1
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Das S, McClintock T, Cormack BE, Bloomfield FH, Harding JE, Lin L. High protein intake on later outcomes in preterm children: a systematic review and meta-analysis. Pediatr Res 2024:10.1038/s41390-024-03296-z. [PMID: 38858504 DOI: 10.1038/s41390-024-03296-z] [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: 07/11/2023] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Appropriate protein intake is crucial for growth and development in children born preterm. We assessed the effects of high (HP) versus low protein (LP) intake on neurodevelopment, growth, and biochemical anomalies in these children. METHODS Randomised and quasi-randomised trials providing protein to children born preterm (<37 completed weeks of gestation) were searched following PRISMA guideline in three databases and four registers (PROSPERO registration CRD42022325659). Random-effects model was used for assessing the effects of HP (≥3.5 g/kg/d) vs. LP (<3.5 g/kg/d). RESULTS Data from forty-four studies (n = 5338) showed HP might slightly reduce the chance of survival without neurodisability at ≥12 months (four studies, 1109 children, relative risk [RR] 0.95 [95% CI 0.90, 1.01]; P = 0.13; low certainty evidence) and might increase risk of cognitive impairment at toddler age (two studies; 436 children; RR 1.36 [0.89, 2.09]; P = 0.16; low certainty evidence). At discharge or 36 weeks, HP intake might result in higher weight and greater head circumference z-scores. HP intake probably increased the risk of hypophosphatemia, hypercalcemia, refeeding syndrome and high blood urea, but reduced risk of hyperglycaemia. CONCLUSIONS HP intake for children born preterm may be harmful for neonatal metabolism and later neurodisability and has few short-term benefits for growth. IMPACT STATEMENT Planned high protein intake after birth for infants born preterm might be harmful for survival, neurodisability and metabolism during infancy and did not improve growth after the neonatal period. Protein intake ≥3.5 g/kg/d should not be recommended for children born preterm.
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Affiliation(s)
- Subhasish Das
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Nutrition Research Division, International Centre for Diarrhoeal Diseases Research, Bangladesh, Dhaka, Bangladesh
| | | | - Barbara E Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Newborn Services, Starship Child Health, Auckland, New Zealand
| | | | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Luling Lin
- Liggins Institute, University of Auckland, Auckland, New Zealand.
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2
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Brown LD, Stremming J, Robinson DT. Targeting optimal protein delivery in parenteral and enteral nutrition for preterm infants: a review of randomized, controlled trials. J Perinatol 2024; 44:603-611. [PMID: 38123801 DOI: 10.1038/s41372-023-01847-6] [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] [Received: 08/25/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
Close attention to nutritional management is essential for optimizing growth and neurodevelopment of the preterm infant. Protein intake and the protein to energy ratio are the main determinants of growth and body composition. Yet large, multi-center, randomized controlled trials are lacking to guide protein delivery for the preterm infant. Until these studies are pursued, smaller trials must be used to inform clinical practice. This review summarizes the randomized controlled trials that have been performed to test the impact of higher vs. lower protein delivery to the preterm infant. We consider the trials that varied protein delivery rates during parenteral and enteral phases of nutrition. Considerable heterogeneity exists across study designs. Still, cumulative evidence from these trials provides a framework for current recommendations for protein intake in the preterm infant.
