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Roberts AG, Younge N, Greenberg RG. Neonatal Necrotizing Enterocolitis: An Update on Pathophysiology, Treatment, and Prevention. Paediatr Drugs 2024; 26:259-275. [PMID: 38564081 DOI: 10.1007/s40272-024-00626-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
Necrotizing enterocolitis (NEC) is a life-threatening disease predominantly affecting premature and very low birth weight infants resulting in inflammation and necrosis of the small bowel and colon and potentially leading to sepsis, peritonitis, perforation, and death. Numerous research efforts have been made to better understand, treat, and prevent NEC. This review explores a variety of factors involved in the pathogenesis of NEC (prematurity, low birth weight, lack of human breast milk exposure, alterations to the microbiota, maternal and environmental factors, and intestinal ischemia) and reports treatment modalities surrounding NEC, including pain medications and common antibiotic combinations, the rationale for these combinations, and recent antibiotic stewardship approaches surrounding NEC treatment. This review also highlights the effect of early antibiotic exposure, infections, proton pump inhibitors (PPIs), and H2 receptor antagonists on the microbiota and how these risk factors can increase the chances of NEC. Finally, modern prevention strategies including the use of human breast milk and standardized feeding regimens are discussed, as well as promising new preventative and treatment options for NEC including probiotics and stem cell therapy.
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Chang MR, Tetarbe M, Barton L, Ramanathan R, Cayabyab R. 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. Am J Perinatol 2024; 41:e2824-e2831. [PMID: 37657486 DOI: 10.1055/a-2164-7957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
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..
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Affiliation(s)
- Millie R Chang
- Division of Neonatology, CHOC Pediatric Subspecialty Faculty Inc., Orange, California
| | - Manas Tetarbe
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California
| | - Lorayne Barton
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California
| | - Rowena Cayabyab
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California
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Chou FS, Zhang J, Nguyen C, Faison GM, Thompson LR, Villosis MFB, Barseghyan K, Lakshmanan A. The impact of exclusive human milk diet on short-term growth of very preterm infants. J Perinatol 2024:10.1038/s41372-024-01980-w. [PMID: 38678082 DOI: 10.1038/s41372-024-01980-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 04/29/2024]
Abstract
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.
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Affiliation(s)
- Fu-Sheng Chou
- Southern California Permanente Medical Group, Pasadena, CA, USA.
- Kaiser Permanente Riverside Medical Center, Riverside, CA, USA.
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Jing Zhang
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, CA, USA
| | - Cammie Nguyen
- Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Giulia M Faison
- Southern California Permanente Medical Group, Pasadena, CA, USA
- Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Lindsey R Thompson
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Maria Fe B Villosis
- Southern California Permanente Medical Group, Pasadena, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Kaiser Permanente Panorama City Medical Center, Panorama City, CA, USA
| | - Karine Barseghyan
- Southern California Permanente Medical Group, Pasadena, CA, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Kaiser Permanente Panorama City Medical Center, Panorama City, CA, USA
| | - Ashwini Lakshmanan
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Fu TT, Poindexter BB. Human Milk Fortification Strategies in the Neonatal Intensive Care Unit. Clin Perinatol 2023; 50:643-652. [PMID: 37536769 DOI: 10.1016/j.clp.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Multicomponent fortification is the standard of care to support short-term growth in preterm infants receiving human milk. There is no consensus regarding the optimal timing, method, or products used to fortify human milk. Both bovine milk-based and human milk-based human milk fortifiers are safe options, though increased fortification and enrichment may be needed to achieve adequate growth. Additional studies are needed to evaluate newer fortifier products and fortification strategies.
