Beyond Necrotizing Enterocolitis Prevention: Improving Outcomes with an Exclusive Human Milk-Based Diet

The impact of exclusive human milk diet on short-term growth of very preterm infants

OBJECTIVES

The impact of exclusive human milk diet (EHMD) on postnatal growth remains controversial. This study aims to investigate the association between EHMD and short-term growth.

METHODS

This multicenter retrospective study aims to compare growth between the EHMD and non-EHMD groups among infants <32 weeks of gestation. Primary outcomes include weight, length, and head circumference growth trajectories between birth and 34 weeks postmenstrual age. Sensitivity and subgroup analyses were performed.

RESULTS

An EHMD was independently associated with poorer length growth, especially in infants born at ≥28 weeks' gestation or those exposed to hypertensive disorders of pregnancy. While initiating fortification at <26 kcal/oz on an EHMD showed inferior growth, initiating fortification at ≥26 kcal/oz was associated with improved weight growth, and similar length and head circumference growth when compared to the non-EHMD group.

CONCLUSIONS

An EHMD with initial fortification at ≥26 kcal/oz may be implemented to avoid bovine milk exposure while sustaining comparable growth.

A budget impact analysis of exclusive human milk diet in very low birth weight infants in United Arab Emirates

INTRODUCTION

Very low birth weight (VLBW) infants have the highest rate of neonatal intensive care unit (NICU) admissions owing to the higher comorbidities associated with premature birth and long hospital stays. VLBW infants fed a bovine (BOV)-based diet have higher mortality rates, necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and other comorbidities than those fed 100% human milk-based products. This study aims to evaluate the budgetary impact of adopting an exclusive human milk diet (EHMD) instead of a BOV-based diet in VLBW infants from Al-Ain Hospital, Sheikh Shakhbout Medical City, and Dubai Health Authority (DHA) in the United Arab Emirates (UAE).

METHODS

We use a decision tree model to estimate the budget impact of adopting EHMD versus the current local practice (BOV) over five years. Patients enter the tree model and have a probability of transitioning to one of the following mutually exclusive health states: NEC, which may be treated medically or surgically; LOS, NEC, and LOS; or neither NEC nor LOS. Depending on the feeding strategy, infants in the aforementioned health states are likely to develop any of the following complications: retinopathy of prematurity, bronchopulmonary dysplasia, or short bowel syndrome. The model accounts for the costs associated with diet, management of health states and complications, and the follow-up period.

RESULTS

Al-Ain Hospital saved United Arab Emirates Dirham (AED) 3.3 million ($1.4million) in the first year of the EHMD feeding arm and AED 16.6 million ($7.1million) over the course of five years. In comparison to Sheikh Shabout Medical City and DHA, AED 36.7 million ($15.8million) and AED 24 million ($10.3million) were saved over five years, respectively, with AED 7.3 million ($3.1million) and 4.8 million ($2million) saved in the first year. The estimated pooled results across the three institutions were AED 5.1 million ($2.2million) and AED 25.7 million ($11million) savings in the first year and over five years, respectively.

CONCLUSION

Implementing the EHMD feeding scheme in VLBWs that has significant clinical benefits has resulted in substantial budget savings from the payer's perspective in the UAE owing to fewer comorbidities associated with premature birth and shorter hospital stays. It is highly recommended for the Emirati health care settings to evaluate the real-world neonatal complication rates.

Early human milk feeding: Relationship to intestinal barrier maturation and postnatal growth

OBJECTIVES

Early exposure to mother's own milk (MOM) promotes intestinal barrier maturation in preterm infants. We hypothesized (1) donor human milk (DHM) supplementation reduces intestinal permeability (IP) similar to exclusive MOM and (2) early HM exposure and low IP at 7-10 days postnatal age (PNA) are associated with improved growth outcomes.

METHODS

IP was measured by the standard sugar absorption test (SAT) in infants <33 weeks gestation between 7-10 days PNA. Nutritional and anthropometric data were recorded. Postnatal growth failure (PNGF) was defined as a decrease in weight z-score >1 from birth to discharge to home.

RESULTS

Of 158 preterm infants, the mean (SD) gestational age was 29.9(2.3) weeks and birthweight 1388(424) g. Diet prior to SAT was exclusive MOM [N = 55(35%)], DHM ± MOM [N = 52(33%)], or preterm formula±MOM [N = 51(32%)]. The mean Lactulose(La)/Rhamnose(Rh) ratio was lower in the exclusive MOM [0.06(0.07)] and DBM ± MOM [0.05(0.07)] groups compared to the preterm formula±MOM group [0.11(0.11)], p < 0.01). Cumulative intake >150 ml/kg MOM ± DHM, but not preterm formula within 7-10 days PNA was associated with early intestinal barrier maturation. Low IP was not associated with lower risk of PNGF at discharge.

CONCLUSIONS

Low IP is associated with cumulative intake of MOM alone or supplemented with DHM > 150 ml/kg within 7-10 days PNA.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT01756040 ; web link to study on registry: https://clinicaltrials.gov/study/NCT01756040 .

IMPACT

Key message Early intestinal barrier maturation is associated with cumulative intake of exclusive MOM alone or supplemented with DHM > 150 ml/kg within 7-10 days after birth, but is not associated with lower risk of PNGF at time of discharge. What it adds to existing literature? This observational study is the first study to demonstrate that supplemental DHM promotes intestinal barrier maturation similar to MOM alone. What is the impact? The findings underscore the importance of early introduction of human milk feeds as MOM or MOM supplemented with DHM in sufficient volume to promote early intestinal barrier maturation.

Exclusive Human Milk Diets and the Reduction of Necrotizing Enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is common in preterm infants, especially infants less than 32 weeks gestation. Mortality from NEC is 7% and occurs in 1 out of 1000 preterm infants. Studies have shown the efficacy of an exclusive milk from mother diet in decreasing rates of NEC and associated mortality.

PURPOSE

To evaluate the effectiveness of an existing exclusive human milk diet (EHMD) protocol on the incidence of NEC in extremely premature infants. EHMD, for the purposes of this project is defined as breast milk of mother, with or without human milk-based fortifier.

METHODS

A single-center retrospective quasi-experimental study. The sample included 201 infants born less than 32 weeks gestation, weighing less than 1250 grams, small for gestational age (SGA) and with low Apgar scores. Outcomes measured included incidences of NEC, mortality, and co-morbidities in infants pre- and postinitiation of an EHMD protocol.

RESULTS

Just 4.8% of the EHMD group had a NEC diagnosis compared to 10.5% of the bovine-based (BOV) group. There was a 1% mortality rate of the EHMD group as compared to 6% in the BOV group. The EHMD group had a statistically significant greater weight gain during hospitalization as compared to infants fed BOV ( P = < .05).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal intensive care units should consider EHMDs for use in this infant population. Future research is needed to support dissemination of the use of EHMD as standard of practice.

The association of different types of human milk with bronchopulmonary dysplasia in preterm infants

Objective

To evaluate the association between different types of human milk feeds and bronchopulmonary dysplasia (BPD) in preterm infants.

Methods

Data on dispensed mother's own milk (MOM) and donor human milk (DHM) from Leipzig Milk Bank for hospitalized infants with a gestational age (GA) ≤32 weeks observed from birth to 36 weeks' postmenstrual age or prior discharge were used. BPD was assessed based on documented International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis and on electronic hospital records (EHR) of data on ventilation and oxygen supplementation. Associations of dispensed milk feed variations with BPD were investigated using logistic regressions in crude and adjusted models.

Results

866 infants were included with a BPD prevalence of 15.4% (EHR) and 23.2% (ICD). The mean GA was 29.1 weeks. The majority (84.4%, n = 746) of infants were nurtured with a mix of MOM, DHM supplemented by formula or parenteral (other) nutrition during hospitalization. For which, MOM comprised the highest median [Q1-Q3] percentage proportion (53[31-81] %) of this mix. Exclusive fresh milk and exclusive MOM feeds were dispensed on a mean of 40 and 34% patient-days, respectively. Statistically significant associations with lower BPD incidence were only observed for 70-80% MOM vs. DHM, and 60% fresh vs. frozen milk, in crude and adjusted models.