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Affiliation(s)
- Laura D Brown
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Jane Stremming
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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3
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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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4
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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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5
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Sun J, Akıllıoğlu HG, Aasmul‐Olsen K, Ye Y, Lund P, Zhao X, Brunse A, Nielsen CF, Chatterton DEW, Sangild PT, Lund MN, Bering SB. Ultra-High Temperature Treatment and Storage of Infant Formula Induces Dietary Protein Modifications, Gut Dysfunction, and Inflammation in Preterm Pigs. Mol Nutr Food Res 2022; 66:e2200132. [PMID: 36052940 PMCID: PMC9786312 DOI: 10.1002/mnfr.202200132] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/10/2022] [Indexed: 12/30/2022]
Abstract
SCOPE Ready-to-feed liquid infant formula is increasingly used for preterm infants when human milk is unavailable. These formulas are sterilized by ultra-high temperature treatment, but heating and storage may reduce bioactivity and increase formation of Maillard reaction products with potential negative consequences for immature newborns. METHODS AND RESULTS Using preterm pigs as a model for sensitive newborn infants, the study tests the intestinal responses of feeding experimental liquid formula within 5 days. A pasteurized formula (PAST) with the same nutrient composition but less protein modifications serves as control to ultra-high temperature-treated formula without (UHT) and with prolonged storage (SUHT). Relative to PAST, UHT contains lower levels of lactoferrin and IgG. Additional storage (40 °C, 60 days, SUHT) reduces antimicrobial capacity and increases non-reducible protein aggregates and Maillard reaction products (up to 13-fold). Pigs fed SUHT have more diarrhea and show signs of intestinal inflammation (necrotizing enterocolitis) compared with pigs fed PAST and UHT. These clinical effects are accompanied by accumulation of Maillard reaction products, protein cross-links, and inflammatory responses in the gut. CONCLUSION The results demonstrate that feeding UHT infant formulas, particularly after prolonged storage, adversely affects gut maturation and function in preterm pigs used as a model of preterm infants.
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Affiliation(s)
- Jing Sun
- Comparative Pediatrics and NutritionDepartment of Veterinary and Animal SciencesUniversity of CopenhagenDyrlægevej 68Frederiksberg C1870Denmark
| | - Halise Gül Akıllıoğlu
- Department of Food ScienceUniversity of CopenhagenRolighedsvej 26Frederiksberg1958Denmark
| | - Karoline Aasmul‐Olsen
- Comparative Pediatrics and NutritionDepartment of Veterinary and Animal SciencesUniversity of CopenhagenDyrlægevej 68Frederiksberg C1870Denmark
| | - Yuhui Ye
- Department of Food ScienceUniversity of CopenhagenRolighedsvej 26Frederiksberg1958Denmark
| | - Pernille Lund
- Department of Food ScienceUniversity of CopenhagenRolighedsvej 26Frederiksberg1958Denmark
| | - Xiao Zhao
- Department of Food ScienceUniversity of CopenhagenRolighedsvej 26Frederiksberg1958Denmark
| | - Anders Brunse
- Comparative Pediatrics and NutritionDepartment of Veterinary and Animal SciencesUniversity of CopenhagenDyrlægevej 68Frederiksberg C1870Denmark
| | | | | | - Per Torp Sangild
- Comparative Pediatrics and NutritionDepartment of Veterinary and Animal SciencesUniversity of CopenhagenDyrlægevej 68Frederiksberg C1870Denmark,Department of Pediatrics and Adolescent MedicineRigshospitaletBlegdamsvej 9Copenhagen Ø2100Denmark,Hans Christian Andersen Children's HospitalJ. B. Winsløws Vej 4Odense C5000Denmark
| | - Marianne N. Lund
- Department of Food ScienceUniversity of CopenhagenRolighedsvej 26Frederiksberg1958Denmark,Department of Biomedical SciencesUniversity of CopenhagenBlegdamsvej 3BCopenhagen N2200Denmark
| | - Stine Brandt Bering
- Comparative Pediatrics and NutritionDepartment of Veterinary and Animal SciencesUniversity of CopenhagenDyrlægevej 68Frederiksberg C1870Denmark
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6
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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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7
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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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8
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Moreira-Monteagudo M, Leirós-Rodríguez R, Marqués-Sánchez P. Effects of Formula Milk Feeding in Premature Infants: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:150. [PMID: 35204871 PMCID: PMC8870637 DOI: 10.3390/children9020150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/19/2022] [Accepted: 01/22/2022] [Indexed: 12/24/2022]
Abstract
The preterm baby is born at a critical period for the growth and development of the gastrointestinal and neuromotor systems. Breast milk is the food of choice for infants during the first months of life, as it provides multiple short- and long-term benefits to preterm and sick newborns. Despite this, breastfeeding is often nutritionally insufficient, requiring the addition of fortifiers. In other cases, it is important to ensure the necessary nutrients and calories, which can be provided by formula milk or pasteurized and fortified donated human milk. However, the specific guidelines for the use of formula milk have not yet been determined. Therefore, a systematic search was considered necessary in order to identify the effects of feeding with formula milk in preterm infants. A systematic search in Scopus, Medline, Pubmed, Cinahl, ClinicalTrials and Web of Science with the terms Infant Formula and Infant Premature was conducted. A total of 18 articles were selected, of which, eight were experimental and ten were observational studies. Among the objectives of the analyzed investigations, we distinguished nine that compared the effects of feeding with formula milk, breast milk and donated human milk, five that evaluated the effects of different compositions of formula milk and/or fortifiers and four investigations that compared the effects of formula milk and donated human milk. In conclusion, when breast milk is insufficient or unavailable, formula milk is a good nutritional option, due to its higher caloric density and protein content. Nevertheless, the preterm infant's diet should incorporate breast milk to reduce the incidence of morbidities such as necrotizing enterocolitis and sepsis (related to hospital handling of fortifiers and formula milk).