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Affiliation(s)
- Ting Ting Fu
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Brenda B Poindexter
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta and Emory University School of Medicine, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA
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Monzon N, Kasahara EM, Gunasekaran A, Burge KY, Chaaban H. Impact of neonatal nutrition on necrotizing enterocolitis. Semin Pediatr Surg 2023; 32:151305. [PMID: 37257267 PMCID: PMC10750299 DOI: 10.1016/j.sempedsurg.2023.151305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Necrotizing enterocolitis (NEC) is the leading cause of morbidity and mortality in preterm infants. NEC is multifactorial and the result of a complex interaction of feeding, dysbiosis, and exaggerated inflammatory response. Feeding practices in the neonatal intensive care units (NICUs) can vary among institutions and have significant impact on the vulnerable gastointestinal tract of preterm infants. . These practices encompass factors such as the type of feeding and fortification, duration of feeding, and rate of advancement, among others. The purpose of this article is to review the data on some of the most common feeding practices in the NICU and their impact on the development of NEC in preterm infants. Data on the human milk bioactive component glycosaminoglycans, specifically hyaluronan, will also be discussed in the context of postnatal intestinal development and NEC prevention.
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Affiliation(s)
- Noahlana Monzon
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma, OKC, 73104
| | - Emma M Kasahara
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma, OKC, 73104
| | - Aarthi Gunasekaran
- Department of Pediatrics, Division of Neonatology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Kathryn Y Burge
- Department of Pediatrics, Division of Neonatology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Hala Chaaban
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma, OKC, 73104; Department of Pediatrics, Division of Neonatology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104.
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Pados BF. State of the Science on the Benefits of Human Milk for Hospitalized, Vulnerable Neonates. Nurs Womens Health 2023; 27:121-140. [PMID: 36871597 DOI: 10.1016/j.nwh.2023.01.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/16/2022] [Accepted: 01/26/2023] [Indexed: 03/06/2023]
Abstract
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.
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Senthilkumaran R, Devi U, Amboiram P, Balakrishnan U. Bovine milk-based and human milk-based fortification for postnatal weight gain in very preterm neonates-a cohort study. J Trop Pediatr 2022; 69:6965014. [PMID: 36579930 DOI: 10.1093/tropej/fmac110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Postnatal growth failure happens in about half of the very low birth weight infants and this can have long-term consequences. Human milk-based multi-nutrient fortifiers (HMBF) are thought to be better tolerated than bovine milk-based multi-nutrient fortifiers (BMBF), thus facilitating early progression to full feeds and improved growth in preterm neonates. This study was done to find the advantage of HMBF over BMBF on postnatal growth and other clinical outcomes. METHODS This is a retrospective cohort study where babies <1500 g birth weight or gestational age <32 weeks were included to compare the velocity of weight gain (g/kg/day), duration of hospital stay and clinical outcomes between fortification using HMBF and BMBF till 34 weeks postmenstrual age. RESULTS Eligible neonates included in the study were 322, out of whom 123 (37%) received HMBF and 209 (63%) received BMBF. During the stay, 18 babies were changed from BMBF to HMBF and vice versa in 24 babies due to logistic reasons and parents' preferences. The mean birth weight of the babies was 1124 ± 237 g. Weight gain was higher in the exclusive HMBF group [mean difference 0.77 (0.14, 1.39) g/kg/day; p-value = 0.018]. Feed intolerance [odds ratio (OR) 0.45 (0.22, 0.95), p-value 0.037] was also significantly less in this group. However, other morbidities did not differ significantly between the groups. CONCLUSION Higher weight gain and lower feed intolerance in the HMBF group underscores the possible advantage of using HMBF over BMBF. Larger prospective studies might bring out its effect on the duration of hospital stay and other morbidities.
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Affiliation(s)
- Ravikumar Senthilkumaran
- Department of Neonatology, Sri Ramachandra Institute of Higher Education & Research, Chennai 600116, India
| | - Usha Devi
- Department of Neonatology, Sri Ramachandra Institute of Higher Education & Research, Chennai 600116, India
| | - Prakash Amboiram
- Department of Neonatology, Sri Ramachandra Institute of Higher Education & Research, Chennai 600116, India
| | - Umamaheswari Balakrishnan
- Department of Neonatology, Sri Ramachandra Institute of Higher Education & Research, Chennai 600116, India
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Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital. Adv Neonatal Care 2022; 22:503-512. [PMID: 36413779 DOI: 10.1097/anc.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes. PURPOSE To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital. METHODS The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization. FINDINGS NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention. IMPLICATIONS FOR PRACTICE Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals. IMPLICATIONS FOR RESEARCH Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.
