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Kigozi P, Bando N, Mahlase R, Kotsopoulos K, O'Connor DL, Unger S. Biochemical response in preterm infants fed a human versus bovine milk-based fortifier. J Perinatol 2024:10.1038/s41372-024-02089-w. [PMID: 39152323 DOI: 10.1038/s41372-024-02089-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 07/15/2024] [Accepted: 07/30/2024] [Indexed: 08/19/2024]
Affiliation(s)
- Phoebe Kigozi
- Paediatrics, Sinai Health, Toronto, ON, Canada
- Paediatrics, Nottingham University Hospitals, Nottingham, UK
| | | | - Roselina Mahlase
- Paediatrics, Sinai Health, Toronto, ON, Canada
- Paediatrics, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Deborah L O'Connor
- Paediatrics, Sinai Health, Toronto, ON, Canada
- Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Sharon Unger
- Paediatrics, Sinai Health, Toronto, ON, Canada.
- Nutritional Sciences, University of Toronto, Toronto, ON, Canada.
- Izaak Walton Killam Health Centre, Halifax, NS, Canada.
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2
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Mustapha M, Blair H, Leake N, Johnson V, van den Akker CHP, Embleton ND. The evolution of nutritional care in preterm infants with a focus on the extreme preterm infant. J Hum Nutr Diet 2024. [PMID: 39054762 DOI: 10.1111/jhn.13353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
The evolution of nutritional care in preterm infants, particularly those classified as extremely preterm, has undergone significant advancements in recent years. These infants, born at less than 28 weeks of gestation, face unique challenges related to their elevated nutrient requirements, underdeveloped organ systems and minimal reserves, posing a need for timely and specialised nutritional strategies. Historically, the nutritional management of preterm infants focussed on short-term goals to promote survival. In recent years, the focus has shifted to the quality of nutrient provision to optimise neurodevelopment and longer-term health outcomes. This review highlights the shift from a generalised nutritional approach to a robust, evidence-based approach for preterm infants, acknowledging the intricate interplay between nutrition, holistic care and developmental outcomes. As neonatal care continues to evolve, ongoing research will refine nutritional interventions, optimise growth and enhance the long-term health outcomes of these vulnerable infants.
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Affiliation(s)
| | | | - Nadia Leake
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Chris H P van den Akker
- Department of Pediatrics-Neonatology, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicholas D Embleton
- Ward 35, Royal Victoria Infirmary, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK
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Essex C, Hegedus C, Vincent K, Shiflett A, Rohrer A, Chetta KE. Maternal, neonatal, and nutritional risk factors for medical and surgical necrotizing enterocolitis. J Perinatol 2024:10.1038/s41372-024-02066-3. [PMID: 39030319 DOI: 10.1038/s41372-024-02066-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE To identify maternal and neonatal risk factors associated with progression to surgery or death after diagnosis of NEC. STUDY DESIGN Forty-seven demographic and clinical factors were evaluated across 216 validated cases of NEC occurring between 2010-2020. Nutrition at NEC onset was evaluated in 149 cases. The binary outcome of surgical NEC (progressing to surgery or death) vs. medical NEC (resolved with antibiotic/bowel rest) was compared across variables. RESULTS Elevated CRP, rapidly decreasing platelet counts, inotropic medication, intubation, and positive blood cultures within 24 h of diagnosis were associated with progression to surgery/death. Infants with surgical NEC had higher abdominal circumferences at birth. Maternal milk intake and receipt of human milk fortifiers were associated with medical NEC, and infants receiving fortified, maternal milk showed the lowest progression to surgery/death. CONCLUSION The index of suspicion should be heightened for surgical NEC when these risk factors are present.
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Affiliation(s)
- Clare Essex
- Medical University of South Carolina, 96 Jonathan Lucas Street Suite 601, MSC 617, Charleston, SC, 29425, USA
| | - Clifford Hegedus
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Katherine Vincent
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Alanna Shiflett
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Allison Rohrer
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA
| | - Katherine E Chetta
- C.P. Darby Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, 10 McClennan Banks Drive, MSC 915, Charleston, SC, 29425, USA.
- C.P. Darby Children's Research Institute, Medical University of South Carolina, Shawn Jenkins Children's Hospital, 171 Ashley Avenue, Charleston, SC, 29425, USA.
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O'Connor DL. Time to Step-Up Our Game Concerning Nutrient Analysis of Pasteurized Donor Human Milk? Adv Nutr 2024; 15:100242. [PMID: 38908895 PMCID: PMC11251403 DOI: 10.1016/j.advnut.2024.100242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/24/2024] Open
Affiliation(s)
- Deborah L O'Connor
- Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Sinai Health, Toronto, Ontario, Canada.
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5
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Miklavcic JJ, Paterson N, Hahn-Holbrook J, Glynn L. Impact of FADS genotype on polyunsaturated fatty acid content in human milk extracellular vesicles: A genetic association study. JPEN J Parenter Enteral Nutr 2024; 48:479-485. [PMID: 38566550 DOI: 10.1002/jpen.2628] [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] [Received: 09/12/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Extracellular vesicles in human milk are critical in supporting newborn growth and development. Bioavailability of dietary extracellular vesicles may depend on the composition of membrane lipids. Single-nucleotide polymorphisms (SNPs) in the fatty acid desaturase gene cluster impact the content of long-chain polyunsaturated fatty acids in human milk phospholipids. This study investigated the relation between variation in FADS1 and FADS2 with the content of polyunsaturated fatty acids in extracellular vesicles from human milk. METHODS Milk was obtained from a cohort of mothers (N = 70) at 2-4 weeks of lactation. SNPs in the FADS gene locus were determined using pyrosequencing for rs174546 in FADS1 and rs174575 in FADS2. Quantitative lipidomic analysis of polyunsaturated fatty acids in human milk and extracellular vesicles from human milk was completed by gas chromatography-mass spectrometry. RESULTS The rs174546 and rs174575 genotypes were independent predictors of the arachidonic acid content in extracellular vesicles. The rs174546 genotype also predicted eicosapentaenoic acid and docosahexaenoic acid in extracellular vesicles. The reduced content of long-chain polyunsaturated fatty acids in extracellular vesicles in human milk may be due to lower fatty acid desaturase activity in mothers who are carriers of the A allele in rs174546 or the G allele in rs174575. CONCLUSION The polyunsaturated fatty acid composition of milk extracellular vesicles is predicted by the FADS genotype. These findings yield novel insights regarding extracellular vesicle content and composition that can inform the design of future research to explore how lipid metabolites impact the bioavailability of human milk extracellular vesicles.
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Affiliation(s)
- John J Miklavcic
- Schmid College of Science and Technology, Chapman University, Orange, California, USA
- School of Pharmacy, Chapman University, Irvine, California, USA
| | - Natalie Paterson
- Schmid College of Science and Technology, Chapman University, Orange, California, USA
| | - Jennifer Hahn-Holbrook
- Department of Psychological Services, University of California, Merced, Merced, California, USA
| | - Laura Glynn
- Crean College of Science, Chapman University, Orange, California, USA
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6
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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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Holzapfel LF, Unger JP, Gordon P, Yang H, Cluette-Brown JE, Gollins LA, Hair AB, Martin CR. Fatty acid concentrations in preterm infants fed the exclusive human milk diet: a prospective cohort study. J Perinatol 2024; 44:680-686. [PMID: 38082071 PMCID: PMC11090710 DOI: 10.1038/s41372-023-01841-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/03/2023] [Accepted: 11/23/2023] [Indexed: 02/01/2024]
Abstract
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.