Conclusion

Our findings suggest a protective association of MOM and fresh milk with lower odds of BPD, which may be dependent on the proportion of MOM or fresh milk administered. These results highlight the importance of MOM as an ideal source of nutrition during early infancy.

Nutrition and the gut-brain axis in neonatal brain injury and development

Early nutritional exposures, including during embryogenesis and the immediate postnatal period, affect offspring outcomes in both the short- and long-term. Alterations of these modifiable exposures shape the developing gut microbiome, intestinal development, and even neurodevelopmental outcomes. A gut-brain axis exists, and it is intricately connected to early life feeding and nutritional exposures. Here, we seek to discuss the (1) origins of the gut-brain access and relationship with neurodevelopment, (2) components of human milk (HM) beyond nutrition and their role in the developing newborn, and (3) clinical application of nutritional practices, including fluid management and feeding on the development of the gut-brain axis, and long-term neurodevelopmental outcomes. We conclude with a discussion on future directions and unanswered questions that are critical to provide further understanding and insight into how clinicians and healthcare providers can optimize early nutritional practices to ensure children not only survive, but thrive, free of neurodevelopmental impairment.

Strategies for the prevention of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a common morbidity affecting preterm infants and is associated with substantial long-term disabilities. The pathogenesis of BPD is multifactorial, and the clinical phenotype is variable. Extensive research has improved the current understanding of the factors contributing to BPD pathogenesis. However, effectively preventing and managing BPD remains a challenge. This review aims to provide an overview of the current evidence regarding the prevention of BPD in preterm infants, offering practical insights for clinicians.

Factors Associated with Low Volumes of Mother's Own Milk at Neonatal Intensive Care Unit Discharge of Very Low Birth Weight Infants-a Cohort Study

Background: Mother's own milk (MOM) provides health benefits for infants with very low birth weight (VLBW). This study aimed to describe the incidence and factors associated with low volumes of MOM (<50% of total diet volume) at discharge for VLBW infants. Methods: A prospective cohort study of infants with VLBW and gestational age of <30 weeks, who survived to discharge and had no contraindication to MOM. We conducted bivariate analyses to investigate associations with the volume of MOM at discharge, using chi-square, t, and Mann-Whitney tests. All p-value analyses were two-tailed. The variables significantly associated with "low volumes of MOM" entered the multivariable analysis. Univariate and multivariate relative risk (confidence interval [CI] 95%) estimates were obtained from Poisson regression with a robust estimate of variance and controlled by the length of hospital stay. Results: Of 414 infants included and followed until discharge, 32.9% (n = 136) received less than 50% of the total daily volume of MOM. This outcome was associated with gestational age <28 weeks, lower birth weight, multiple births, developing bronchopulmonary dysplasia, and longer lengths of stay. After Poisson regression, low volumes of MOM at discharge were associated only with being born multiples (RR 2.01; CI 95% 1.53-2.64, p < 0.001) and with longer length of stay (RR 1.07; CI 95% 1.01-1.14, p = 0.01). Conclusions: Most VLBW infants were discharged home receiving predominantly MOM. Each neonatal intensive care unit (NICU) should acknowledge which clinical characteristics of mothers and VLBW infants are associated with difficulties maintaining MOM volumes until discharge.

Fatty acid concentrations in preterm infants fed the exclusive human milk diet: a prospective cohort study

OBJECTIVE

Quantify blood fatty acids and growth outcomes in preterm infants fed the exclusive human milk diet.

METHODS

A prospective cohort study of 30 infants 24-34 weeks gestation and ≤1250 g fed the exclusive human milk diet. Blood fatty acids were quantified at two time points. Comparisons were made using two-sample t-tests and Wilcoxon rank sum.

RESULTS

Donor human milk-fed (n = 12) compared to mother's own milk-fed infants (n = 18) from birth to after 28 days of life, had an increased interval change of linoleic to docosahexaenoic acid ratio (5.5 vs. -1.1 mole percent ratio, p = 0.034). Docosahexaenoic and eicosapentaenoic acid interval changes were similar between groups. The arachidonic acid change was similar between groups (-2.3 vs. -0.9 mole percent, p = 0.37), however, both experienced a negative change across time. At 36 weeks postmenstrual age, growth velocities were similar for groups.

CONCLUSION

An exclusive human milk diet maintains birth docosahexaenoic and eicosapentaenoic acid concentrations. However, the postnatal deficit in arachidonic acid was not prevented.

Transient Hypoglycemia and Biochemical Differences in Infants Less Than 1,250 G at Birth Fed Human Milk with Human Milk-Derived Fortifier versus Cow Milk-Derived Fortifier

OBJECTIVE

Fortification of human milk (HM) with either human milk-derived fortifier (HMDF) or cow milk-derived fortifier (CMDF) is important in preterm infants. The objective is to compare the incidence of hypoglycemia, and biochemical values in infants less than 1,250 g at birth fed HMDF versus CMDF.

STUDY DESIGN

It is a retrospective cohort study on infants less than 1,250 g at birth who were fed with HMDF or CMDF. Hypoglycemia was defined as blood glucose (BG) level equal to or less than 60 mg/dL within 72 hours of full enteral feeds when off total parenteral nutrition and intravenous fluids.

RESULTS

Ninety infants were enrolled (HMDF = 61, CMDF = 29). HMDF group had a higher rate of hypoglycemia (46 vs. 24%; p = 0.048) after achievement of full enteral feeding. The median minimum BG was lower (61 vs. 71; p ≤ 0.01), while blood urea nitrogen (12 vs. 6; p ≤ 0.01) and albumin (3.1 vs. 2.7; p ≤ 0.01) were higher in HMDF group compared with CMDF.

CONCLUSION

At full enteral feedings in infants less than 1,250 g at birth, an HMDF diet may predispose to hypoglycemia needing intervention. Close monitoring of BG levels once off parenteral nutrition is recommended.

KEY POINTS

· Exclusive human milk (EHM) feeding results in better nutritional indices.. · EHM feeding at higher calorie/ounce improves growth.. · Blood glucose needs to be monitored when off TPN during EHM feeding..

Proactive Use of a Human Milk Fat Modular in the Neonatal Intensive Care Unit: A Standardized Feeding Protocol

An exclusive human milk diet (EHMD) and standardized feeding protocols are two critical methods for safely feeding very low birth weight (VLBW) infants. Our institution initiated a standardized feeding protocol for all VLBW infants in 2018. In this protocol, a human milk fat modular was used only reactively when an infant had poor weight gain, fluid restriction, or hypoglycemia. As part of our NICU quality improvement program, internal utilization review data revealed a potential opportunity to improve growth and reduce costs. While maintaining the EHMD, a simple feeding guideline process change could provide cost savings without sacrificing caloric density or growth. We examined this process change in pre-post cohorts of VLBW infants.

METHODS

Our revised feeding protocol, established in October 2021, called for a human milk fat modular (Prolact CR) to be added to all infant feeding when parenteral nutrition (PN) and lipids were discontinued. The human milk fat modular concentration is 4 mL per 100 mL feed, providing approximately an additional 2 kcal/oz. We tracked data to compare (1) the use of the human milk fat modular, (2) the use of the human milk +8 fortifier, (3) overall growth before and after feeding protocol changes, and (4) cost differences between protocols.

RESULTS

Thirty-six VLBW infants were followed prospectively upon the introduction of the revised feeding protocol. In the revised era, the need for human milk +8 fortifier decreased from 43% to 14%. The decrease in the cost of a more costly fortifier provided a cost savings of USD 2967.78 on average per infant. Overall growth improved from birth to discharge, with severe malnutrition declining from 3.3% to 2.7% and moderate malnutrition declining from 37% to 8%.

CONCLUSIONS

With the proactive use of a human milk fat modular in a standardized feeding protocol, our VLBW infants showed improved growth, lower malnutrition rates, and decreased use of higher caloric fortifiers.