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Bharadwaj N, Panigrahy N, Bagga N, Chirla DK. Human Milk-Derived Fortifier as Rescue Therapy in Very Preterm Infants Intolerant to Cow's Milk-Derived Fortifier. Indian J Pediatr 2022; 89:1131-1133. [PMID: 35904719 DOI: 10.1007/s12098-022-04309-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 06/08/2022] [Indexed: 11/05/2022]
Abstract
This was a retrospective, descriptive study where human milk-derived fortifier (HMDF) was used to rescue infants intolerant to cow's milk-derived fortifier (CMDF). Rescue therapy was used for newborns with feed intolerance, systemic symptoms, or thrombocytosis. In a total of 412 very preterm infants (gestational age ≤ 32 wk) admitted to NICU during the study period, 14 infants met the rescue protocol inclusion criteria. The mean gestational age of these 14 infants was 29.2 ± 1.2 wk and birth weight was 1161 ± 201 g. All the infants who received rescue protocol by changing over to HMDF tolerated feeds well and showed a positive growth trend. Four infants had thrombocytosis, out of which 2 infants had elevated platelet count even with HMDF. Premature infants with intolerance to CMDF were effectively managed using HMDF as a rescue protocol. Infants tolerated HMDF well and showed positive growth trends till the discharge.
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Affiliation(s)
- Namala Bharadwaj
- Neonatology Department, Rainbow Children's Hospital, Hyderabad, Telangana, 500034, India
| | - Nalinikanta Panigrahy
- Neonatology Department, Rainbow Children's Hospital, Hyderabad, Telangana, 500034, India.
| | - Nitasha Bagga
- Neonatology Department, Rainbow Children's Hospital, Hyderabad, Telangana, 500034, India
| | - Dinesh Kumar Chirla
- Neonatology Department, Rainbow Children's Hospital, Hyderabad, Telangana, 500034, India
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10
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Abstract
How nutritional management of very preterm neonates impacts microbiota development and clinical outcomes remains incompletely understood. In this issue of Cell Host & Microbe, Asbury et al. present a randomized controlled trial assessing the microbiota of very preterm infants fed human milk supplemented with human milk or cow's milk-based fortification.
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Affiliation(s)
- Samuli Rautava
- New Children's Hospital, Neonatal Intensive Care Unit, University of Helsinki & Helsinki University Hospital, Helsinki, Finland.
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11
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Effect of an exclusive human milk diet on feeding tolerance in preterm infants. J Perinatol 2022; 42:1070-1075. [PMID: 35184144 DOI: 10.1038/s41372-022-01348-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/13/2022] [Accepted: 02/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the time to full enteral feeds in preterm infants fed exclusive human milk (EHM) - mother's own milk (MOM) fortified with human milk-based fortifier (HMBF), to those who received partial human milk (PHM) - MOM fortified with bovine milk-based fortifier (BMBF), and exclusive formula. STUDY DESIGN A single-center retrospective study of infants with birth weight <1250 g from 2013 to 2018. Data on feeding, growth and other short-term neonatal morbidities were collected. RESULTS On regression analysis, time to full enteral feeds was significantly higher in PHM compared to EHM group (β-coefficient 4.14, 95% CI 0.00-8.29) and formula-fed group compared to EHM (β-coefficient 4.3, 95% CI 0.32-8.20). No significant differences in growth velocity, length of stay and other morbidities were found between the groups. CONCLUSION Infants in EHM had better feeding tolerance and reached their enteral feed goals sooner compared to PHM and formula-fed groups.