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Affiliation(s)
- Lindsay F Holzapfel
- Department of Pediatrics, Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, USA.
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Jana P Unger
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Pam Gordon
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Clinical Research Nutrition Center, Texas Children's Hospital, Houston, TX, USA
| | - Heeju Yang
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joanne E Cluette-Brown
- Department of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Laura A Gollins
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Amy B Hair
- Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Camilia R Martin
- Division of Neonatology, Weill Cornell Medicine, New York, NY, USA
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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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Ackley D, Yin J, D'Angio C, Meyers J, Young B. Human milk derived fortifiers are associated with glucose, phosphorus, and calcium derangements. J Perinatol 2024:10.1038/s41372-024-01977-5. [PMID: 38658693 DOI: 10.1038/s41372-024-01977-5] [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: 12/18/2023] [Revised: 04/12/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE In 2017, our Level IV NICU switched from providing bovine-derived (BOV-fort) to human milk-derived fortifiers (HM-fort) and donor human milk (DHM) to premature infants born ≤ 30 weeks or ≤1250 g. Following this change, providers anecdotally observed increased hypoglycemia, hypercalcemia, and hyperphosphatemia. This study investigated potential laboratory differences between infants fed Bovine vs. Human milk derived fortifier. METHODS Lab measurements from 402 infants (232 BOV-fort, 170 HM-fort) born between 2015 and 2019 were compared between groups. RESULTS The proportion of infants ever having a blood glucose ≤ 45 mg/dL (p < 0.0001) was higher in the HM-fort group. The proportion of infants ever experiencing a phosphorus > 8.0 mg/dL were higher in the HM-fort group (p < 0.0001). The proportion of infants ever experiencing calcium > 11.4 mg/dL was higher in the HM-Fort group (p = 0.019). CONCLUSIONS Provision of HM-Fort and DHM to extremely premature infants is associated with metabolic derangements.
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Affiliation(s)
- Danielle Ackley
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Jiamin Yin
- Department of Pediatrics, Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Carl D'Angio
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeffrey Meyers
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Bridget Young
- Division of Breastfeeding & Lactation Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Lavassani E, Tauber KA, Cerone JB, Ludke J, Munshi UK. Human milk-derived versus bovine milk-derived fortifier use in very low birth weight infants: growth and vitamin D status. Front Pediatr 2024; 12:1354683. [PMID: 38445079 PMCID: PMC10913192 DOI: 10.3389/fped.2024.1354683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/05/2024] [Indexed: 03/07/2024] Open
Abstract
Background Human milk-derived fortifier (HMDF) coupled with human milk feeding in extremely premature infants reduces the adverse outcome risks of early exposure to bovine milk ingredients but may not provide enough nutrients for adequate catch-up growth compared with bovine milk-derived fortifier (BMDF). Objective This study aims to compare HMDF and BMDF effects on growth parameters and serum 25-hydroxy vitamin D (25OHD) levels in preterm very low birth weight (VLBW) infants during the first 8 weeks of life. Methods We present a retrospective chart review of inpatient VLBW infants with birth weight <1,500 g and gestational age <32 completed weeks who received either their mother's milk or donor breast human milk fortified with HMDF or BMDF for the first 8 weeks. Weight, head circumference, length gain, and 25OHD level were calculated at 4 and 8 weeks of age. Results A total of 139 VLBW infants (91 HMDF + 48 BMDF) received fortified human milk without any supplemental premature formula from birth to 4 weeks of age, of whom 44 (37 HMDF + 7 BMDF) continued until 8 weeks of age. There was no statistically significant difference in the growth parameters between the two groups at 4 and 8 weeks of age. Serum 25OHD level in the HMDF group was significantly higher compared with that in the BMDF group at 4 weeks of age despite receiving lower vitamin D supplementation. Conclusion Similar gain in growth parameters in HMDF and BMDF groups at 4 and 8 weeks of age was observed, suggesting that HMDF provides adequate nutrients for growth in VLBW infants. A higher 25OHD level in HMDF may suggest better absorption.
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Affiliation(s)
- Emmanuelle Lavassani
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Kate A. Tauber
- Department of Pediatrics, Albany Medical Center, Albany, NY, United States
| | - Jennifer B. Cerone
- Department of Pediatrics, Albany Medical Center, Albany, NY, United States
| | - Jennifer Ludke
- Department of Pediatrics, Albany Medical Center, Albany, NY, United States
| | - Upender K. Munshi
- Department of Pediatrics, Albany Medical Center, Albany, NY, United States
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Landau-Crangle E, O’Connor D, Unger S, Hopperton K, Somerset E, Nir H, Hoban R. Associations of maternal inflammatory states with human milk composition in mothers of preterm infants. Front Nutr 2024; 10:1290690. [PMID: 38638527 PMCID: PMC11025471 DOI: 10.3389/fnut.2023.1290690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/26/2023] [Indexed: 04/20/2024] Open
Abstract
Introduction Overweight/obesity (ow/ob) is increasing in prevalence in pregnant women, and it is associated with other pro-inflammatory states, such as pre-eclampsia, gestational diabetes, and preterm labor. Data are lacking if mothers experiencing inflammatory states who deliver preterm have mother's own milk (MOM) with differing inflammatory markers or pro-inflammatory fatty acid (FA) profiles. Methods The aim was to explore associations of maternal pre- and perinatal inflammatory states with levels of inflammatory markers and/or FAs in longitudinal samples of MOM from mothers of preterm infants born <1,250 g. Inflammatory states included pre-pregnancy ow/ob, diabetes, chorioamnionitis (chorio), preterm labor (PTL), premature rupture of membranes (PROM), pre-eclampsia, and cesarian delivery. In MOM, inflammatory markers studied included c-reactive protein (CRP), free choline, IFN-Ɣ, IL-10, IL-1β, IL-1ra, IL-6, IL-8, and TNF-α, and FAs included omega-6:omega-3 ratio, arachidonic acid, docosahexaenoic acid, linoleic acid, monounsaturated FAs, and saturated FAs. The above inflammatory states were assessed individually, and the healthiest mothers (normal BMI, no chorio, and ± no pre-eclampsia) were grouped. Regression analysis tested associations at baseline (day 5) and over time using generalized estimating equations. Results A total of 92 infants were included who were delivered to mothers (42% ow/ob) at a median gestational age of 27.7 weeks and birth weight of 850 g. MOM CRP was 116% higher (relative change 2.16) in mothers with ow/ob at baseline than others (p = 0.01), and lower (relative change 0.46, 0.33, respectively) in mothers in the two "healthy groups" at baseline (both p < 0.05) than others. MOM IL-8 levels were lower with chorio and PTL at baseline. No significant associations were found for other individual or grouped inflammatory states nor for other MOM inflammatory markers nor FA profiles at baseline. Discussion In conclusion, MOM CRP levels are positively associated with inflammatory states, such as ow/ob. Reassuringly, there was no association between FA profiles or most other inflammatory markers and maternal inflammatory states. Further studies are needed to determine potential associations or ramifications of MOM CRP in vulnerable preterm infants.