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Affiliation(s)
- Marta Moreira-Monteagudo
- Faculty of Physical Therapy, Universidade de Vigo, Campus a Xunqueira, s/n, 36005 Pontevedra, Spain;
| | - Raquel Leirós-Rodríguez
- SALBIS Research Group, Faculty of Health Sciences, University of León, Astorga Ave. s/n, 24401 Ponferrada, Spain;
| | - Pilar Marqués-Sánchez
- SALBIS Research Group, Faculty of Health Sciences, University of León, Astorga Ave. s/n, 24401 Ponferrada, Spain;
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9
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Lin YF, Lin WH, Lin SH, Zhang QL, Chen Q, Zheng YR. Using Human Milk Fortifiers to Improve the Preoperative Nutritional Status of Infants With Non-restricted Ventricular Septal Defect. Front Pediatr 2022; 10:900012. [PMID: 35832586 PMCID: PMC9271765 DOI: 10.3389/fped.2022.900012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To explore the effects of human milk fortifier (HMF) on improving the preoperative nutritional status of infants with non-restricted ventricular septal defect (VSD). METHODS A prospective randomized controlled study was conducted in a provincial hospital in China. Participants were randomly divided into an intervention group (n = 29) and a control group (n = 29). HMFs were added proportionally to the infants' feeds in the intervention group based on breastfeeding status, and the infants in the control group received exclusive breastfeeding as needed. The nutritional status of the two groups was compared 1 month after the intervention. RESULTS Compared with the control group, the weight, head circumference, height, albumin level, and prealbumin level of the human milk fortifier group were significantly higher 1 month after the intervention (p < 0.05). The STRONGkids score of the HMF group was significantly lower than that of the non-HMF group (p < 0.05). There was no significant difference in pneumonia, liver insufficiency, feeding intolerance, or jaundice between the two groups. CONCLUSION The addition of HMFs based on the breastfeeding status of infants with non-restricted VSD can improve the preoperative nutritional status and does not increase the incidence of gastrointestinal complications. CLINICAL TRIAL REGISTRATION http://www.chictr.org.cn/index.aspx, identifier: ChiCTR2000041135.
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Affiliation(s)
- Yun-Feng Lin
- Department of Neonatology, Fujian Branch of Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, Fuzhou, China.,Department of Neonatology, Fujian Children's Hospital, Fuzhou, China.,Department of Neonatology, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Hao Lin
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shi-Hao Lin
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qi-Liang Zhang
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yi-Rong Zheng
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Children's Hospital, Fuzhou, China.,Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics and Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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10
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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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11
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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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12
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Schulz EV, Wagner CL. Powdered to Liquid Human Milk Fortifiers in the Preterm Infant. Neoreviews 2021; 22:e360-e369. [PMID: 34074641 DOI: 10.1542/neo.22-6-e360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In preterm infants, the goal of aggressive extrauterine nutritional management is to mimic in utero growth and nutrient accretion. Over the latter half of the 20th century, nutritional optimization through the practice of fortifying human milk rose to practice with increased survival rates in preterm infants of younger gestational age. The quest for optimal preterm fortification and nutrition remains a contentious area of debate. This review aims to summarize the historical perspectives of human milk fortification as well as the current literature advocating for the use of liquid human milk fortifiers in enterally fed premature infants.