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Elliott MJ, Golombek SG. Evolution of Preterm Infant Nutrition from Breastfeeding to an Exclusive Human Milk Diet: A Review. Neoreviews 2022; 23:e558-e571. [PMID: 35909104 DOI: 10.1542/neo.23-8-e558] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Melinda J Elliott
- Department of Neonatology, Pediatrix Medical Group of Maryland, Rockville, MD
| | - Sergio G Golombek
- Prolacta Bioscience, Duarte, CA.,Departments of Neonatology and Pediatrics, SUNY Downstate Health Sciences University, Brooklyn, NY
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Bergner EM, Taylor SN, Gollins LA, Hair AB. Human Milk Fortification: A Practical Analysis of Current Evidence. Clin Perinatol 2022; 49:447-460. [PMID: 35659096 DOI: 10.1016/j.clp.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Human milk (HM) with appropriate fortification is the recommended nutrition for very low birth weight (VLBW) infants. Fortification provides additional nutrients, vitamins, and minerals to support the growing preterm infant during critical periods of development. This article discusses the variability of HM including differences between maternal and pasteurized donor human milk (DHM), fortification of HM through the use of single- and multi-nutrient fortifiers, and clinical controversies including the timing of fortification, volume of feedings, and future innovations in HM fortification.
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Affiliation(s)
- Erynn M Bergner
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, 1200 North Everett Drive, ETNP 7504 Oklahoma City, OK 73104, USA. https://twitter.com/ErynnBergner
| | - Sarah N Taylor
- Section of Neonatology, Department of Pediatrics, Yale School of Medicine, PO Box 208064 New Haven, CT 06520, USA
| | - Laura A Gollins
- Neonatal Nutrition Program, Neonatology, Texas Children's Hospital, 6621 Fannin Street, Suite WT6104, Houston, TX 77030, USA
| | - Amy B Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Suite WT6104, Houston, TX 77030, USA.
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Reyes SM, Patra B, Elliott MJ. The Impact of Homogenization on Donor Human Milk and Human Milk-Based Fortifiers and Implications for Preterm Infant Health. Curr Dev Nutr 2022; 6:nzab147. [PMID: 35059551 PMCID: PMC8764228 DOI: 10.1093/cdn/nzab147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Melinda J Elliott
- Prolacta Bioscience®, Duarte, CA, USA
- Pediatrix Medical Group of Maryland, Rockville, MD, USA
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Jensen GB, Ahlsson F, Domellöf M, Elfvin A, Naver L, Abrahamsson T. Nordic study on human milk fortification in extremely preterm infants: a randomised controlled trial-the N-forte trial. BMJ Open 2021; 11:e053400. [PMID: 34815288 PMCID: PMC8611420 DOI: 10.1136/bmjopen-2021-053400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Georg Bach Jensen
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Paediatrics, Linköping University, Linköping, Östergötland, Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Anders Elfvin
- Institute of Clinical Sciences, Department of Paediatrics, Sahlgrenska Academy, Göteborg, Sweden
- Queen Silvia Children's Hospital, Department of Paediatrics, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Lars Naver
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Abrahamsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Paediatrics, Linköping University, Linköping, Östergötland, Sweden
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Hanford J, Mannebach K, Ohler A, Patten M, Pardalos J. Rates of Comorbidities in Very Low Birth Weight Infants Fed an Exclusive Human Milk Diet Versus a Bovine Supplemented Diet. Breastfeed Med 2021; 16:814-820. [PMID: 34415775 DOI: 10.1089/bfm.2020.0345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Our level III neonatal intensive care unit (NICU) implemented the use of an exclusive human milk diet (EHD) and sought to determine its effect on the severe co-morbidities of preterm infants as well as the potential cost-savings due to the anticipated reduction in these co-morbidities. Methods: A retrospective cohort study was completed to determine if an EHD statistically decreased the rate of co-morbidities including length of stay (LOS), days on total parental nutrition (TPN), rates of late onset sepsis, necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), and severe retinopathy of prematurity (ROP). Results: An EHD significantly decreased the odds of severe ROP (adjusted odds-ratio (aOR)=0.349; 95%CI [0.156, 0.739]; p=0.008) and late onset sepsis (aOR=0.323; 95%CI [0.123, 0.768]; p=0.014). Analysis of cost-effectiveness of an EHD relative to a BSD based on the incremental costs of these co-morbidities determined the net loss in direct hospital costs per patient were estimated to be $420 in 2016 US dollars; however, given the long-term health-care costs and non-pecuniary damages from the co-morbidities of severe ROP and sepsis this net loss appears negligible. Conclusion: This study found that an EHD significantly decreased the odds of severe ROP and late onset sepsis; though not significant, there was a positive trend in decreasing cases of medical NEC; our surgical NEC rates dropped to 0. The benefits of human milk are vital, and the costs are nominal.