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Affiliation(s)
- Erin Landau-Crangle
- The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Deborah O’Connor
- The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Sharon Unger
- The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Sinai Health System, Toronto, ON, Canada
| | | | - Emily Somerset
- Ted Rogers Centre for Heart Research, The Hospital for Sick Children, University Health Network, Toronto, ON, Canada
| | - Hadar Nir
- The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Rebecca Hoban
- The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, University of Washington, Seattle, WA, United States
- Seattle Children’s Hospital, Seattle, WA, United States
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12
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Tetarbe M, Chang MR, Barton L, Cayabyab R, Ramanathan R. Economic and Clinical Impact of Using Human Milk-Derived Fortifier in Very Low Birth Weight Infants. Breastfeed Med 2024; 19:114-119. [PMID: 38294868 DOI: 10.1089/bfm.2023.0163] [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] [Indexed: 02/01/2024]
Abstract
Background: Implementation of exclusive human milk (EHM) feeding defined as mother's own milk or donor human milk fortified with human milk-derived fortifiers can place an economic burden on institutions. Methods: Retrospective study of very low birth weight (VLBW) infants before and after the implementation of EHM feedings. Neonatal demographics and clinical outcomes including necrotizing enterocolitis, severe retinopathy of prematurity, bronchopulmonary dysplasia, late-onset sepsis, days on parenteral nutrition (PN), and length-of-stay were collected. The net cost to the institution was estimated using published data. Results: Sixty-four infants in the pre-EHM period and 57 infants in the post-EHM period were enrolled. Net product acquisition cost in 2020 and 2021 was $884,823. The EHM feeding guideline led to a reduction in the mean length of stay and mean days of PN use by 6.3 and 6.8 days per infant, respectively. This led to a cost saving of $1,813,444 ($31,815 per infant). No significant difference in incidence of short-term morbidities was observed. Combining the cost avoidance from clinical outcomes, the estimated financial impact over 2 years excluding insurance reimbursement was an estimated $ 913,840 ($16,032 per infant). Conclusion: Implementation of EHM-based feeding in VLBW infants is a cost-effective option for neonatal intensive care units that can result in reduced length of stay and days on PN without adversely impacting short-term morbidities.
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Affiliation(s)
- Manas Tetarbe
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Millie Rocio Chang
- CHOC Children's Specialists, Division of Neonatology, Orange, California, USA
| | - Lorayne Barton
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Rowena Cayabyab
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC, Los Angeles, California, USA
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13
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Pedaveeti M, Iqbal F, Purkayastha J, Bharadwaj SK, Patil AK, Lewis LES. Comparative Growth Outcomes in Very Low Birth Weight Infants: Evaluating Different Feeding Strategies. Indian J Pediatr 2024:10.1007/s12098-023-04989-9. [PMID: 38206546 DOI: 10.1007/s12098-023-04989-9] [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] [Received: 06/24/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVES To assess the growth pattern of preterm, very low birth weight (VLBW) appropriate for gestational age (AGA) infants on three different feeding regimens. METHODS This prospective open label three-arm parallel randomized controlled trial was conducted at neonatal intensive care unit, Kasturba Hospital, Manipal. One hundred twenty VLBW (weight between 1000-1500 g and gestational age 28-32 wk) preterm AGA infants admitted from April 2021 through September 2022 were included. Three feeding regimens were compared: Expressed breast milk (EBM); EBM supplemented with Human milk fortifier (HMF); EBM supplemented with Preterm formula feed (PTF). Primary outcome measure was assessing the growth parameters such as weight, length, head circumference on three different feeding regimens at birth 2, 3, 4, 5 and 6 wk/discharge. Secondary outcomes included incidence of co-morbidities and cost-effectiveness. RESULTS Of 112 infants analyzed, Group 2 supplemented with HMF showed superior growth outcomes by 6th wk/discharge of intervention, with mean weight of 2053±251 g, mean length of 44.6±1.9 cm, and mean head circumference of 32.9±1.4 cm. However, infants in Group 3, supplemented with PTF, registered mean weight of 1968±203 g, mean length of 43.6±2.0 cm, and mean head circumference of 32.0±1.6 cm. Infants exclusively on EBM presented with mean weight of 1873±256 g, mean length of 43.0±2.0 cm and mean head circumference of 31.4±1.6 cm. CONCLUSIONS Addition of 1 g of HMF to 25 ml of EBM in neonates weighing 1000-1500 g showed better weight gain and head circumference at 6 wk/discharge, which was statistically significant. However, no significant differences in these parameters were observed at postnatal or 2, 3, 4, and 5 wk.
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Affiliation(s)
- Mounika Pedaveeti
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Udupi District, Manipal, Karnataka, 576104, India
| | - Faiza Iqbal
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Udupi District, Manipal, Karnataka, 576104, India
| | - Jayashree Purkayastha
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Udupi District, Manipal, Karnataka, 576104, India
| | - Shruthi K Bharadwaj
- Department of Neonatology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Udupi District, Manipal, Karnataka, 576104, India
| | - Anand Kumar Patil
- Department of Neonatology, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Udupi District, Manipal, Karnataka, 576104, India
| | - Leslie Edward S Lewis
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education (MAHE), Udupi District, Manipal, Karnataka, 576104, India.
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Shenker N, Linden J, Wang B, Mackenzie C, Hildebrandt AP, Spears J, Davis D, Nangia S, Weaver G. Comparison between the for-profit human milk industry and nonprofit human milk banking: Time for regulation? MATERNAL & CHILD NUTRITION 2024; 20:e13570. [PMID: 37830377 PMCID: PMC10749996 DOI: 10.1111/mcn.13570] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/17/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023]
Abstract
Human milk (HM) is a highly evolutionary selected, complex biofluid, which provides tailored nutrition, immune system support and developmental cues that are unique to each maternal-infant dyad. In the absence of maternal milk, the World Health Organisation recommends vulnerable infants should be fed with screened donor HM (DHM) from a HM bank (HMB) ideally embedded in local or regional lactation support services. However, demand for HM products has arisen from an increasing awareness of the developmental and health impacts of the early introduction of formula and a lack of prioritisation into government-funded and nonprofit milk banking and innovation. This survey of global nonprofit milk bank leaders aimed to outline the trends, commonalities and differences between nonprofit and for-profit HM banking, examine strategies regarding the marketing and placement of products to hospital and public customers and outline the key social, ethical and human rights concerns. The survey captured information from 59 milk bank leaders in 30 countries from every populated continent. In total, five companies are currently trading HM products with several early-stage private milk companies (PMCs). Products tended to be more expensive from PMC than HMB, milk providers were financially remunerated and lactation support for milk providers and recipients was not a core function of PMCs. Current regulatory frameworks for HM vary widely, with the majority of countries lacking any framework, and most others placing HM within food legislation, which does not include the support and care of milk donors and recipient prioritisation. Regulation as a Medical Product of Human Origin was only in place to prevent the sale of HM in four countries; export and import of HM was banned in two countries. This paper discusses the safety and ethical concerns raised by the commodification of HM and the opportunities policymakers have globally and country-level to limit the potential for exploitation and the undermining of breastfeeding.
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Affiliation(s)
- Natalie Shenker
- Department of Surgery and Cancer, Imperial College LondonIRDBLondonUK
- The Human Milk FoundationRothamsted Institute, HertsHarpendenUK
| | - Jonathan Linden
- Centre for Environmental PolicyImperial College LondonLondonUK
| | - Betty Wang
- Centre for Environmental PolicyImperial College LondonLondonUK
| | | | | | - Jacqui Spears
- Centre for Environmental PolicyImperial College LondonLondonUK
| | - Danielle Davis
- Centre for Environmental PolicyImperial College LondonLondonUK
| | - Sushma Nangia
- Department of NeonatologyLady Hardinge Medical CollegeNew DelhiIndia
| | - Gillian Weaver
- The Human Milk FoundationRothamsted Institute, HertsHarpendenUK
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15
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Parker LA. Taking Human Milk Fortification to the Next Level. J Perinat Neonatal Nurs 2024; 38:15-17. [PMID: 38278639 DOI: 10.1097/jpn.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Affiliation(s)
- Leslie A Parker
- College of Nursing University of Florida Gainesville, Florida
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16
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Tomlinson C, Haiek LN. Breastfeeding and human milk in the NICU: From birth to discharge. Paediatr Child Health 2023; 28:510-526. [PMID: 38638537 PMCID: PMC11022875 DOI: 10.1093/pch/pxad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/20/2022] [Indexed: 04/20/2024] Open
Abstract
It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.