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.

Human Milk Cessation in the NICU in Infants with Bronchopulmonary Dysplasia

OBJECTIVE

The objective of this study was to identify factors associated with the cessation of human milk prior to neonatal intensive care unit (NICU) discharge for infants diagnosed with bronchopulmonary dysplasia (BPD).

STUDY DESIGN

Participants were recruited from the Johns Hopkins BPD Clinic between January 2016 and October 2018. Clinical and demographic characteristics were analyzed based on whether participants stopped human milk before or after NICU discharge.

RESULTS

Of the 224 infants included, 109 (48.7%) infants stopped human milk prior to discharge. The median duration of human milk intake was less for infants who stopped human milk prior to discharge compared with those who continued after discharge (2 vs. 8 months, p < 0.001). In multivariate regression analysis, pulmonary hypertension (odds ratio [OR]: 2.90; p = 0.016), public insurance (OR: 2.86; p < 0.001), and length of NICU admission (OR: 1.26 per additional month; p = 0.002) were associated with human milk cessation prior to NICU discharge.

CONCLUSION

Infants with BPD who have severe medical comorbidities and markers of lower socioeconomic status may be at higher risk for earlier human milk discontinuation.

KEY POINTS

· Half of infants in our study with BPD who received human milk stopped human milk prior to NICU discharge.. · For infants on human milk after discharge, the duration of human milk intake was 8.6 months.. · Infants with pulmonary hypertension, tracheostomies, and ventilation stopped human milk earlier.. · Non-White race, lower income, and public insurance were predictors of early human milk cessation..

Monitoring the Use of Human Milk, the Ideal Food for Very Low-Birth-Weight Infants-A Narrative Review

Aware of the utmost importance of feeding premature babies-especially those of lower weight-with human milk, as well as the need to monitor this important element of neonatal care, we focused on four aspects in this review. First of all, we reviewed the beneficial effects of feeding premature infants with breast milk in the short and long term. Secondly, we performed a quantitative evaluation of the rates of breastfeeding and feeding with human milk in Very-Low-Birth-Weight infants (VLBWs) during hospitalization in the Neonatal Intensive Care Unit (NICU) and at discharge. Our aim was to take a snapshot of the current status of human milk-feeding care and track its trends over time. Then we analyzed, on the one hand, factors that have been proven to facilitate the use of maternal milk and, on the other hand, the risk factors of not feeding with breast milk. We also considered the spread of human milk banking so as to assess the availability of donated milk for the most vulnerable category of premature babies. Finally, we proposed a protocol designed as a tool for the systematic monitoring of actions that could be planned and implemented in NICUs in order to achieve the goal of feeding even more VLBWs with human milk.

Late-onset vitamin K deficiency bleeding in an extremely preterm infant fed an exclusively human milk-based diet

All newborns need extra phylloquinone (vitamin K1; K1) to prevent vitamin K deficiency bleeding (VKDB). In preterm babies, the main sources are prophylactic K1 given at birth and parenteral and/or enteral feeding thereafter. Preterm babies are at risk of late-onset VKDB if ongoing K1 supplementation is inadequate. For extremely preterm infants fed an exclusive human milk diet, the low K1 content of human milk may predispose them to vitamin K deficiency. Human milk fortification with either bovine milk-derived fortifier or human milk-based fortifier (HMF) made from pooled donor milk is a widely used strategy to improve the micronutrient and growth status of preterm infants. However, the K1 content of HMF is markedly lower than that of bovine-based preparations. We present an unusual case of late-onset VKDB in an extremely preterm infant who received an exclusive human milk diet and HMF and quantify total K1 intake prior to the bleeding.

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.

Gut Microbiome and Retinopathy of Prematurity

Retinopathy of prematurity (ROP), a leading cause of childhood blindness worldwide, is strongly associated with gestational age and weight at birth. Yet, many extremely preterm infants never develop ROP or develop only mild ROP with spontaneous regression. In addition, a myriad of other factors play a role in the retinal pathology, one of which may include the early gut microbiome. The complications associated with early gestational age include dysbiosis of the dynamic neonatal gut microbiome, as evidenced by the development of often concomitant conditions, such as necrotizing enterocolitis. Given this, alongside growing evidence for a gut-retina axis, there is an increasing interest in how the early intestinal environment may play a role in the pathophysiology of ROP. Potential mechanisms include dysregulation of vascular endothelial growth factor and insulin-like growth factor 1. Furthermore, the gut microbiome may be impacted by other known risk factors for ROP, such as intermittent hypoxia and sepsis treated with antibiotics. This mini-review summarizes the literature supporting these proposed avenues, establishing a foundation to guide future studies.

Predictors of Human Milk Feeding and Direct Breastfeeding for Infants with Single Ventricle Congenital Heart Disease: Machine Learning Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Registry

OBJECTIVE

To identify factors that support or limit human milk (HM) feeding and direct breastfeeding (BF) for infants with single ventricle congenital heart disease at neonatal stage 1 palliation (S1P) discharge and at stage 2 palliation (S2P) (∼4-6 months old).

STUDY DESIGN

Analysis of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry (2016-2021; 67 sites). Primary outcomes were any HM, exclusive HM, and any direct BF at S1P discharge and at S2P. The main analysis involved multiple phases of elastic net logistic regression on imputed data to identify important predictors.

RESULTS

For 1944 infants, the strongest predictor domain areas included preoperative feeding, demographics/social determinants of health, feeding route, clinical course, and site. Significant findings included: preoperative BF was associated with any HM at S1P discharge (OR = 2.02, 95% CI = 1.74-3.44) and any BF at S2P (OR = 2.29, 95% CI = 1.38-3.80); private/self-insurance was associated with any HM at S1P discharge (OR = 1.91, 95% CI = 1.58-2.47); and Black/African-American infants had lower odds of any HM at S1P discharge (OR = 0.54, 95% CI = 0.38-0.65) and at S2P (0.57, 0.30-0.86). Adjusted odds of HM/BF practices varied among NPC-QIC sites.

CONCLUSIONS

Preoperative feeding practices predict later HM and BF for infants with single ventricle congenital heart disease; therefore, family-centered interventions focused on HM/BF during the S1P preoperative time are needed. These interventions should include evidence-based strategies to address implicit bias and seek to minimize disparities related to social determinants of health. Future research is needed to identify supportive practices common to high-performing NPC-QIC sites.

Using the theory of planned behavior model to predict factors influencing breastfeeding behavior among preterm mothers at week 6 postpartum: the mediating effect of breastfeeding intention

Background

Exclusive breastfeeding (EBF) in the first 6 weeks postpartum is key to continued breastfeeding. This study aimed to explore the role of EBF-related predictors (particularly breastfeeding intention) in breastfeeding behavior among preterm mothers at week 6 postpartum based on the theory of planned behavior (TPB).

Methods

A total of 352 mothers of preterm infants were recruited, 340 of whom participated in this study. Prior to discharge, participants completed the Chinese versions of the modified Breastfeeding Attrition Predictive Tool, the Breastfeeding Knowledge Questionnaire (BKQ), the Infant Feeding Intention, and the Edinburgh Postnatal Depression Scale. Responses to the items of the Breastfeeding Behavioral Questionnaire (BBQ) were also collected by telephone at week 6 postpartum. The final analyses included 321 participants who completed the full two-wave data collection.

Results

The fitness indices of the modified TPB model were acceptable. Breastfeeding knowledge and EBF before discharge positively impacted breastfeeding intention, whereas depression had a negative impact. Before discharge, breastfeeding intention fully mediated the impacts of breastfeeding attitude, social and professional support, knowledge, depression, and EBF on breastfeeding behavior and partially mediated the influence of perceived breastfeeding control on breastfeeding behavior.

Conclusion

These findings indicate that TPB accurately predicts breastfeeding behavior among preterm mothers at week 6 postpartum, and breastfeeding intention is key to the above-mentioned EBF-related factors and breastfeeding behavior. The findings underline the need for further longitudinal studies and corresponding interventions for preterm mothers with a high risk of EBF attrition.

