 (2.52-4.12)] had moderate CoE for its association with PVL. Other factors such as hypocarbia, chorioamnionitis, PPROM >48 hour, multifetal pregnancy reduction, antenatal indomethacin, lack of antenatal steroids, perinatal asphyxia, ventilation, shock/hypotension, patent ductus arteriosus requiring surgical ligation, late-onset circulatory collapse, sepsis, necrotizing enterocolitis, and neonatal surgery showed significant association with PVL after adjustment for confounders (CoE: very low to low). Amongst the risk factors associated with mother placental fetal (MPF) triad, there was paucity of literature related to genetic predisposition and defective placentation. Sensitivity analysis revealed that the strength of association between invasive ventilation and PVL decreased over time (P < 0.01), suggesting progress in ventilation strategies. Limited studies had evaluated diffuse PVL.

CONCLUSION

Despite decades of research, our findings indicate that the CoE is low to very low for most of the commonly attributed risk factors of PVL. Future studies should evaluate genetic predisposition and defective placentation in the MPF triad contributing to PVL. Studies evaluating exclusively diffuse PVL are warranted.

Immunoglobulin A, an Active Liaison for Host-Microbiota Homeostasis

Mucosal surfaces in the gastrointestinal tract are continually exposed to native, commensal antigens and susceptible to foreign, infectious antigens. Immunoglobulin A (IgA) provides dual humoral responses that create a symbiotic environment for the resident gut microbiota and prevent the invasion of enteric pathogens. This review features recent immunological and microbial studies that elucidate the underlying IgA and microbiota-dependent mechanisms for mutualism at physiological conditions. IgA derailment and concurrent microbiota instability in pathological diseases are also discussed in detail. Highlights of this review underscore that the source of IgA and its structural form can dictate microbiota reactivity to sustain a diverse niche where both host and bacteria benefit. Other important studies emphasize IgA insufficiency can result in the bloom of opportunistic pathogens that encroach the intestinal epithelia and disseminate into circulation. The continual growth of knowledge in these subjects can lead to the development of therapeutics targeting IgA and/or the microbiota to treat life threatening diseases.

Effect of Postpartum Depo Medroxyprogesterone Acetate on Lactation in Mothers of Very Low-Birth-Weight Infants

Objective: This study examined the effect of postpartum administration of depo medroxyprogesterone acetate (DMPA) on milk production, time to onset of secretory activation, lactation duration, and infant consumption of mother's own milk (MOM) in mothers of preterm very low-birth-weight (VLBW) infants. Materials and Methods: We conducted a secondary analysis of data from mothers who delivered infants weighing ≤1,500 g and at ≤32 weeks' gestation. The volume of milk produced was measured on days 1-7, 14, and 21 by weighing all expressed milk on an electronic scale. Time to secretory activation was determined through self-report of a feeling of breast fullness. Information on lactation duration and the percent of feeds consisting of MOM consumed by infants was obtained from the medical records. Results: Mothers who received postpartum DMPA were more likely to be African American (72.4% versus 31.4%; p = 0.0006), unemployed (65.5% versus 44.5%; p = 0.027), and Medicaid eligible (89.7% versus 67.2%; p = 0.019). There were no differences in daily milk production between mothers who received DMPA before hospital discharge (n = 29) compared with those who did not (n = 141). When mothers who reached secretory activation before receiving DMPA were removed from analysis, receiving DMPA was associated with a later onset of secretory activation (103.7 versus 88.6 hours; p = 0.028). There were no statistically significant differences between the study groups in lactation duration or infant MOM consumption. Conclusions: DMPA, when administered postpartum to mothers of preterm VLBW infants, delayed secretory activation, but had no detrimental effect on milk production or lactation duration. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01892085.

Human Milk, More Than Simple Nourishment

Human breast milk not only has nutritional properties but also holds a functional role. It contains various bioactive factors (lactoferrin, lysozyme, leukocytes, immunoglobulins, cytokines, hormones, human milk oligosaccharides, microbiome, microRNAs and stem cells) shown to contribute to several short- and long-term health outcomes. Some of these factors appear to be involved in the infant's neuro-cognitive development, anti-oncogenic processes, cellular communication and differentiation. Furthermore, breast milk is increasingly recognized to have dynamic characteristics and to play a fundamental role in the cross-talking mother-neonate. This narrative review aims to provide a summary and an update on these bioactive substances, exploring their functions mainly on immunomodulation, microbiome and virome development. Although the knowledge about breast milk potentiality has significantly improved, leading to discovering unexpected functions, the exact mechanisms with which breast milk exercises its bioactivity have not been completely clarified. This can represent a fertile ground for exploring and understanding the complexity behind these functional elements to develop new therapeutic strategies.