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Affiliation(s)
- Christopher Tomlinson
- Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario, Canada
| | - Laura N Haiek
- Canadian Paediatric Society, Nutrition and Gastroenterology Committee, Ottawa, Ontario, Canada
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17
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Hoban R, Nir H, Somerset E, Lewis J, Unger S, O’Connor DL. Inflammatory Markers in Mother's Own Milk and Infant Stool of Very Low Birthweight Infants. J Hum Lact 2023; 39:656-665. [PMID: 37653641 PMCID: PMC10580668 DOI: 10.1177/08903344231192441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/16/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Mother's breastmilk is the gold standard for feeding preterm infants. Preterm delivery may be precipitated by inflammatory maternal states, but little is known about milk cytokine profiles and how they correlate with markers of infant gut inflammation (i.e., stool calprotectin) in this vulnerable population. RESEARCH AIM To assess cytokines and inflammatory markers in milk from parents of very preterm infants over time as well as correlations between milk and infant's stool calprotectin. METHOD This is a secondary analysis of milk samples collected during OptiMoM, a triple-blind randomized clinical trial of infants born < 1250 g (NCT02137473). Longitudinally collected samples were analyzed for cytokines, choline, and inflammatory markers (C-reactive protein [CRP], IFN-γ, IL-10, IL-1β, IL-1ra, IL-6, IL-8, TNF-α). Infant stools were collected for longitudinal calprotectin analysis. Generalized estimating equations quantified longitudinal profiles of milk markers and stool calprotectin, their associations, and the correlation between free choline and C-reactive protein over follow-up. RESULT Participants included 92 parents and infants (median weeks of gestation 27.3, median birth weight 845 g, and prevalence of male infants 45%). In all, 212 milk samples and 94 corresponding stool calprotectin levels were collected 1-11 weeks postpartum. C-reactive protein was present in much higher concentrations than other markers, and was highest in Week 1 postpartum. It decreased over time. IL-8 and free choline also changed over time while other markers did not. There was no correlation between any milk markers and stool calprotectin. CONCLUSION Milk from mothers of very preterm infants has detectable inflammatory markers, some of which change over time. Research is needed to determine if infant outcomes are associated with these markers.
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Affiliation(s)
- Rebecca Hoban
- Department of Paediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Hadar Nir
- Department of Paediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Neonatology, Shamir Medical Center, Tel-Aviv University, Israel
| | - Emily Somerset
- Rogers Computational Program, Ted Rogers Centre for Heart Research, The Hospital for Sick Children, University Health Network, Toronto, ON, Canada
| | - Jordan Lewis
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
- University of Toronto School of Medicine, Toronto, ON, Canada
| | - Sharon Unger
- Department of Paediatrics, Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Nutrition, University of Toronto, Toronto, ON, Canada
| | - Deborah L. O’Connor
- Department of Nutrition, University of Toronto, Toronto, ON, Canada
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
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18
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Moreira DH, Gregory SB, Younge NE. Human milk fortification and use of infant formulas to support growth in the neonatal intensive care unit. Nutr Clin Pract 2023; 38 Suppl 2:S56-S65. [PMID: 37721458 PMCID: PMC10662944 DOI: 10.1002/ncp.11038] [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] [Received: 03/07/2023] [Revised: 06/03/2023] [Accepted: 06/10/2023] [Indexed: 09/19/2023] Open
Abstract
Newborn infants require adequate nutrition to achieve full potential growth and development. Early life nutrition and health impacts long-term outcomes through adulthood. Human milk is the optimal source of nutrition during the first 6 months of life. However, infants admitted to the neonatal intensive care unit (NICU) often have comorbidities that create more or different nutrition demands than healthy newborns. There are different strategies to meet the nutrition needs of sick newborns, including use of parenteral nutrition, human milk fortifiers (HMFs), and infant formulas. Multinutrient HMFs are frequently used to achieve the higher nutrition demands of preterm infants. They are available in various presentations, such as human milk- or cow milk-derived, liquid or powder, and acidified or nonacidified, each of which has different risks and benefits associated with its use. Infant formulas are available to meet a demand when mother's own milk or donor breast milk is not available or sufficient, and there are also specialty formulas for infants with certain diseases that present unique nutrition needs. This review is focused on the use of HMFs to support the unique nutrition requirements of preterm infants for healthy growth, as well as the indications for the use of formulas among infants in the NICU.
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Affiliation(s)
- Denise H Moreira
- Department of Pediatrics, Division of Neonatology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah B Gregory
- Department of Pediatrics, Division of Neonatology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Noelle E Younge
- Department of Pediatrics, Division of Neonatology, Duke University School of Medicine, Durham, North Carolina, USA
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19
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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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20
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Yeung T, Rolnitsky A, Bando N, Trang S, Geer A, Kiss A, O'Connor DL, Unger S. A comparison of tertiary level NICU costs for infants born <1250 g supplemented with human versus bovine milk-based fortifiers. J Perinatol 2023; 43:1113-1118. [PMID: 37085523 DOI: 10.1038/s41372-023-01677-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/22/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023]
Abstract
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.
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Affiliation(s)
- Telford Yeung
- Department of Pediatrics, Sinai Health, Toronto, ON, Canada
- Section of Neonatology, Windsor Regional Hospital, Windsor, ON, Canada
| | - Asaph Rolnitsky
- Neonatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Nicole Bando
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Susan Trang
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Andy Geer
- System Funding and Analytics, Sinai Health, Toronto, ON, Canada
| | - Alex Kiss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Deborah L O'Connor
- Department of Pediatrics, Sinai Health, Toronto, ON, Canada
- Translational Medicine Program, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Sharon Unger
- Department of Pediatrics, Sinai Health, Toronto, ON, Canada.
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada.
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21
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Sami AS, Frazer LC, Miller CM, Singh DK, Clodfelter LG, Orgel KA, Good M. The role of human milk nutrients in preventing necrotizing enterocolitis. Front Pediatr 2023; 11:1188050. [PMID: 37334221 PMCID: PMC10272619 DOI: 10.3389/fped.2023.1188050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/22/2023] [Indexed: 06/20/2023] Open
Abstract
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.
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Affiliation(s)
- Ahmad S. Sami
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren C. Frazer
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Claire M. Miller
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Dhirendra K. Singh
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lynda G. Clodfelter
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kelly A. Orgel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Misty Good
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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22
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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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23
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Swanson JR, Becker A, Fox J, Horgan M, Moores R, Pardalos J, Pinheiro J, Stewart D, Robinson T. Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs. BMC Pediatr 2023; 23:237. [PMID: 37173652 PMCID: PMC10176849 DOI: 10.1186/s12887-023-04047-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
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.