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Affiliation(s)
- Elizabeth V Schulz
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Carol L Wagner
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC
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13
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Fenton TR, Griffin IJ, Groh-Wargo S, Gura K, Martin CR, Taylor SN, Rozga M, Moloney L. Very Low Birthweight Preterm Infants: A 2020 Evidence Analysis Center Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2021; 122:182-206. [PMID: 33820749 DOI: 10.1016/j.jand.2021.02.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/24/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Tanis R Fenton
- Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB; Canada Nutrition Services, Alberta Health Services, Calgary, AB; Community Health Sciences, Nutrition Services, Alberta Health Services, Calgary, Canada
| | - Ian J Griffin
- Clinical and Translational Research, Biomedical Research Institute of New Jersey, Cedar Knolls, NJ; Department of Pediatrics, Morristown Medical Center, Morristown, NJ
| | - Sharon Groh-Wargo
- Departments of Nutrition and Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland, OH
| | - Kathleen Gura
- Clinical Research Program, Department of Pharmacy, Boston Children's Hospital, Boston, MA
| | - Camilia R Martin
- Department of Neonatology, Director for Cross-Disciplinary Research Partnerships, Division of Translational Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah N Taylor
- Department of Pediatrics, Yale School of Medicine, 430 Congress Avenue, New Haven, CT
| | - Mary Rozga
- Academy of Nutrition and Dietetics, Evidence Analysis Center, Chicago, IL
| | - Lisa Moloney
- Academy of Nutrition and Dietetics, Evidence Analysis Center, Chicago, IL.
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Abstract
Human milk is the preferred enteral diet for preterm infants. It provides macronutrients, micronutrients, and bioactive factors that support physical growth and neurodevelopment. Challenges of the human milk diet include the variability in its composition and a need for fortification to mirror placental nutrient delivery and prevent extrauterine growth restriction. Various strategies exist to attain target nutrient provision and optimize growth, including leveraging new technology for point-of-care human milk analysis. When maternal milk is unavailable or in short supply, pasteurized donor human milk is the preferred alternative. Infants fed donor milk may have slower weight gain than those fed exclusively maternal milk or formula, whereas infants fed fortified maternal milk have similar weight gain to preterm formula-fed infants. Future directions include more rigorous characterization of the variation in human milk, further investigation of the clinical benefits of non-nutrient bioactive factors in milk, and novel approaches to optimize fortification.
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Affiliation(s)
- Margaret L Ong
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Latheef F, Wahlgren H, Lilja HE, Diderholm B, Paulsson M. The Risk of Necrotizing Enterocolitis following the Administration of Hyperosmolar Enteral Medications to Extremely Preterm Infants. Neonatology 2021; 118:73-79. [PMID: 33567438 DOI: 10.1159/000513169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Necrotizing enterocolitis (NEC) is a disease predominantly affecting preterm infants. The administration of hyperosmolar solutions could lead to the development of NEC. The objective of this study was to measure the osmolality of enteral medications used in clinical practice and to assess the risk of NEC following exposure to hyperosmolar medications. METHODS A retrospective cohort study in extremely preterm infants (gestational age <28 weeks) born between 2010 and 2016 at a tertiary neonatal intensive care unit in Sweden. 465 infants were identified via the Swedish Neonatal Quality register. Data relating to enteral administrations received during a two-week period were collected from the medical records. The osmolalities of medications were measured using an osmometer. Logistic regression was used to calculate the odds ratio of developing NEC. RESULTS A total of 253 patients met the inclusion criteria. The osmolalities of 5 commonly used medications significantly exceeded the recommended limit of 450 mOsm/kg set by the American Academy of Paediatrics (AAP). Most patients (94%) received at least one hyperosmolar medication. No significant risk of developing NEC could be found. CONCLUSION The medications used in clinical practice can significantly exceed the limit set by the AAP. This study does not indicate an increased risk of developing NEC in extremely preterm infants following exposure to hyperosmolar medications. Further studies in larger cohorts are needed to determine the specific cut-off level of osmolality in relation to the pathogenesis of NEC.