Feeding Twins with Human Milk and Factors Associated with Its Duration: A Qualitative and Quantitative Study in Southern Italy

BACKGROUND

Over the past year, there has been a rise in twin births. The current scientific consensus recommended breast-feed milk for all newborns for at least 6 months. They stated that it is possible to meet the nutritional needs of two or more newborns with only one mother's milk. More information would be desirable about the factors that influence or lead to the initiation and interruption of breastfeeding. The quality of the evidence available from multiple studies has been inconclusive and therefore led to controversial interpretations and practices.

AIMS

The first aim of this study was to analyze the extent of the feeding of multiples with breast milk in the experience of our clinical unit in terms of incidence and duration. The second objective was to evaluate the correlation between maternal, perinatal and neonatal variables with breast milk feeding rates and duration.

METHODS

The study was conducted between 2015 and 2020, in a NICU in Southern Italy (San Giovanni Rotondo, Foggia). Sixty-one women who have given birth to multiples were enrolled into the study. Newborn data were retrospectively collected by informatic database and breastfeeding information were collected by a questionnaire.

RESULTS

In our centre, the percentage of twins out of the total number of births over the years has almost doubled from 1.28% in 2015 to 2.48% in 2020 and the 88% of twins are premature. 18.1% received breast milk for more than 6 months and 6.3% received it for more than 12 months. Infants of lower gestational age and weight, born to multiparous, more mature and medium-high schooling mothers received breast milk for a longer period. 35% of women explained that the interruption of breastfeeding was due to the insufficient milk production and 41% to the stress and difficulties in managing the twins. Qualitative analysis of maternal narrative revealed, for many of them, the awareness of the importance of breastfeeding and the efforts made to try to give breast milk, but also fears about the quantity of milk and satiety of their children.

CONCLUSIONS

It is important to identify the factors both favoring and obstructing maternal milk feeding of multiples and it would be desirable the activation of a network of training and support for mothers after discharge, with particular regard to the categories found to be less inclined.

Early breast expression for very low birth infants admitted to neonatal intensive care unit: the challenges of cesarean deliveries

AIM OF THE STUDY

In preterm infants, the use of human milk is associated with unique benefits. However, successful breast feeding rates and prolonged breastfeeding duration is often reduced in preterm infants. Nevertheless, early initiation of breast expression after birth is believed to be one of the major variables that should improve the odds of successful breastfeeding. Hence, we aimed to assess correlation between timing of milk expression initiation and volume produced in regards to mode-of-delivery.

MATERIALS AND METHODS

Prospective, observational study. Mothers delivering infants weighing < 1500 g measured 24-h milk volumes on days 1-7, 14, and 21.

RESULTS

Mothers delivering vaginally (N = 11) expressed milk sooner (3.82 ± 5.03 h) than mothers in the cesarean group (N = 42; 11.5 ± 9.1 h). There were no significant differences in daily number of expressions (i.e. day 1 3.6 ± 1.6 versus 2.5 ± 2.1, p = .125) or daily volume (i.e. day 1 - 7.5 ± 6.1 ml versus 11.6 ± 22.9 ml, p = .563), until day 6 from which, both were lower in the cesarean group (i.e. day 21 - number - 6.0 ± 1.3 versus 4.6 ± 1.7, p = .029; volume - 796 ± 465ml versus 435 ± 368ml, p = .018). Expressed volume initially did not correlate with earlier expression, however, latter expressed volume inversely correlated with earlier expression. In multivariate-analysis, mode of delivery, gestational age, and daily number of expressions were correlated with volumes on day 21 (p = .001).

CONCLUSIONS

Earlier human-milk expression is related to volumes on the second and the third week of lactation. This is overwhelmed by delivery mode, and by frequent milk expression from day 2. When early milk expression is not possible, more frequent milk expression might help increasing volumes.

Breastfeeding in Mothers with COVID-19: Insights from Laboratory Tests and Follow-Up from Early Outbreak of the Pandemic in China

Objective: The outbreak of Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) threatens a surging number of community groups within society, including women actively breastfeeding. Breastfeeding involves intimate behaviors, a major transmission route of SARS-CoV-2, and is integral to the close mother-baby relationship highly correlated with maternal psychological status. Materials and Methods: Twenty-three pregnant women and puerperae with either confirmed or suspected diagnoses of COVID-19 were enrolled in the study. The clinical characteristics and outcomes of the mothers and neonates were recorded. The presence of SARS-CoV-2, IgG, and IgM in breast milk, maternal blood, and infant blood, together with feeding patterns, was assessed within 1 month after delivery. Feeding patterns and maternal psychological status were also recorded in the second follow-up. Results: No positive detection of SARS-CoV-2 was found in neonates. All breast milk samples were negative for the detection of SARS-CoV-2. The presence of IgM for SARS-CoV-2 in breast milk was correlated with IgM presence in the maternal blood. The results of IgG detection for SARS-CoV-2 were negative in all breast milk samples. All infants were in a healthy condition in two follow-ups, and antibody tests for SARS-CoV-2 were negative. The rate of breast milk feeding increased during two follow-ups. All mothers receiving a second follow-up experienced negative psychological factors and status. Conclusions: Our findings support the feasibility of breastfeeding in women infected with SARS-CoV-2. The additional negative psychological status of mothers due to COVID-19 should also be considered during the puerperium period.