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Affiliation(s)
| | - Amy Becker
- Shady Grove Medical Center, Baltimore, MD, USA
| | - Jenny Fox
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - Michael Horgan
- Division of Neonatal Medicine, Albany Medical Center, Bernard & Millie Duker Children's Hospital, Albany, NY, USA
| | - Russell Moores
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, VA, USA
| | - John Pardalos
- University of Missouri Health Care-Columbia, Columbia, MO, USA
| | - Joaquim Pinheiro
- Albany Medical Center, Bernard & Millie Duker Children's Hospital, Albany, NY, USA
| | - Dan Stewart
- Norton Children's Hospital and University of Louisville School of Medicine, Louisville, KY, USA
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Ackley D, Wang H, D'Angio CT, Meyers J, Young BE. Human milk-derived fortifiers are linked with feed extension due to Hypoglycemia in infants <1250 g or <30 weeks: a matched retrospective chart review. J Perinatol 2023; 43:624-628. [PMID: 36991141 PMCID: PMC10717733 DOI: 10.1038/s41372-023-01654-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To investigate differences in hypoglycemia and extended feed prescriptions among premature infants provided bovine-derived human milk fortifiers (Bov-fort) with mother's milk or formula vs human milk-derived human milk fortifiers (HM-fort) with mother's milk or donor human milk. STUDY DESIGN This was a retrospective chart review (n = 98). Infants receiving HM-fort were matched with infants receiving Bov-fort. Blood glucose values and feed orders were retrieved from the electronic medical record. RESULTS Prevalence of ever having blood glucose <60 mg/dL was 39.1% in the HM-fort group vs. 23.9% in the Bov-fort group (p = 0.09). Blood glucose ≤45 mg/dL occurred in 17.4% of HM-fort vs 4.3% in Bov-fort (p = 0.07). Feeds were extended for any reason in 55% of HM-fort vs. 20% of Bov-fort (p < 0.01). Feed extension due to hypoglycemia occurred in 24% of HM-fort vs. 0% of Bov-fort (p < 0.01). CONCLUSION Predominately HM-based feeds are associated with feed extension due to hypoglycemia. Prospective research is warranted to elucidate underlying mechanisms.
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Affiliation(s)
- Danielle Ackley
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Hongyue Wang
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Carl T D'Angio
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Jeffrey Meyers
- Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Bridget E Young
- Division of Pediatric Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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25
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Dilemmas in human milk fortification. J Perinatol 2023; 43:103-107. [PMID: 36097287 DOI: 10.1038/s41372-022-01502-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/10/2022] [Accepted: 08/26/2022] [Indexed: 02/07/2023]
Abstract
Fortification of human milk is the standard of care for very low birth weight (VLBW) infants and is required to support adequate postnatal growth and development. Achieving adequate growth velocity and preventing growth faltering is critical for the developing neonatal brain and optimizing long-term neurodevelopmental outcomes. Mother's milk is the gold standard nutrition to feed preterm infants, however, it does not provide the nutrients needed to support the growth of VLBW infants. After the decision is made to use mother's milk (if available) or alternatively, donor human milk, many dilemmas exist with regards to additional treatment decisions surrounding the type of fortification to use, when to fortify, and the duration of fortification. In this article, we will review the differences in mother's milk compared to donor milk, the different types of human milk fortifiers, the optimal timing of fortification, and discuss when to discontinue human milk fortification.
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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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Gates A, Evans HV, Gatto AM, Le Vin J, Thornton JL, Langley K, Hodges BS, Valentine C. Perceptions of the impact of a multidose human‐milk fortifier on human‐milk preparation practices in United States neonatal intensive care units: A survey of nutrition care team members. Nutr Clin Pract 2022. [DOI: 10.1002/ncp.10937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/26/2022] [Accepted: 10/30/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Amy Gates
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Heather V. Evans
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Alayne M. Gatto
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Jodee Le Vin
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Jessica L. Thornton
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Katina Langley
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Bethany S. Hodges
- Reckitt/Mead Johnson Nutrition Evansville Indiana USA
- Department of Pediatrics, Medical College of Georgia Augusta University Augusta Georgia USA
| | - Christina Valentine
- University Medical Center, College of Medicine University of Arizona Tucson Arizona USA
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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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29
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Adamkin DH. Use of human milk and fortification in the NICU. J Perinatol 2022; 43:551-559. [PMID: 36257977 DOI: 10.1038/s41372-022-01532-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 09/13/2022] [Accepted: 09/26/2022] [Indexed: 11/09/2022]
Abstract
Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow's milk, however there are concerns regarding a possible association between the use of cow's milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or "blind fortification", adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.
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Affiliation(s)
- David H Adamkin
- Division of Neonatal Medicine, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA.
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30
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Kumbhare SV, Jones WD, Fast S, Bonner C, Jong G', Van Domselaar G, Graham M, Narvey M, Azad MB. Source of human milk (mother or donor) is more important than fortifier type (human or bovine) in shaping the preterm infant microbiome. Cell Rep Med 2022; 3:100712. [PMID: 36029771 PMCID: PMC9512671 DOI: 10.1016/j.xcrm.2022.100712] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/13/2022] [Accepted: 07/14/2022] [Indexed: 12/20/2022]
Abstract
Milk fortifiers help meet the nutritional needs of preterm infants receiving their mother's own milk (MOM) or donor human milk. We conducted a randomized clinical trial (NCT03214822) in 30 very low birth weight premature neonates comparing bovine-derived human milk fortifier (BHMF) versus human-derived fortifier (H2MF). We found that fortifier type does not affect the overall microbiome, although H2MF infants were less often colonized by an unclassified member of Clostridiales Family XI. Secondary analyses show that MOM intake is strongly associated with weight gain and microbiota composition, including Bifidobacterium, Veillonella, and Propionibacterium enrichment. Finally, we show that while oxidative stress (urinary F2-isoprostanes) is not affected by fortifier type or MOM intake, fecal calprotectin is higher in H2MF infants and lower in those consuming more MOM. Overall, the source of human milk (mother versus donor) appears more important than the type of milk fortifier (human versus bovine) in shaping preterm infant gut microbiota.
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Affiliation(s)
- Shreyas V Kumbhare
- Manitoba Interdisciplinary Lactation Centre (MILC), Winnipeg, MB, Canada; Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - William-Diehl Jones
- Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB, Canada; Faculty of Health Disciplines, Athabasca University, Athabasca, AB, Canada
| | - Sharla Fast
- Department of Nutrition and Food Services, Health Sciences Centre, Winnipeg, MB, Canada
| | - Christine Bonner
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Geert 't Jong
- Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Gary Van Domselaar
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada; Department of Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - Morag Graham
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada; Department of Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - Michael Narvey
- Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Meghan B Azad
- Manitoba Interdisciplinary Lactation Centre (MILC), Winnipeg, MB, Canada; Children's Hospital Research Institute of Manitoba (CHRIM), Winnipeg, MB, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada.
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31
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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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32
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Asbury MR, Shama S, Sa JY, Bando N, Butcher J, Comelli EM, Copeland JK, Forte V, Kiss A, Sherman PM, Stintzi A, Taibi A, Tomlinson C, Unger S, Wang PW, O'Connor DL. Human milk nutrient fortifiers alter the developing gastrointestinal microbiota of very-low-birth-weight infants. Cell Host Microbe 2022; 30:1328-1339.e5. [PMID: 35987195 DOI: 10.1016/j.chom.2022.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/14/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Abstract
Nutrient fortifiers are added to human milk to support the development of very-low-birth-weight infants. Currently, bovine-milk-based fortifiers (BMBFs) are predominantly administered, with increasing interest in adopting human-milk-based fortifiers (HMBFs). Although beneficial for growth, their effects on the gastrointestinal microbiota are unclear. This triple-blind, randomized clinical trial (NCT02137473) tested how nutrient-enriching human milk with HMBF versus BMBF affects the gastrointestinal microbiota of infants born < 1,250 g during hospitalization. HMBF-fed infants (n = 63, n = 269 stools) showed lower microbial diversity, altered microbial community structure, and changes in predicted microbial functions compared with BMBF-fed infants (n = 56, n = 239 stools). HMBF-fed infants had higher relative and normalized abundances of unclassified Enterobacteriaceae and lower abundances of Clostridium sensu stricto. Post hoc analyses identified dose-dependent relationships between individual feed components (volumes of mother's milk, donor milk, and fortifiers) and the microbiota. These results highlight how nutrient fortifiers impact the microbiota of very-low-birth-weight infants during a critical developmental window.