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Affiliation(s)
- Faiza Latheef
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden, .,Department of Hospital Pharmacy, Region Västmanland, Västerås, Sweden,
| | - Hanna Wahlgren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Barbro Diderholm
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Mattias Paulsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Gao C, Miller J, Collins CT, Rumbold AR. Comparison of different protein concentrations of human milk fortifier for promoting growth and neurological development in preterm infants. Cochrane Database Syst Rev 2020; 11:CD007090. [PMID: 33215474 PMCID: PMC8092673 DOI: 10.1002/14651858.cd007090.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Human milk alone may provide inadequate amounts of protein to meet the growth requirements of preterm infants because of restrictions in the amount of fluid they can tolerate. It has become common practice to feed preterm infants with breast milk fortified with protein and other nutrients but there is debate about the optimal concentration of protein in commercially available fortifiers. OBJECTIVES To compare the effects of different protein concentrations in human milk fortifier, fed to preterm infants, on growth and neurodevelopment. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 8), Ovid MEDLINE and CINAHL on 15 August 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included all published and unpublished randomised, quasi-randomised and cluster-randomised trials comparing two different concentrations of protein in human milk fortifier. We included preterm infants (less than 37 weeks' gestational age). Participants may have been exclusively fed human milk or have been supplemented with formula. The concentration of protein was classified as low (< 1g protein/100 mL expressed breast milk (EBM)), moderate (≥ 1g to < 1.4g protein/100 mL EBM) or high (≥ 1.4g protein/100 mL EBM). We excluded trials that compared two protein concentrations that fell within the same category. DATA COLLECTION AND ANALYSIS We undertook data collection and analyses using the standard methods of Cochrane Neonatal. Two review authors independently evaluated trials. Primary outcomes included growth, neurodevelopmental outcome and mortality. Data were synthesised using risk ratios (RR), risk differences and mean differences (MD), with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We identified nine trials involving 861 infants. There is one trial awaiting classification, and nine ongoing trials. The trials were mostly conducted in infants born < 32 weeks' gestational age or < 1500 g birthweight, or both. All used a fortifier derived from bovine milk. Two trials fed infants exclusively with mother's own milk, three trials gave supplementary feeds with donor human milk and four trials supplemented with preterm infant formula. Overall, trials were small but generally at low or unclear risk of bias. High versus moderate protein concentration of human milk fortifier There was moderate certainty evidence that a high protein concentration likely increased in-hospital weight gain compared to moderate concentration of human milk fortifier (MD 0.66 g/kg/day, 95% CI 0.51 to 0.82; trials = 6, participants = 606). The evidence was very uncertain about the effect of high versus moderate protein concentration on length gain (MD 0.01 cm/week, 95% CI -0.01 to 0.03; trials = 5, participants = 547; very low certainty evidence) and head circumference gain (MD 0.00 cm/week, 95% CI -0.01 to 0.02; trials = 5, participants = 549; very low certainty evidence). Only one trial reported neonatal mortality, with no deaths in either group (participants = 45). Moderate versus low protein concentration of human milk fortifier A moderate versus low protein concentration fortifier may increase weight gain (MD 2.08 g/kg/day, 95% CI 0.38 to 3.77; trials = 2, participants = 176; very low certainty evidence) with little to no effect on head circumference gain (MD 0.13 cm/week, 95% CI 0.00 to 0.26; I² = 85%; trials = 3, participants = 217; very low certainty evidence), but the evidence is very uncertain. There was low certainty evidence that a moderate protein concentration may increase length gain (MD 0.09 cm/week, 95% CI 0.05 to 0.14; trials = 3, participants = 217). Only one trial reported mortality and found no difference between groups (RR 0.48, 95% CI 0.05 to 5.17; participants = 112). No trials reported long term growth or neurodevelopmental outcomes including cerebral palsy and developmental delay. AUTHORS' CONCLUSIONS Feeding preterm infants with a human milk fortifier containing high amounts of protein (≥ 1.4g/100 mL EBM) compared with a fortifier containing moderate protein concentration (≥ 1 g to < 1.4 g/100 mL EBM) results in small increases in weight gain during the neonatal admission. There may also be small increases in weight and length gain when infants are fed a fortifier containing moderate versus low protein concentration (< 1 g protein/100 mL EBM). The certainty of this evidence is very low to moderate; therefore, results may change when the findings of ongoing studies are available. There is insufficient evidence to assess the impact of protein concentration on adverse effects or long term outcomes such as neurodevelopment. Further trials are needed to determine whether modest increases in weight gain observed with higher protein concentration fortifiers are associated with benefits or harms to long term growth and neurodevelopment.