The road to zero nosocomial infections in neonates-a narrative review

Aim

Nosocomial infections (NI) in neonates are associated with prolonged hospitalisation, adverse neurodevelopmental outcome and high mortality. Over the past decade, numerous prevention strategies have resulted in significant reductions in NI rates. In this review, we aim to provide an overview of current NI rates from large, geographically defined cohorts.

Methods

PubMed, Web of Science, EMBASE and Cochrane Library were searched for evidence regarding epidemiology and prevention of NI in neonates. Extracted studies were synthesised in a narrative form with experiential reflection.

Results

Despite the abundance of geographically defined incidence proportions, an epidemiological overview of NI is difficult to provide, given the lack of consensus definition for neonatal NI and different baseline populations being compared. Successful prevention efforts have focused on implementing evidence‐based practices while eliminating outdated strategies. The most promising model for reduction in infection rates is based on quality improvement (QI) collaboratives and benchmarking, involving identification and implementation of best practices, selection of measurable outcomes and fostering a sense of community and transparency.

Conclusion

The preventative rather than curative approach forms the new paradigm for reducing the burden of neonatal infections. Despite progress achieved, continued work towards improved prevention practices is required in the strive towards zero NIs.

Indicators of Secretory Activation in Mothers of Preterm Very Low Birth Weight Infants

BACKGROUND

Inconsistent information exists regarding indicators of secretory activation in mothers delivering very low birth weight infants.

RESEARCH AIMS

To compare time to the onset of secretory activation using three separate indicators. A secondary aim examined the association between indicators of secretory activation and milk production.

METHODS

Indicators of secretory activation included maternal perception, volume attainment (production of ≥ 20 mL in two consecutive expression sessions) and biomarkers (sodium and lactose) obtained at volume attainment. Milk production was measured on Days 1-7 and then weekly for 6 weeks.

RESULTS

In 69 mothers of infants born ≤ 32 weeks' gestation and < 1500 g, we found no correlation in time to secretory activation between indicators. Earlier volume attainment was associated with increased milk production on Days 1-7, 14, 21, and 28 (all p < .007). Participants who exhibited both normal lactose and sodium levels produced more milk on Days 28 and 42 (p = .028 and .011), those with only normal lactose levels produced more on Day 42 (p = .026) and those with only normal sodium levels on Day 28 (p = .036). Earlier secretory activation by volume attainment was associated with increased expression frequency during Days 2-5 (all p < .014) and participants with normal biomarkers expressed more frequently during Days 2-5 (all p < .020).

CONCLUSION

Mothers of very low birth weight infants are at risk for delayed secretory activation, which may decrease their milk production. Frequent expression during the first 5 days postpartum may promote earlier secretory activation. Valid methods of determining secretory activation are necessary to develop interventions promoting earlier secretory activation.

Demographic, Social, and Personal Factors Associated With Lactation Cessation by 6 Weeks in Mothers of Very Low Birth Weight Infants

BACKGROUND

Although mother's own milk decreases prematurity-associated morbidities, mothers of infants born preterm and very low birth weight experience a significantly shorter lactation duration. Little is known regarding factors associated with lactation cessation during the hospitalization of a very low birth weight infant.

RESEARCH AIM

To determine demographic, social, and personal factors associated with lactation cessation by 6-weeks postpartum in mothers delivering very low birth weight infants.

METHODS

We used a retrospective, longitudinal, two-group comparison design using data from a randomized control study. Mothers of very low birth weight infants (N = 142) were enrolled from a labor and delivery unit associated with a Level 4 neonatal intensive care unit. Demographic, social, and health information was obtained from the medical records. Participants were surveyed regarding lactation goals, experience, and reason(s) for cessation.

RESULTS

Participants who did not continue lactating for more than 6 weeks were more likely to be unemployed (p = .019), Medicaid eligible (p = .009), less educated (p < .031), smoke (p = .002), provide less skin-to-skin care (p = .007), and to delay the decision to provide their milk to their infant (p = .007). After Bonferroni adjustment, only minutes of skin-to-skin care remained statistically significant. Insufficient maternal milk production was the most common reason for lactation cessation.

CONCLUSION

While the etiology of lactation cessation is often non-modifiable, strategies aimed at maintaining mother's own milk production, smoking cessation, increasing skin-to-skin care, and promoting an earlier decision to lactate, may prolong lactation duration in this vulnerable population.This RCT was registered (2012-00071) with ClinicalTrials.com on 6/28/2013.