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Affiliation(s)
- Michelle R Asbury
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Sara Shama
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Jong Yup Sa
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Nicole Bando
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - James Butcher
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON K1N 6N5, Canada; Ottawa Institute of Systems Biology, University of Ottawa, Ottawa ON, K1H 8M5, Canada
| | - Elena M Comelli
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Julia K Copeland
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, ON M5S 3B2, Canada
| | - Victoria Forte
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Alex Kiss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada; Evaluative and Clinical Sciences, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Philip M Sherman
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Cell Biology Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada; Faculty of Dentistry, University of Toronto, Toronto, ON M5G 1X3, Canada
| | - Alain Stintzi
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON K1N 6N5, Canada; Ottawa Institute of Systems Biology, University of Ottawa, Ottawa ON, K1H 8M5, Canada
| | - Amel Taibi
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Christopher Tomlinson
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada; Rogers Hixon Ontario Human Milk Bank, Toronto, ON M5G 1X5, Canada
| | - Pauline W Wang
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, ON M5S 3B2, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada; Rogers Hixon Ontario Human Milk Bank, Toronto, ON M5G 1X5, Canada.
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33
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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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34
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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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35
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Wickland J, Wade C, Micetic B, Meredith K, Martin G. A Retrospective Analysis of the Effects of an Exclusively Human Milk Protein Diet on Neonatal Feeding Tolerance. Am J Perinatol 2022; 39:995-1000. [PMID: 33249551 DOI: 10.1055/s-0040-1721374] [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] [Indexed: 10/22/2022]
Abstract
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..
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Affiliation(s)
- Jessica Wickland
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas.,Division of Neonatology, Phoenix Children's Medical Group, Phoenix, Arizona
| | - Christine Wade
- Mednax Services Inc./Phoenix Perinatal Associates, Phoenix, Arizona
| | - Becky Micetic
- Mednax Services Inc./Phoenix Perinatal Associates, Phoenix, Arizona
| | - Keith Meredith
- Mednax Services Inc./Phoenix Perinatal Associates, Phoenix, Arizona
| | - Gregory Martin
- Division of Neonatology, Phoenix Children's Medical Group, Phoenix, Arizona.,Mednax Services Inc./Phoenix Perinatal Associates, Phoenix, Arizona
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36
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Picaud J. Review highlights the importance of donor human milk being available for very low birth weight infants. Acta Paediatr 2022; 111:1127-1133. [PMID: 35170785 PMCID: PMC9314126 DOI: 10.1111/apa.16296] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/31/2022] [Accepted: 02/14/2022] [Indexed: 12/14/2022]
Abstract
Aim The aim of this paper was to review the role that donor human milk plays in caring for very low birth weight (VLBW) infants. Methods This review focussed on academic papers and background information published in English and French up to 8 August 2021. Results Donor human milk provides a useful bridge to successful breastfeeding in hospitalised neonates and does not have a negative impact on the use of mother's own milk and breastfeeding rates at discharge. It helps to prevent key complications of prematurity, particularly necrotising enterocolitis up to 36 weeks of postmenstrual age, which is more common in infants fed formulas based on cows' milk. When it is carefully fortified, it supports the postnatal growth of the majority of very preterm infants. Well‐organised, accessible human milk banks are required to cover the needs of hospitalised infants, and donor human milk must be prioritised for patients who derive the greatest health benefit from it. These include very preterm infants and those born at term, or near term, with surgical digestive malformations or congenital heart disease. Conclusion Safe, high‐quality donor human milk, which is distributed by well‐organised human milk banks, is essential for the most vulnerable hospitalised neonates.
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Affiliation(s)
- Jean‐Charles Picaud
- Department of Neonatology Hôpital de la Croix‐Rousse Hospices civils de Lyon Lyon France
- CarMen laboratory INSERM INRA Claude Bernard University Lyon1 Pierre‐Benite France
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37
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Beggs MR, Bando N, Unger S, O'Connor DL. State of the evidence from clinical trials on human milk fortification for preterm infants. Acta Paediatr 2022; 111:1115-1120. [PMID: 35143058 DOI: 10.1111/apa.16283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/08/2022] [Indexed: 12/22/2022]
Abstract
Infants born preterm or low birth weight are at risk for morbidity, mortality and later neuroimpairment. Appropriate early post-natal growth is associated with better outcomes in-hospital and post-discharge. Therefore, nutritional strategies that support growth may improve the long-term health of this population. Mother's milk with donor milk as a supplement are preferred sources of nutrition for these infants but may not always support growth, especially amongst infants born of very low birth weight (<1500 g) and or those with a major morbidity. Systematic reviews of randomised controlled trials to date demonstrate that multi-nutrient fortification of human milk improves in-hospital growth of preterm infants although data on long-term neurodevelopment are lacking. Further, individualised approaches to fortification based on milk analysis or the infant's metabolic response may improve growth over standard fortification. The evidence is insufficient to inform the timing of introducing fortifier, routine fortification of feeds post-discharge or routine use of fortifiers made from human instead of bovine milk. Importantly, there is insufficient data to determine if these fortification practices improve relevant clinical or neurodevelopmental outcomes. In sum, there is an urgent need for well-designed clinical trials to assess potential benefits and risks of fortification practices and at what cost.
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Affiliation(s)
- Megan R. Beggs
- Translational Medicine Program The Hospital for Sick Children Toronto Ontario Canada
| | - Nicole Bando
- Translational Medicine Program The Hospital for Sick Children Toronto Ontario Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Sharon Unger
- Department of Nutritional Sciences, Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
- Department of Pediatrics Sinai Health Toronto Ontario Canada
| | - Deborah L. O'Connor
- Translational Medicine Program The Hospital for Sick Children Toronto Ontario Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
- Department of Pediatrics Sinai Health Toronto Ontario Canada
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38
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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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Hopperton KE, Pitino MA, Walton K, Kiss A, Unger SL, O'Connor DL, Bazinet RP. Docosahexaenoic acid and arachidonic acid levels are correlated in human milk: Implications for new European infant formula regulations. Lipids 2022; 57:197-202. [PMID: 35170053 DOI: 10.1002/lipd.12338] [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] [Received: 10/29/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 02/03/2023]
Abstract
From February 2022, all infant formula sold in the European Union must contain docosahexaenoic acid (DHA) at ~0.33%-1.14% of total fat with no minimum requirement for arachidonic acid (ARA). This work examines the association between DHA and ARA levels in human milk, the gold standard for infant feeding. Human milk (n = 470) was collected over 12-weeks postpartum from lactating mothers (n = 100) of infants born weighing <1250 g (NCT02137473). Fatty acids were analyzed by gas chromatography. ARA and DHA concentrations were associated in human milk (β = 0.47 [95% confidence interval 0.38-0.56] mol%), including transitional and mature milk, but not colostrum. This remained significant upon adjustment for percentages of other saturated, monounsaturated, n-3, or n-6 fatty acids, day of sample collection, or maternal characteristics (body mass index, ethnicity, education, and income). Infant formulas containing relatively high concentrations of DHA without ARA, as permitted by the new regulations, would not reflect the balance of these fatty acids in human milk.