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Affiliation(s)
- Chang Gao
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jacqueline Miller
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Carmel T Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
- Discipline of Paediatrics, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Alice R Rumbold
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
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[Clinical guidelines for the diagnosis and treatment of feeding intolerance in preterm infants (2020)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 33059799 PMCID: PMC7568993 DOI: 10.7499/j.issn.1008-8830.2008132] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Feeding intolerance (FI) is one of the most common clinical problems in preterm infant and often leads to the delay in reaching total enteral nutrition and prolonged hospital stay. The prevention and treatment of FI are of great significance in improving the survival rate of preterm infants. With reference to current evidence in China and overseas, the clinical guidelines for the diagnosis and treatment of FI in preterm infants were developed based on Grading of Recommendations Assessment, Development and Evaluation (GRADE), so as to help neonatal pediatricians, nursing staff, and nutritionists with early identification and standard management of FI in preterm infants.
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中国医师协会新生儿科医师分会循证专业委员会. [Clinical guidelines for the diagnosis and treatment of feeding intolerance in preterm infants (2020)]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:1047-1055. [PMID: 33059799 PMCID: PMC7568993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/03/2020] [Indexed: 03/31/2024]
Abstract
Feeding intolerance (FI) is one of the most common clinical problems in preterm infant and often leads to the delay in reaching total enteral nutrition and prolonged hospital stay. The prevention and treatment of FI are of great significance in improving the survival rate of preterm infants. With reference to current evidence in China and overseas, the clinical guidelines for the diagnosis and treatment of FI in preterm infants were developed based on Grading of Recommendations Assessment, Development and Evaluation (GRADE), so as to help neonatal pediatricians, nursing staff, and nutritionists with early identification and standard management of FI in preterm infants.
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Affiliation(s)
- 中国医师协会新生儿科医师分会循证专业委员会
- 唐军, 女, 教授, 四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室, ; 封志纯, 男, 教授, 解放军总医院第七医学中心附属八一儿童医院NICU, ; 母得志, 男, 教授, 四川大学华西第二医院儿科/出生缺陷与相关妇儿疾病教育部重点实验室,
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Johnson TJ, Berenz A, Wicks J, Esquerra-Zwiers A, Sulo KS, Gross ME, Szotek J, Meier P, Patel AL. The Economic Impact of Donor Milk in the Neonatal Intensive Care Unit. J Pediatr 2020; 224:57-65.e4. [PMID: 32682581 PMCID: PMC7484385 DOI: 10.1016/j.jpeds.2020.04.044] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/17/2020] [Accepted: 04/16/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the cost-effectiveness of mother's own milk supplemented with donor milk vs mother's own milk supplemented with formula for infants of very low birth weight in the neonatal intensive care unit (NICU). STUDY DESIGN A retrospective analysis of 319 infants with very low birth weight born before (January 2011-December 2012, mother's own milk + formula, n = 150) and after (April 2013-March 2015, mother's own milk + donor milk, n = 169) a donor milk program was implemented in the NICU. Data were retrieved from a prospectively collected research database, the hospital's electronic medical record, and the hospital's cost accounting system. Costs included feedings and other NICU costs incurred by the hospital. A generalized linear regression model was constructed to evaluate the impact of feeding era on NICU total costs, controlling for neonatal and sociodemographic risk factors and morbidities. An incremental cost-effectiveness ratio was calculated for each morbidity that differed significantly between feeding eras. RESULTS Infants receiving mother's own milk + donor milk had a lower incidence of necrotizing enterocolitis (NEC) than infants receiving mother's own milk + formula (1.8% vs 6.0%, P = .048). Total (hospital + feeding) median costs (2016 USD) were $169 555 for mother's own milk + donor milk and $185 740 for mother's own milk + formula (P = .331), with median feeding costs of $1317 and $936, respectively (P < .001). Mother's own milk + donor milk was associated with $15 555 lower costs per infant (P = .045) and saved $1812 per percentage point decrease in NEC incidence. CONCLUSIONS The additional cost of a donor milk program was small compared with the cost of a NICU hospitalization. After its introduction, the NEC incidence was significantly lower with small cost savings per case. We speculate that NICUs with greater NEC rates may have greater cost savings.