Human Milk Feeding and Direct Breastfeeding Improve Outcomes for Infants With Single Ventricle Congenital Heart Disease: Propensity Score-Matched Analysis of the NPC-QIC Registry

Background Infants with single ventricle congenital heart disease undergo 3 staged surgeries/interventions, with risk for morbidity and mortality. We estimated the effect of human milk (HM) and direct breastfeeding on outcomes including necrotizing enterocolitis, infection-related complications, length of stay, and mortality. Methods and Results We analyzed the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry (2016-2021), examining HM/breastfeeding groups during stage 1 and stage 2 palliations. We calculated propensity scores for feeding exposures, then fitted Poisson and logistic regression models to compare outcomes between propensity-matched cohorts. Participants included 2491 infants (68 sites). Estimates for all outcomes were better in HM/breastfeeding groups. Infants fed exclusive HM before stage 1 palliation (S1P) had lower odds of preoperative necrotizing enterocolitis (odds ratio [OR], 0.37 [95% CI, 0.17-0.84]; P=0.017) and shorter S1P length of stay (rate ratio [RR], 0.87 [95% CI, 0.78-0.98]; P=0.027). During the S1P hospitalization, infants with high HM had lower odds of postoperative necrotizing enterocolitis (OR, 0.28 [95% CI, 0.15-0.50]; P<0.001) and sepsis (OR, 0.29 [95% CI, 0.13-0.65]; P=0.003), and shorter S1P length of stay (RR, 0.75 [95% CI, 0.66-0.86]; P<0.001). At stage 2 palliation, infants with any HM (RR, 0.82 [95% CI, 0.69-0.97]; P=0.018) and any breastfeeding (RR, 0.71 [95% CI, 0.57-0.89]; P=0.003) experienced shorter length of stay. Conclusions Infants with single ventricle congenital heart disease in high-HM and breastfeeding groups experienced multiple significantly better outcomes. Given our findings of improved health, strategies to increase the rates of HM/breastfeeding in these patients should be implemented. Future research should replicate these findings with granular feeding data and in broader congenital heart disease populations, and should examine mechanisms (eg, HM components, microbiome) by which HM/breastfeeding benefits these infants.

A comparison of tertiary level NICU costs for infants born <1250 g supplemented with human versus bovine milk-based fortifiers

BACKGROUND

Human milk-based fortifiers (HMBF) are more costly than bovine milk-based fortifiers (BMBF); but, the efficacy of human or bovine fortification for infants born <1250 g has yet to be fully elucidated. Our objective was to determine the effect of fortifier source on tertiary neonatal costs.

METHODS

Costs associated with tertiary neonatal care, including direct and indirect hospital expenditures, feed-related costs and physician billing were analysed retrospectively for participants of OptiMoM (NCT02137473), a blinded RCT comparing fortifier type for babies born <1250 g. A generalized linear model of cost according to fortifier type was created.

RESULTS

Mean [95% confidence interval] daily costs per patient, adjusted for birth gestation and weight, was significantly greater in the human than the BMBF group ($3,452 [$3,186 - $3,740] Canadian dollars (CAD) versus $2,451 [$2,257 - $2,662] CAD) respectively, p < 0.0001).

CONCLUSION

HMBF usage entails additional costs on NICU stay that should be considered with implementation.

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.

Retinopathy of Prematurity: The Role of Nutrition

Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. ROP occurs in infants who are born very preterm. In ROP, retinal blood vessel development, which is prematurely arrested in preterm infants, is altered by perinatal exposures like oxygen and inflammation. Optimizing nutritional practices for preterm infants may mitigate the risk of ROP. In this article, we review the evidence that postnatal growth, hyperglycemia, polyunsaturated fatty acids, and breast milk provision may affect ROP risk. We also outline the current management strategies for ROP and describe the vision outcomes of children affected by ROP. [Pediatr Ann. 2023;52(8):e303-e308.].

The role of human milk nutrients in preventing necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is an intestinal disease that primarily impacts preterm infants. The pathophysiology of NEC involves a complex interplay of factors that result in a deleterious immune response, injury to the intestinal mucosa, and in its most severe form, irreversible intestinal necrosis. Treatments for NEC remain limited, but one of the most effective preventative strategies for NEC is the provision of breast milk feeds. In this review, we discuss mechanisms by which bioactive nutrients in breast milk impact neonatal intestinal physiology and the development of NEC. We also review experimental models of NEC that have been used to study the role of breast milk components in disease pathophysiology. These models are necessary to accelerate mechanistic research and improve outcomes for neonates with NEC.

New insights into the pathogenesis of necrotizing enterocolitis and the dawn of potential therapeutics

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disorder in premature infants that causes significant morbidity and mortality. Research efforts into the pathogenesis of NEC have discovered a pivotal role for the gram-negative bacterial receptor, Toll-like receptor 4 (TLR4), in its development. TLR4 is activated by dysbiotic microbes within the intestinal lumen, which leads to an exaggerated inflammatory response within the developing intestine, resulting in mucosal injury. More recently, studies have identified that the impaired intestinal motility that occurs early in NEC has a causative role in disease development, as strategies to enhance intestinal motility can reverse NEC in preclinical models. There has also been broad appreciation that NEC also contributes to significant neuroinflammation, which we have linked to the effects of gut-derived pro-inflammatory molecules and immune cells which activate microglia in the developing brain, resulting in white matter injury. These findings suggest that the management of the intestinal inflammation may secondarily be neuroprotective. Importantly, despite the significant burden of NEC on premature infants, these and other studies have provided a strong rationale for the development of small molecules with the capability of reducing NEC severity in pre-clinical models, thus guiding the development of specific anti-NEC therapies. This review summarizes the roles of TLR4 signaling in the premature gut in the pathogenesis of NEC, and provides insights into optimal clinical management strategies based upon findings from laboratory studies.

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

BACKGROUND

Human milk-based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk-based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines.

METHODS

Nine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population.

RESULTS

Implementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution's size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution.

CONCLUSIONS

The data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.

Human milk feeding and direct breastfeeding improve outcomes for infants with single ventricle congenital heart disease: Propensity score matched analysis of the NPC-QIC registry

Background

Infants with single ventricle (SV) congenital heart disease (CHD) undergo three staged surgeries/interventions, with risk for morbidity and mortality. We estimated the effect of human milk (HM) and direct breastfeeding (BF) on outcomes including necrotizing enterocolitis (NEC), infection-related complications, length of stay (LOS), and mortality.

Methods

We analyzed the National Pediatric Cardiology Quality Improvement Collaborative registry (2016-2021), examining HM/BF groups during stage 1 (S1P) and stage 2 (S2P) palliations. We calculated propensity scores for feeding exposures, then fitted Poisson and logistic regression models to compare outcomes between propensity-matched cohorts.

Results

Participants included 2491 infants (68 sites). Estimates for all outcomes were better in HM/BF groups. Infants fed exclusive HM before S1P had lower odds of preoperative NEC (OR=0.37, 95% CI=0.17-0.84, p=0.017) and shorter S1P LOS (RR=0.87, 0.78-0.98, p=0.027). During the S1P hospitalization, infants with high HM had lower odds of postoperative NEC (OR=0.28, 0.15-0.50, p<0.001) and sepsis (0.29, 0.13-0.65, p=0.003), and shorter S1P LOS (RR=0.75, 0.66-0.86, p<0.001). At S2P, infants with any HM (0.82, 0.69-0.97, p=0.018) and any BF (0.71, 0.57-0.89, p=0.003) experienced shorter LOS.

Conclusions

Infants with SV CHD in high HM and BF groups experienced multiple significantly better outcomes. Given our findings of improved health, strategies to increase the rates of HM/BF in these patients should be implemented. Future research should replicate these findings with granular feeding data and in broader CHD populations, and should examine mechanisms (eg, HM components; microbiome) by which HM/BF benefits these infants.