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Affiliation(s)
- Kathryn E Hopperton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael A Pitino
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn Walton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alex Kiss
- Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Evaluative and Clinical Sciences, Sunnybrook Research Institute and the Institute of Health Policy, Toronto, Ontario, Canada
| | - Sharon L Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Paediatrics, Sinai Health, Toronto, Ontario, Canada
| | - Deborah L O'Connor
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Richard P Bazinet
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
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40
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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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41
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Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants. Nutrients 2021; 13:nu13124307. [PMID: 34959859 PMCID: PMC8704746 DOI: 10.3390/nu13124307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/29/2022] Open
Abstract
Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.
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42
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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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43
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Parker MG, Stellwagen LM, Noble L, Kim JH, Poindexter BB, Puopolo KM. Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant. Pediatrics 2021; 148:peds.2021-054272. [PMID: 34635582 DOI: 10.1542/peds.2021-054272] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Margaret G Parker
- Department of Pediatrics, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts
| | - Lisa M Stellwagen
- University of California Health Milk Bank, San Diego, California.,Department of Pediatrics, University of California, San Diego, Health, San Diego, California
| | - Lawrence Noble
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.,New York City Health + Hospitals/Elmhurst
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brenda B Poindexter
- Children's Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
| | - Karen M Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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44
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Gu X, Shi X, Zhang L, Zhou Y, Cai Y, Jiang W, Zhou Q. Evidence summary of human milk fortifier in preterm infants. Transl Pediatr 2021; 10:3058-3067. [PMID: 34976771 PMCID: PMC8649601 DOI: 10.21037/tp-21-476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/17/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND To search for and collect evidence on human milk fortifier in preterm infants, and to summarize the latest and best evidence, so as to provide reference for clinical work. METHODS We searched the databases of UpToDate, American Guide Network, Cochrane Library, Joanna Briggs Institute (JBI), PubMed, ResearchGate, China National Knowledge Infrastructure (CNKI), Wan Fang, Chinese Biology Medicine disc (CBM), and Yi Maitong, and collected relevant guidelines, systematic reviews, evidence summaries, expert consensuses, and randomized controlled trials (RCTs). The retrieval time limit was from the database establishment to July 2021. The quality of the literature was independently evaluated by 2 researchers, who then extracted and summarized the evidence from qualifying articles. RESULTS A total of 16 articles were selected, including 3 guidelines, 3 systematic reviews, 5 expert consensuses, 3 RCTs, and 1 best practice guideline, including indications, time for usage, methods, monitoring and management, time of cessation, health education, and post-discharge feeding. CONCLUSIONS This study summarized the best evidence for human milk fortifier in preterm infants. Medical staff should assess the specific clinical conditions and parental wishes when applying the best evidence to ensure the effectiveness and safety of human milk fortifier, thus improving the quality of clinical nursing.
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Affiliation(s)
- Xin Gu
- Department of Obstetrics, Wuxi People's Hospital, Wuxi, China
| | - Xiaofen Shi
- Department of Nursing, Wuxi People's Hospital, Wuxi, China
| | - Limin Zhang
- Department of Respiratory, Wuxi People's Hospital, Wuxi, China
| | - Ying Zhou
- Department of Respiratory, Wuxi People's Hospital, Wuxi, China
| | - Yinghua Cai
- Department of Nursing, Wuxi People's Hospital, Wuxi, China
| | - Wujia Jiang
- Department of Obstetrics, Wuxi People's Hospital, Wuxi, China
| | - Qunyan Zhou
- Department of Nutrition, Wuxi People's Hospital, Wuxi, China
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45
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Wiechers C, Fusch C, Poets CF, Franz AR. Ernährung von sehr unreifen Frühgeborenen. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01330-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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46
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Clinical Presentation and Multifactorial Pathogenesis of Necrotizing Enterocolitis in the Preterm Infant. Adv Neonatal Care 2021; 21:349-355. [PMID: 33958518 DOI: 10.1097/anc.0000000000000880] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a serious infection of the bowel wall induced by multiple pathological factors, which include inflammation and tissue invasion with bacteria known to cause severe infections. NEC is now understood to be several disease processes under one umbrella. The most common form occurs in premature infants and can exert significant impacts to preterm morbidity and mortality. PURPOSE This narrative review describes current knowledge of the clinical presentation and pathophysiology of NEC in premature infants. METHODS/SEARCH STRATEGY A review of literature was conducted using key words in PubMed and CINAHL with preference for years 2015 to 2020. FINDINGS/RESULTS Several converging and interrelated factors including characteristics of the premature intestinal mucosa, gut ischemia, dysregulation of the microbiome, enteral feeding, and genetics create an environment where NEC is more likely to occur. IMPLICATIONS FOR PRACTICE To recognize and diagnose NEC in preterm infants, an understanding of underlying factors that create an optimal environment for disease acquisition in premature infants is essential. IMPLICATIONS FOR RESEARCH Prevention of NEC remains the most important strategy for decreasing morbidity and mortality. Multiple areas of potential study exist for NEC pathophysiology including those that consider how the factors discussed in this review are interrelated and how each particular pathway can be optimized to prevent the onset of NEC.
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47
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Gates A, Thompson AB, Marin T, Waller JL, Patel J, Stansfield BK. Novel multinutrient human milk-based human milk fortifier promotes growth and tolerance in premature infants. JPEN J Parenter Enteral Nutr 2021; 46:817-827. [PMID: 34370335 DOI: 10.1002/jpen.2249] [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: 11/09/2022]
Abstract
BACKGROUND The objective of this study was to determine whether human milk supplemented with a novel human milk-based human milk fortifier (Novel HMF), compared with a bovine milk-based HMF (Bovine HMF), supports preterm infant growth through 36 weeks' postmenstrual age (PMA). METHODS This single-center, prospective trial compared growth and nutrition outcomes of preterm infants provided a human milk-based diet (mother's own milk or donor milk) supplemented with a Novel HMF with historic controls provided Bovine HMF. Preterm infants with an estimated gestational age (EGA) between 23 and 33 weeks' PMA and birth weight between 750 and 1800 g were eligible for study inclusion. Weight, length, and head circumference (HC) were monitored weekly. The occurrence of late-onset sepsis, nil per os (NPO) days, necrotizing enterocolitis, metabolic acidosis, and serious adverse events were monitored. RESULTS Birth weight, length, HC, and EGA were similar between the Novel HMF (n = 37) and Bovine HMF (n = 49) groups. The days to regain birth weight was shorter in the Novel HMF group (9.4 ± 4.0 vs 11.4 ± 4.8, P = .0343), with similar weight gain (g/day) from birth to 36 weeks' PMA. Adjusted weight growth velocity (g/kg/day) was significantly higher in the Novel HMF group at 14 and 21 days but similar at 36 weeks' PMA. The Novel HMF group experienced fewer NPO days with a similar total number of feeding days. CONCLUSIONS A novel, multinutrient, human milk-based HMF is well tolerated and meets the nutrition needs of preterm infants.