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Affiliation(s)
- Jennifer Hanford
- Division of Neonatology, Department of Child Health, Women's and Children's Hospital, University of Missouri Health Care, Columbia, Missouri, USA
| | - Kimberly Mannebach
- Division of Neonatology, Department of Child Health, Women's and Children's Hospital, University of Missouri Health Care, Columbia, Missouri, USA
| | - Adrienne Ohler
- Division of Neonatology, Department of Child Health, Women's and Children's Hospital, University of Missouri Health Care, Columbia, Missouri, USA
| | - Michael Patten
- Division of Neonatology, Department of Child Health, Women's and Children's Hospital, University of Missouri Health Care, Columbia, Missouri, USA
| | - John Pardalos
- Division of Neonatology, Department of Child Health, Women's and Children's Hospital, University of Missouri Health Care, Columbia, Missouri, USA
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[Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021. [PMID: 33476530 DOI: 10.7499/j.issn.1008-8830.2011145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.
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中国医师协会新生儿科医师分会循证专业委员会. [Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:1-11. [PMID: 33476530 PMCID: PMC7818154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2023]
Abstract
Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.
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Affiliation(s)
- 中国医师协会新生儿科医师分会循证专业委员会
- 唐军, 女, 教授, 四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室, ; 封志纯, 男, 教授, 解放军总医院第七医学中心附属八一儿童医院NICU, ; 母得志, 男, 教授, 四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室,
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Rai S, Lofiego P, Samedi V. Severe feeding intolerance in extremely preterm neonates successfully treated with human milk derived human milk fortifier: A case series. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_210_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Relationship between Fatty Acids Composition/Antioxidant Potential of Breast Milk and Maternal Diet: Comparison with Infant Formulas. Molecules 2020; 25:molecules25122910. [PMID: 32599866 PMCID: PMC7356699 DOI: 10.3390/molecules25122910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 02/02/2023] Open
Abstract
The fatty acid composition of human breast milk is relevant for the energy, immunity and eicosanoid production in infants. Additionally, the antioxidant properties of foods are essential for human health. Therefore, in the present study we aimed to investigate the relationship between maternal diet and fatty acids composition as well as the antioxidant potential of breast milk from donors to human milk bank of Perugia's hospital, Italy. Results were compared with infant formulas. We observed increased levels of total fatty acids and, in particular, saturated and monounsaturated fatty acids in milk from mothers fed on a vegetable and fruit-rich diet compared with a Mediterranean diet. In the same milk, a reduced antioxidant potential was found. All infant formulas resulted in richer total fatty acid content than human breast milk. Only some formulas were qualitatively similar to breast milk. Of note, the antioxidant potential of the formulas was higher or lower than the human milk with the exception of one sample. The antioxidant potential of four formulas was very high. Dietary supplementation with antioxidants has been shown to have a teratogenic effect and to increase the formation of metastases in adult. There are no data on the effects of excess antioxidants in the infants, but the possibility that they can be harmful cannot be excluded.
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