Clinical Perspective

What is new?: This is the first large, multisite study examining the impact of human milk and breastfeeding on outcomes for infants with single ventricle congenital heart disease.All outcome estimates were better in high human milk and breastfeeding groups, with significantly lower odds of necrotizing enterocolitis, sepsis, and infection-related complications; and significantly shorter length of stay at both the neonatal stage 1 palliation and the subsequent stage 2 palliation.All estimates of all-cause mortality were substantially lower in human milk and breastfeeding groups, with clinically important estimates of 75%-100% lower odds of mortality in direct breastfeeding groups.What are the clinical implications?: There is a critical need for improved, condition-specific lactation support to address the low prevalence of human milk and breastfeeding for infants with single ventricle congenital heart disease.Increasing the dose and duration of human milk and direct breastfeeding has strong potential to substantially improve the health outcomes of these vulnerable infants.

Predictive factors of exclusive breastfeeding attrition at Week 6 post-partum among mothers of preterm infants based on the theory of planned behaviour

Breastfeeding plays an important role in the growth and development of preterm infants, and exclusive breastfeeding (EBF) in the first 6 weeks post-partum is the key to continuous breastfeeding. This study was designed to explore the influencing factors that contribute to breastfeeding attrition among mothers of preterm infants at Week 6 post-partum based on the theory of planned behaviour (TPB). We herein adopted a prospective observational study design in which 97 mothers who exclusively breastfed at Week 6 post-partum at a tertiary specialised hospital in Shanghai from June 2021 to February 2022 were taken as the EBF group, and 179 mothers without EBF were assigned to the EBF attrition group. Through an extensive literature review and expert consultation, we determined the possible factors influencing EBF attrition, analysed those factors that showed statistical significance in our univariate analysis by applying binary logistic regression, and constructed a nomogram model for predicting EBF attrition. The results revealed that negative breastfeeding sentiment (odds ratio [OR] = 1.006; 95% confidence interval [CI], 1.000-1.011) generated a greater risk of breastfeeding attrition. However, positive breastfeeding sentiment (OR = 0.991; 95% CI, 0.983-0.999), social and professional support (OR = 0.993; 95% CI, 0.987-0.999), breastfeeding control (OR = 0.945; 95% CI, 0.896-0.996), knowledge (OR = 0.893; 95% CI, 0.799-0.998), and intention to EBF at Week 6 post-partum (OR = 0.522; 95% CI, 0.276-0.988) were the protective factors and facilitated the development of our nomogram model. The Hosmer-Lemeshow goodness-of-fit test generated a χ² value of 11.344 (p = 0.183) and an area under the curve of 0.822 (95% CI, 0.771-0.873). The C-index was 0.800 in the internal bootstrap validation, indicating that the nomogram model possessed favourable predictive accuracy and discrimination.

An equitable, community-engaged translational framework for science in human lactation and infant feeding-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 5

Human milk is the ideal source of nutrition for most infants, but significant gaps remain in our understanding of human milk biology. As part of addressing these gaps, the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project Working Groups 1-4 interrogated the state of knowledge regarding the infant-human milk-lactating parent triad. However, to optimize the impact of newly generated knowledge across all stages of human milk research, the need remained for a translational research framework specific to the field. Thus, with inspiration from the simplified environmental sciences framework of Kaufman and Curl, Working Group 5 of the BEGIN Project developed a translational framework for science in human lactation and infant feeding, which includes 5 nonlinear, interconnected translational stages, T1: Discovery; T2: Human health implications; T3: Clinical and public health implications; T4: Implementation; and T5: Impact. The framework is accompanied by 6 overarching principles: 1) Research spans the translational continuum in a nonlinear, nonhierarchical manner; 2) Projects engage interdisciplinary teams in continuous collaboration and cross talk; 3) Priorities and study designs incorporate a diverse range of contextual factors; 4) Research teams include community stakeholders from the outset through purposeful, ethical, and equitable engagement; 5) Research designs and conceptual models incorporate respectful care for the birthing parent and address implications for the lactating parent; 6) Research implications for real-world settings account for contextual factors surrounding the feeding of human milk, including exclusivity and mode of feeding. To demonstrate application of the presented translational research framework and its overarching principles, 6 case studies are included, each illustrating research gaps across all stages of the framework. Applying a translational framework approach to addressing gaps in the science of human milk feeding is an important step toward the aligned goals of optimizing infant feeding across diverse contexts as well as optimizing health for all.

Models of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of death and disability from gastrointestinal disease in premature infants. The mortality of patients with NEC is approximately 30%, a figure that has not changed in many decades, reflecting the need for a greater understanding of its pathogenesis. Progress towards understanding the cellular and molecular mechanisms underlying NEC requires the study of highly translational animal models. Such animal models must mimic the biology and physiology of premature infants, while still allowing for safe experimental manipulation of environmental and microbial factors thought to be associated with the risk and severity of NEC. Findings from animal models have yielded insights into the interactions between the host, the colonizing microbes, and the innate immune receptor Toll-like Receptor 4 (TLR4) in driving disease development. This review discusses the relative strengths and weaknesses of available in vivo, in vitro, and NEC-in-a-dish models of this disease. We also highlight the unique contributions that each model has made to our understanding of the complex interactions between enterocytes, microbiota, and immune cells in the pathogenesis of NEC. The overall purpose of this review is to provide a menu of options regarding currently available animal models of NEC, while in parallel hopefully reducing the potential uncertainty and confusion regarding NEC models to assist those who wish to enter this field from other disciplines.

Effects of human milk on body composition and growth in very low birthweight infants

OBJECTIVE

To compare body composition and growth in very low birthweight infants according to their source of human milk: maternal expressed breast milk (MEBM) versus donor breast milk (DBM). We hypothesized that infants fed predominately MEBM would exhibit reduced body fat percentage compared to those fed predominately DBM.

METHODS

Premature infants weighing ≤1500 g on an exclusive human milk diet were enrolled in a single-center study between 2017 and 2021. Demographic data and anthropometric measurements were collected. All infants underwent body composition analysis via dual energy x-ray absorptiometry at 36 weeks corrected post menstrual age.

RESULTS

A total of 60 infants were enrolled and 48 were included in the primary analysis. No differences were detected in percent body fat (14 vs. 12%, p = 0.7) or fat-free mass (2050 vs. 2130 g, p = 0.7). Both groups displayed similar growth and anthropometric measurements. Caloric and macronutrient intake between groups was similar.

CONCLUSION

In the cohort of patients studied, no differences were observed in percent body fat based on primary human milk type intake in the first 28 postnatal days. Further investigation is required in a larger population of exclusive human milk fed preterm infants to determine if body composition differences exist based on an infant's primary human milk source.

IMPACT

Premature infants are at risk for altered body composition at term corrected age, specifically increased body fat percentage, which may have implications for the future. To our knowledge this is the first study exploring body composition outcomes based on an infant's primary human milk source. Infants fed exclusive human milk (e.g., donor vs. maternal) displayed similar percent body fat and growth outcomes.

Breastfeeding in Neonates Admitted to an NICU: 18-Month Follow-Up

Introduction: The admission of neonates to Neonatal Intensive Care Units (NICUs) has been identified as a primary inhibiting factor in the establishment of breastfeeding. The aims of this study were to (1) estimate the prevalence and duration of breastfeeding in infants/toddlers who had been admitted to an NICU in Greece and (2) to investigate factors, associated with the NICU stay, which affected the establishment and maintenance of breastfeeding in infants/toddlers previously admitted to the NICU. Materials and methods: Data for this cohort study were retrieved from interviews with mothers of infants/toddlers who had been admitted to our NICU as neonates during the period of 2017−2019. Interviews were conducted based on a questionnaire regarding the child’s nutrition from birth to the day of the interview, including previous maternal experience with breastfeeding. Information related to the prenatal period, gestation age, delivery mode, duration of NICU stay, and neonatal feeding strategies during their hospital stay were recorded. Results: The response rate to the telephone interviews was 57%, resulting in 279 mother−infant pairs being included in this study. The results showed that 78.1% of children received maternal milk during their first days of life. Of all infants, 58.1% were exclusively breastfed during their first month, with a gradual decrease to 36.9% and 19.4% by the end of the third and sixth months of life, respectively. The prevalence of breastfed children reached 14.7% and 7.5% at the ages of twelve and eighteen months, respectively. In the multivariate analysis, prematurity emerged as an independent prognostic factor for the duration of exclusive and any breastfeeding (aHR 1.64, 95% CI: 1.03−2.62; and 1.69, 95% CI: 1.05−2.72, respectively; p < 0.05). Additionally, the nationality of the mother, NICU breastfeeding experience, the administration of maternal milk during neonatal hospital stay, and previous breastfeeding experience of the mother were independent prognostic factors for the duration of breastfeeding. Conclusions: Although breastfeeding is a top priority in our NICU, the exclusive-breastfeeding rates at 6 months were quite low for the hospitalized neonates, not reaching World Health Organization (WHO) recommendations. Mothers/families of hospitalized neonates should receive integrated psychological and practical breastfeeding support and guidance.