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Affiliation(s)
- Amy Gates
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Amy B Thompson
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Terri Marin
- College of Nursing, Augusta University, Augusta, Georgia, USA
| | - Jennifer L Waller
- Division of Biostatistics and Data Science, Department of Population Health Sciences, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Jenny Patel
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Brian K Stansfield
- Division of Neonatology, Department of Pediatrics, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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48
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Wiechers C, Bernhard W, Goelz R, Poets CF, Franz AR. Optimizing Early Neonatal Nutrition and Dietary Pattern in Premature Infants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:7544. [PMID: 34300000 PMCID: PMC8304391 DOI: 10.3390/ijerph18147544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 12/18/2022]
Abstract
Providing adequate amounts of all essential macro- and micronutrients to preterm infants during the period of extraordinarily rapid growth from 24 to 34 weeks' postmenstrual age to achieve growth as in utero is challenging yet important, since early growth restriction and suboptimal neonatal nutrition have been identified as risk factors for adverse long-term development. Along with now well-established early parenteral nutrition, this review emphasizes enteral nutrition, which should be started early and rapidly increased. To minimize the side effects of parenteral nutrition and improve outcomes, early full enteral nutrition based on expressed mothers' own milk is an important goal. Although neonatal nutrition has improved in recent decades, existing knowledge about, for example, the optimal composition and duration of parenteral nutrition, practical aspects of the transition to full enteral nutrition or the need for breast milk fortification is limited and intensively discussed. Therefore, further prospective studies on various aspects of preterm infant feeding are needed, especially with regard to the effects on long-term outcomes. This narrative review will summarize currently available and still missing evidence regarding optimal preterm infant nutrition, with emphasis on enteral nutrition and early postnatal growth, and deduce a practical approach.
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Affiliation(s)
- Cornelia Wiechers
- Department of Neonatology, University Children′s Hospital, Eberhard Karls University, Calwerstr. 7, 72076 Tübingen, Germany; (W.B.); (R.G.); (C.F.P.); (A.R.F.)
| | - Wolfgang Bernhard
- Department of Neonatology, University Children′s Hospital, Eberhard Karls University, Calwerstr. 7, 72076 Tübingen, Germany; (W.B.); (R.G.); (C.F.P.); (A.R.F.)
| | - Rangmar Goelz
- Department of Neonatology, University Children′s Hospital, Eberhard Karls University, Calwerstr. 7, 72076 Tübingen, Germany; (W.B.); (R.G.); (C.F.P.); (A.R.F.)
| | - Christian F. Poets
- Department of Neonatology, University Children′s Hospital, Eberhard Karls University, Calwerstr. 7, 72076 Tübingen, Germany; (W.B.); (R.G.); (C.F.P.); (A.R.F.)
| | - Axel R. Franz
- Department of Neonatology, University Children′s Hospital, Eberhard Karls University, Calwerstr. 7, 72076 Tübingen, Germany; (W.B.); (R.G.); (C.F.P.); (A.R.F.)
- Center for Pediatric Clinical Studies, University Children′s Hospital, Eberhard Karls University, 72076 Tübingen, Germany
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49
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Hopperton KE, Pitino MA, Chouinard-Watkins R, Shama S, Sammut N, Bando N, Williams BA, Walton K, Kiss A, Unger SL, Bazinet RP, O'Connor DL. Determinants of fatty acid content and composition of human milk fed to infants born weighing <1250 g. Am J Clin Nutr 2021; 114:1523-1534. [PMID: 34254983 PMCID: PMC8488876 DOI: 10.1093/ajcn/nqab222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/10/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Infants born at very low birth weight (VLBW) are vulnerable to deficits in fatty acids (FAs) but little is known of factors that influence the intakes or composition of their human milk feeds. OBJECTIVES We aimed to identify sources of variability in the fat composition of human milk fed to VLBW infants and examine the impact of milk source (mother's own or donor) on fat and FA intakes. METHODS Serial samples of mother's milk (n = 476) and donor milk (n = 53) fed to infants born weighing <1250 g (n = 114 infants from 100 mothers) were collected [Optimizing Mothers' Milk for Preterm Infants (OptiMoM) randomized clinical trial]. Fat and FA were analyzed using a mid-infrared human milk analyzer and GC with flame ionization detection. RESULTS At full enteral feeding, donor milk is estimated to provide 1.3 g · kg-1 · d-1 less total fat than mature mother's milk (recommended intake: 4.8 g · kg-1 · d-1), and 5-9 mg · kg-1 · d-1 less DHA (22:6n-3) and arachidonic acid (20:4n-6) (estimated average requirement: 55-60 and 35-45 mg · kg-1 · d-1, respectively) than colostrum or transitional milk. Similar deficits were observed in measured intakes of a subset of OptiMoM infants. In multivariable-adjusted models, maternal ethnicity had medium to large [≥0.5 SD score (SDS)] effects on DHA, SFAs, and MUFAs. Mothers with prepregnancy BMI in overweight and obese categories had higher milk total fat (β: 0.35; 95% CI: 0.10, 0.61 and β: 0.46; 95% CI: 0.16, 0.77 SDS, respectively). Those with BMI ≥30 in addition had higher proportions of SFAs (β: 0.61; 95% CI: 0.33, 0.89 SDS) and lower DHA (β: -0.54; 95% CI: -0.89, -0.20 SDS). Other factors, such as gestational age and income, were also associated with FA composition. CONCLUSIONS The fat and FA content of human milk fed to VLBW infants is variable. Care must be taken to ensure fat and FA intakes meet recommendations, particularly when feeding a high proportion of donor milk.This trial was registered at clinicaltrials.gov as NCT02137473.
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Affiliation(s)
- Kathryn E Hopperton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael A Pitino
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | | | - Sara Shama
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Natasha Sammut
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Nicole Bando
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brock A Williams
- Department of Food, Nutrition and Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathryn Walton
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alex Kiss
- Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Evaluative and Clinical Sciences, Sunnybrook Research Institute and the Institute of Health Policy, Toronto, Ontario, Canada
| | - Sharon L Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada,Department of Paediatrics, Sinai Health System, Toronto, Ontario, Canada
| | - Richard P Bazinet
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
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50
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Bridges KM, Newkirk M, Byham-Gray L, Chung M. Comparative effectiveness of liquid human milk fortifiers: A systematic review and meta-analysis. Nutr Clin Pract 2021; 36:1144-1162. [PMID: 34101248 DOI: 10.1002/ncp.10663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/07/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the effectiveness of liquid human milk fortifiers (HMFs) derived from exclusive HM or hydrolyzed protein on growth, necrotizing enterocolitis (NEC), or late-onset sepsis in North American very low-birth-weight (VLBW) infants compared with powder HMFs (control). METHODS Prospective trials published between 2009 and 2020 were systematically reviewed, and meta-analysis was conducted by using a random-effects model. RESULTS Five studies were identified for up to 591 participants across 39 centers. Study treatments included whey or casein hydrolysate HMF and exclusive HM HMF. Infants fed whey or casein hydrolysate HMF had growth differences compared with the control. No differences were found across treatments in regard to NEC or sepsis. CONCLUSION Very low-quality evidence suggests greater linear growth in VLBW infants fed whey hydrolysate liquid HMF, as well as greater weight gain in those fed casein hydrolysate HMF, compared with the control. Additional prospective, multicenter randomized controlled trials are needed to confirm these estimates because of sparsity of evidence. There is insufficient evidence to support HMF decisions regarding NEC or late-onset sepsis prophylaxis.
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Affiliation(s)
- Kayla M Bridges
- Department of Clinical and Preventive Nutrition Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey, USA.,Neonatal Intensive Care Unit, Beaumont Children's Hospital, Royal Oak, Michigan, USA
| | - Melanie Newkirk
- Neonatal Intensive Care Unit, Johns Hopkins All Children's Hospital, Saint Petersburg, Florida, USA
| | - Laura Byham-Gray
- Department of Clinical and Preventive Nutrition Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Mei Chung
- Department of Clinical and Preventive Nutrition Sciences, Rutgers, The State University of New Jersey, Newark, New Jersey, USA.,Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
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