Evolution of Preterm Infant Nutrition from Breastfeeding to an Exclusive Human Milk Diet: A Review

The benefits of feeding human milk to human infants are well-established. Preterm infants, particularly those born with very low birthweight (VLBW; <1,500 g), are a uniquely vulnerable population at risk for serious, life-threatening complications as well as disruptions in normal growth and development that can affect their lives into adulthood. Feeding VLBW preterm infants an exclusive human milk diet (EHMD) from birth that consists of the mother's own milk or donor human milk plus a nutritional fortifier made exclusively from human milk has been associated with a reduction in morbidity and mortality and improved early growth and developmental metrics. Preliminary evidence suggests that the health benefits of adopting an EHMD (or avoiding cow milk products) early in life may last into adulthood. This review briefly summarizes the history of breastfeeding and describes the available evidence on the benefits of an EHMD among VLBW preterm infants as well as the importance of high-quality manufacturing standards for producing safe and effective human milk-based products.

Effect of Maternal Diet on Any Necrotizing Enterocolitis in Neonates: A Randomized Double-Blind Study

Background: The etiology of necrotizing enterocolitis (NEC) is controversially discussed. One of the most recently proposed causes of NEC is an allergy to cow's milk protein. This study was designed to evaluate the effect of a maternal diet without bovine protein on the incidence of any NEC in very low birth weight (VLBW) infants. Materials and Methods: A pilot randomized controlled clinical trial was performed at Akbarabadi Hospital, Tehran, Iran, from December 2019 to July 2020, in women with VLBW infants. One hundred twenty mothers with VLBW neonates were randomly assigned to the intervention or the control group (60 in each). In the intervention group, mothers were given a dairy-free diet during the first 14 days after the newborn's onset of feeding. No special diet was given to the control group. The primary outcome of the study was the rate of any NEC in neonates, which was compared between groups. Any NEC was defined as Bell stage I or greater. Results: The minimum and maximum gestational ages were 26 and 33 weeks, respectively. The minimum birth weight of neonates was 700 g. The two groups did not differ significantly in terms of demographic and preinterventional clinical characteristics. Any NEC was reported in 0% and 10% (5/52) of neonates in the intervention and control groups, respectively; the difference was statistically significant (p = 0.028). The NEC symptoms began ∼34 days after birth. Four cases of NEC were classified as Bell stage I, and one was classified as Bell stage II. No statistical association was registered between sex, gestational age, birth weight, and the onset of feeding with the incidence of any NEC. Conclusion: The use of a cow's milk protein-free diet in mothers and exclusive breastfeeding in preterm VLBW infants may reduce the incidence of NEC. We recommend further studies with larger sample sizes in a multicenter setting. The study was registered at the Iranian Registry of Clinical Trials (IRCT20200415047086N1).

A Retrospective Analysis of the Effects of an Exclusively Human Milk Protein Diet on Neonatal Feeding Tolerance

OBJECTIVE

This study was aimed to evaluate the effect of human milk protein fortifier (HMPF) versus bovine milk protein fortifier (BMPF) on feeding tolerance defined as the time to reach full feeds and necrotizing enterocolitis (NEC) in premature very low birth weight (VLBW) infants.

STUDY DESIGN

A retrospective review using the BabySteps Database included 493 infants born ≤33 weeks of gestational age and ≤1,250 g (g) birth weight. A total of 218 infants fed a human milk diet (HMD) with BMPF were compared with 275 infants fed an HMD with HMPF.

RESULTS

Full feeds were reached significantly sooner in the HMPF group (median: 14 vs. 16 days, p = 0.04). Weight at full feeds was significantly lower in the HMPF group (1,060 vs. 1110 g, p = 0.03).

CONCLUSION

Using HMPF to provide an exclusively HMD allowed VLBW infants to achieve full feeds sooner, but did not affect rate of NEC compared with using a BMPF with an HMD.

KEY POINTS

· Human milk fortifiers with human milk are better than bovine human milk protein fortifiers.. · Full feeds are reached sooner with a human milk protein fortifier.. · The incidence of NEC did not change with the use of Prolacta..

Bench to bedside - new insights into the pathogenesis of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the leading cause of death and disability from gastrointestinal disease in premature infants. Recent discoveries have shed light on a unifying theorem to explain the pathogenesis of NEC, suggesting that specific treatments might finally be forthcoming. A variety of experiments have highlighted how the interaction between bacterial signalling receptors on the premature intestine and an abnormal gut microbiota incites a pro-inflammatory response in the intestinal mucosa and its underlying endothelium that leads to NEC. Central amongst the bacterial signalling receptors implicated in NEC development is the lipopolysaccharide receptor Toll-like receptor 4 (TLR4), which is expressed at higher levels in the premature gut than in the full-term gut. The high prenatal intestinal expression of TLR4 reflects the role of TLR4 in the regulation of normal gut development, and supports additional studies indicating that NEC develops in response to signalling events that occur in utero. This Review provides new evidence explaining the pathogenesis of NEC, explores new findings indicating that NEC development has origins before birth, and discusses future questions and opportunities for discovery in this field.

Infant nutrition (donor human milk vs. maternal milk) and long-term neurodevelopmental and growth outcomes in very low birth weight infants

BACKGROUND

Human milk, the ultimate source of nutrition for premature infants, enhances host defense mechanism, gastrointestinal maturation, lowers infection rate, improves neurodevelopmental outcomes, and reduces long-term cardiovascular and metabolic disease. Recently, there has been an increase in donor breast milk (DBM) use for premature infants; however, data are limited on the long-term effects of DBM on the infant's growth and neurodevelopmental outcomes.

OBJECTIVE

To determine if there is an association between type of infant nutrition (maternal breast milk (MBM) or DBM) and neurodevelopmental and growth outcomes in very low birth weight (VLBW) infants.

DESIGN/METHODS

Retrospective cohort study of VLBW (<1500 g) infants admitted to the Baylor Scott & White Memorial Hospital Neonatal Intensive Care Unit from January 2014 to December 2016. Infants with major congenital anomalies, born at an outside hospital, who were nil per os (NPO) for >15 days, or who died before NICU discharge were excluded. Infants were stratified into two groups (MBM or DBM) based on predominant nutrition (>50%) received in the first month of life. Primary outcomes of neurodevelopmental delay(s) between 2 and 4 years of age identified via ICD 9/10 codes. Growth data (weight, length, and head circumference) were obtained from well-check visits at 12-, 18-, 24-, 36-, and 48-months. Severity of illness was determined using the Clinical Risk Index in Babies-II (CRIB-II) score. Generalized linear models were used to assess the relationship between nutrition and neurodevelopmental delay and trends in growth over time.

RESULTS

Two hundred and nine infants were included: 146 MBM; 63 DBM. Median gestational age was 28 weeks (range, 23-35) and median birthweight was 1050 g (range, 410-1470). There were no significant differences in birthweight, gestational age, CRIB-II score, or length of stay between the groups. Infants fed DBM had a significantly larger weight z-score (p=.005), length z-score (p=.01), and head circumference z-score (p=.04), on average from birth to 48 months compared to MBM infants, while controlling for NICU length of stay and number of follow-up months; however, this only equated to DBM infants being 0.5 in taller and 0.9 lbs heavier at 48 months. There were no statistically significant differences among type of infant nutrition and long-term neurodevelopmental outcomes, while controlling for CRIB-II score.

CONCLUSIONS

Infants fed DBM have a slightly greater propensity for growth over time compared to infants fed MBM. Longer follow-up is needed to further determine the effect, infant nutrition has on neurodevelopmental outcomes.

Factors associated with post NICU discharge exclusive breastfeeding rate and duration amongst first time mothers of preterm infants in Shanghai: a longitudinal cohort study

BACKGROUND

Breastfeeding is crucial for the preterm infants. Breast milk is not only food but also medicine. Few studies have focused on the longitudinal effects of exclusive breastfeeding outcome of preterm infants separated from their mothers after discharge, especially in Shanghai. We aimed to examine the exclusive breastfeeding rate and duration amongst first time mothers of preterm infants after discharge and its determinants.

METHODS

Analyses were based on 500 preterm infants separated from their mothers in a tertiary maternity and infant-specialized hospital in Shanghai from September 2018 to September 2019.The Socio-demographic characteristics, breastfeeding knowledge questionnaire, breastfeeding self-efficacy short form scale, Edinburgh postpartum depression scale and breastfeeding family support scale were used for the investigation and the exclusive breastfeeding rate of premature infants was followed up on 1 month, 3 months and 6 months after discharge. The changing trend of breastfeeding knowledge, breastfeeding self-efficacy, postpartum depression and family support were measured by ANOVA at different stages. Using the chi-square test and multiple logistic regression, factors impacting the breastfeeding rate of preterm infants at three time intervals after discharge were investigated. The Kaplan Meier survival curve and cox regression model were used to analyze the determinants of exclusive breastfeeding duration of premature infants after discharge.

RESULTS

Exclusive breastfeeding rates were 19.0, 17.2 and 10.4% at 1 month, 3 months and 6 months after discharge of preterm infants, respectively. The average length of exclusive breastfeeding duration was(3.69 ± 1.80)months. Finally, type of delivery (adjusted odds ratio [AOR] 1.564; 95% confidence interval [CI] 0.513,3.116), gestational age(AOR 0.612, 95% CI 0.236, 3.418), maternal family support (AOR 6.125,95% CI 6.359, 98.452) were discovered to be independent predictors on the exclusive breastfeeding rate at 6 months after preterm infants were discharged. Through the cox regression model, we found that a maternal planned pregnancy (HR 0.681, 95%CI 0.531,0.873), delivering breast milk during hospitalization (HR 0.797, 95%CI 0.412,2.288), NICU feeding mode during hospitalization (HR 1.221, 95%CI 0.128,1.381) and family support (HR 0.561, 95%CI 0.004,2.428) were significantly associated with the exclusive breastfeeding duration after discharge.

CONCLUSIONS

The exclusive breastfeeding outcome of premature infants was affected by many factors, so we should focus on the three levels of individual, family, society and design targeted intervention measures to increase the exclusive breastfeeding rate and prolong exclusive breastfeeding duration.

The Baby-friendly Hospital Initiative for neonatal wards. A mini review

The Baby-friendly Hospital Initiative for Neonatal Wards (Neo-BFHI) is an expansion of the WHO/UNICEF Ten Steps to Successful Breastfeeding to address the needs of infants and families in all levels of neonatal care. The Neo-BFHI includes Three Guiding Principles as basic tenets, Ten Steps to protect, promote and support breastfeeding closely following the original Baby-friendly Hospital Initiative, and adherence to the International Code of Marketing of Breast-milk Substitutes. In 2020, the WHO/UNICEF published recommendations for breastfeeding small, sick and preterm newborns that aligns with the Neo-BFHI. Conclusion: This mini review provides a brief description of the content in the Neo-BFHI.

Impact of introducing a lactation consultant into a neonatal unit

AIM

Benefits of mothers' own milk (MOM) for premature and sick neonates are well documented. To increase access, many neonatal units have a lactation consultant (LC) on staff. This study aimed to assess the impact of a permanent LC on (i) maternal access to LC support; (ii) staff confidence in providing Breast Feeding (BF) education and (iii) provision of MOM.

METHODS

Study included a staff survey and chart audit. Questions provided feedback on access to lactation support and meeting maternal needs. Audit data included: gestational age, birthweight, intention to breastfeed, documentation of LC appointment, provision of MOM at 12 hours, days 3, 7, 28 and discharge. Student's t-tests were used for numerical data and chi-squared tests for categorical variables.

RESULTS

Ninety-one staff surveys were returned, (pre 35/75 (47%), post 56/85 (66%) with staff reporting organising an LC appointment was significantly easier (P < 0.0001). Staff perceived maternal lactation needs and confidence to breastfeed post-discharge had significantly improved post-LC. The chart audit showed a significant increase in maternal access to LC appointments (15% vs. 80%; P < 0.01), breast pump education by day 3 (65% vs. 81%; P < 0.01), and an increase in MOM provision by 12 h (46% vs. 61%; P < 0.01) post-LC but not at days 7, 28 or discharge.

CONCLUSION

A dedicated LC increases staff and maternal access to lactation education and support, improving provision of early MOM. Further research is required to assess the effect of LCs in improving breastfeeding rates in neonatal units.

Pasteurized Donor Human Milk Should Not Replace Mother's Own Milk in Preterm Neonates: A Quality Initiative Toward Decreasing the "PDHM Dependency"

Aim: Mother's own milk (MOM) is the preferred source of neonatal nutrition. Due to various challenges, mothers are often unable to provide exclusive MOM to neonates admitted in neonatal intensive care units (NICUs) and depend on pasteurized donor human milk (PDHM). The aim of this quality improvement (QI) initiative was to enable mothers to provide MOM and consequently decrease the "PDHM dependency." Methods: Neonates <32 weeks of gestation (n = 120) were included. A multidisciplinary team was formed, and a detailed root cause analysis was done to understand the cause of PDHM dependency during the observation phase (November 1 to December 15, 2019). Various evidence-based practices were planned, tested, and implemented through Plan-Do-Study-Act cycles during the intervention phase (December 16, 2019 to January 31, 2020). These were further strengthened and adopted as a unit culture during the maintenance phase (February 1 to July 31, 2020). Results from the observation and intervention phases were compared. Results: Within 6 weeks of QI interventions, the average proportion of MOM significantly increased from 74.4% to 93.5% (p = 0.0003), and the proportion of PDHM significantly decreased from 20.5% to 4.6% (p = 0.005). The proportion of MOM remained at 82.5% during the maintenance phase. There was a significant decrease in the number of days to reach full feeds and regain birth weight. Conclusions: Provision of PDHM from our newly functional milk bank led to a reduced drive to express MOM in mothers of NICU babies. Our QI project focused on various strategies to improve MOM feeding and reduce PDHM dependence.

Exclusive Maternal Milk Compared With Exclusive Formula on Growth and Health Outcomes in Very-Low-Birthweight Preterm Infants: Phase II of the Pre-B Project and an Evidence Analysis Center Systematic Review

As part of the Pre-B Project, a systematic review was conducted to evaluate associations between exclusive maternal milk (≥75%) intake and exclusive formula intake and growth and health outcomes in very-low-birthweight (VLBW) preterm infants. The protocols from the Academy of Nutrition and Dietetics' Evidence Analysis Center and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist were followed. Thirteen observational studies were included; 11 studies reported data that could be synthesized in a pooled analysis. The evidence is very uncertain (very low quality) about the effect of exclusive maternal milk on all outcomes due to observational study designs and risk of selection, performance, detection, and reporting bias in most of the included studies. Very-low-quality evidence suggested that providing VLBW preterm infants with exclusive maternal milk was not associated with mortality, risk of necrotizing enterocolitis, sepsis, or developing bronchopulmonary dysplasia, as compared with exclusive preterm formula, but exclusive maternal milk was associated with a lower risk of retinopathy of prematurity (very low certainty). Results may change when additional studies are conducted. There was no difference in weight, length, and head circumference gain between infants fed fortified exclusive maternal milk and infants receiving exclusive preterm formula; however, weight and length gain were lower in infants fed non-fortified exclusive maternal milk. Given the observational nature of human milk research, cause-and-effect evidence was lacking for VLBW preterm infants.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=86829, PROSPERO ID: CRD42018086829.

Breastfeeding in the context of the COVID-19 pandemic: A discussion paper

Breastfeeding offers one of the most fundamental global health benefits for babies. Breastmilk is lifesaving, providing not only nutrition but immunologic benefits and as such is strongly supported by the World Health Organization and leading healthcare associations worldwide. When the COVID-19 pandemic started in 2020, the impact of the restrictions to prevent the spread of the disease created challenges and questions about provision of safe, quality care, including breastfeeding practices, in a new 'normal' environment. Mothers were temporarily separated from their babies where infection was present or suspected, parents were prevented from being present on neonatal units and vital breastfeeding support was prevented. This discussion paper provides an overview of essential areas of knowledge related to practice for neonatal nurses and midwives who care for breastfeeding mothers and babies, in the context of the COVID-19 pandemic and the latest global guidance. Three areas will be discussed; the protective benefits of breastfeeding, keeping breastfeeding mothers and babies together and supporting mothers to breastfeed their babies. Finally, care recommendations are presented to serve as a summary of key points for application to practice for neonatal nurses and midwives.

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.

The Impact of Homogenization on Donor Human Milk and Human Milk-Based Fortifiers and Implications for Preterm Infant Health

An exclusive human milk diet (EHMD) has been shown to reduce health complications of prematurity in infants born weighing ≤1250 g compared with cow milk-based diets. Accordingly, the number of available human milk (HM)-based nutritional products continues to increase. Newly available products, and those reportedly soon to enter the market, include homogenized donor HM and homogenized HM-based fortifiers. Existing literature demonstrating the benefits of an EHMD, however, is limited to non-homogenized HM-based products. Herein, we summarize existing evidence on the impact of homogenization on HM, with a particular focus on changes to the macromolecular structure of the milk fat globule and the subsequent impact on digestion kinetics. We use these published data to create a conceptual framework for the potential implications of homogenized HM-based nutritional products on preterm infant health. Importantly, we underscore that the safety and efficacy of homogenized HM-based products warrant investigation.

Human milk-based fortifier is associated with less alteration of milk fat globule size than cow milk-based fortifier

We aimed to evaluate if human milk-based fortifier (HMBF) affects human milk fat globule (MFG) size less than cow milk-based fortifier (CMBF), which may impact overall infant feeding tolerance. Measurements of donated human milk were performed before fortification as well as at 1 hour, 24 hours, and 48 hours after fortification with CMBF or HMBF. MFG size in each sample of fortified milk was measured by laser light scattering. MFG size in the fortified milks increased gradually over time. At 24 and 48 hours after fortification, MFG size in the milk with CMBF was larger than that in the milk with HMBF (4.8 ± 0.5 vs 4.3 ± 0.3 μm, p<0.01, 5.1 ± 0.7 vs 4.5 ± 0.4 μm, p = 0.03, respectively). HMBF is associated with less alteration of MFG size than CMBF. This may have an impact on feeding tolerance of very preterm infants.

Percent mother's own milk feedings for preterm neonates predicts discharge feeding outcomes

INTRODUCTION

No studies have determined if there is a threshold whereby use of mother's own milk (MOM) during hospitalization predicts exclusive MOM feeding at discharge.

METHODS

Among 113 very low birthweight neonates, the ratio of MOM to enteral feeds was measured in the first 14 days, 28 days, and overall hospital stay. The primary outcome was exclusive MOM feeding at discharge.

RESULTS

For every 1% increase in MOM consumption in the first 14 and 28 days, the odds of being discharge home on an exclusive MOM diet increased nearly 7-fold (OR 7.01, 95% CI: 2.09-23.50) and 17-fold (OR 17.46, 95% CI 4.67-63.31), respectively. A threshold of >50%, >83%, and >85% MOM consumption compared to overall enteral feeds in the first 14 days, 28 days, and throughout hospitalization, respectively, is recommended.

CONCLUSIONS

Promotion of MOM consumption in the first 2-4 weeks is of paramount importance, with negligible impact of increasing MOM consumption after 28 days.

Nordic study on human milk fortification in extremely preterm infants: a randomised controlled trial-the N-forte trial

INTRODUCTION

The mortality rate of extremely low gestational age (ELGA) (born <gestational week 28+0) infants remains high, and severe infections and necrotising enterocolitis (NEC) are common causes of death. Preterm infants receiving human milk have lower incidence of sepsis and NEC than those fed a bovine milk-based preterm formula. Despite this, fully human milk fed ELGA infants most often have a significant intake of cow's milk protein from bovine-based protein fortifier. The aim of this study is to evaluate whether the supplementation of human milk-based, as compared with bovine-based, nutrient fortifier reduces the prevalence of NEC, sepsis and mortality in ELGA infants exclusively fed with human milk.

METHODS AND ANALYSIS

A randomised-controlled multicentre trial comparing the effect of a human breast milk-based fortifier with a standard bovine protein-based fortifier in 222-322 ELGA infants fed human breast milk (mother's own milk and/or donor milk). The infants will be randomised to either fortifier before reaching 100 mL/kg/day in oral feeds. The intervention, stratified by centre, will continue until the target postmenstrual week 34+0. The primary outcome is a composite of NEC, sepsis or death. Infants are characterised with comprehensive clinical and nutritional data collected prospectively from birth until hospital discharge. Stool, urine, blood and breast milk samples are collected for analyses in order to study underlying mechanisms. A follow-up focusing on neurological development and growth will be performed at 2 and 5.5 years of age. Health economic analyses will be made.

ETHICS AND DISSEMINATION

The study is conducted according to ICH/GCP guidelines and is approved by the regional ethical review board in Linköping Sweden (Dnr 2018/193-31, Dnr 2018/384-32). Results will be presented at scientific meetings and published in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

The study was registered with ClinicalTrials.gov NCT03797157, 9 January 2019.

Factors Associated With Breastfeeding Very Low Birth Weight Infants at Neonatal Intensive Care Unit Discharge: A Single-Center Brazilian Experience

BACKGROUND

The mothers of very low birth weight infants face many challenges to achieve breastfeeding at hospital discharge, especially during long stays.

RESEARCH AIM

The aim of this study was to describe the incidence and factors associated with breastfeeding rates (exclusive or with formula) at discharge, for very low birth weight infants, in a private Neonatal Intensive Care Unit in southern Brazil.

METHODS

We conducted a prospective longitudinal cohort study of infants (N = 335) with very low birth weight and/or less than 30 weeks gestational age, who survived to discharge and had no contraindication to mother's own milk. Participants were initially divided into three groups (exclusive breastfeeding, some breastfeeding, and no breastfeeding) based on their feedings at discharge; however, later, two groups were analyzed (any breastfeeding, no breastfeeding).

RESULTS

Most (93.4%; n = 313) were breastfeeding directly at least once daily at discharge, of which 16.1% (n = 54) were receiving exclusive mother's milk and 77.3% (n = 259) mixed feeding (mother's milk and formula). Breastfeeding at discharge was associated with gestational age ≥ 28 weeks, higher birth weight, not developing neonatal sepsis or bronchopulmonary dysplasia during the hospital stay, shorter lengths of stay, and lower weight at discharge. After Poisson regression, breastfeeding at discharge was associated only with a shorter length of stay (RR 0.98; CI 95% [0.95, 0.99], p < .05).

CONCLUSIONS

In our single unit experience in Brazil, most infants were breastfeeding at discharge. NICU staff might address mothers of infants who have prolonged hospitalization with specific strategies. Mothers and infants at risk can be identified early and personalized interventions can be developed for improving breastfeeding rates at discharge.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.