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Affiliation(s)
- Tricia J. Johnson
- Department of Health Systems Management, Rush University, Chicago, IL, USA
| | - Andrew Berenz
- Department of Pediatrics, Section of Neonatology, Rush University Medical Center, Chicago, IL, USA
| | - Jennifer Wicks
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Kelly S. Sulo
- Department of Pediatrics, Section of Neonatology, Rush University Medical Center, Chicago, IL, USA
| | - Megan E. Gross
- Department of Pediatrics, Section of Neonatology, Rush University Medical Center, Chicago, IL, USA
| | | | - Paula Meier
- Department of Pediatrics, Section of Neonatology, Rush University Medical Center, Chicago, IL, USA,College of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Aloka L. Patel
- Department of Pediatrics, Section of Neonatology, Rush University Medical Center, Chicago, IL, USA
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Rana R, McGrath M, Gupta P, Thakur E, Kerac M. Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review. Nutrients 2020; 12:E2044. [PMID: 32660020 PMCID: PMC7400880 DOI: 10.3390/nu12072044] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/17/2022] Open
Abstract
(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.
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Affiliation(s)
- Ritu Rana
- Indian Institute of Public Health Gandhinagar, Gujarat 382042, India; (P.G.); (E.T.)
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
- Nutrition Research Advisor (MAMI), GOAL Global, A96 C7W7 Dublin, Ireland
| | | | - Paridhi Gupta
- Indian Institute of Public Health Gandhinagar, Gujarat 382042, India; (P.G.); (E.T.)
| | - Ekta Thakur
- Indian Institute of Public Health Gandhinagar, Gujarat 382042, India; (P.G.); (E.T.)
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK;
- Centre for Maternal, Adolescent, Reproductive & Child Health (MARCH), London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
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21
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Brown JV, Lin L, Embleton ND, Harding JE, McGuire W. Multi-nutrient fortification of human milk for preterm infants. Cochrane Database Syst Rev 2020; 6:CD000343. [PMID: 35658821 PMCID: PMC7268980 DOI: 10.1002/14651858.cd000343.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Human breast milk-fed preterm infants can accumulate nutrient deficits leading to extrauterine growth restriction. Feeding preterm infants with multi-nutrient fortified human milk could increase nutrient accretion and growth rates and improve neurodevelopmental outcomes. Concern exists, however, that multi-nutrient fortifiers are associated with adverse events such as feed intolerance and necrotising enterocolitis. OBJECTIVES To determine whether multi-nutrient fortified human milk, compared with unfortified human milk, affects important outcomes (including growth rate and neurodevelopment) of preterm infants without increasing the risk of adverse effects (such as feed intolerance and necrotising enterocolitis). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), MEDLINE via PubMed (1966 to 26 September 2019), Embase (1980 to 26 September 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 26 September 2019). We searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that compared feeding preterm infants with multi-nutrient (protein and energy plus minerals, vitamins, or other nutrients) fortified human breast milk versus unfortified (no added protein or energy) breast milk. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratios (RRs), risk differences, and mean differences (MDs). We assessed the certainty of the body of evidence at the outcome level using "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) methods. MAIN RESULTS We identified 18 trials in which a total of 1456 preterm infants participated. These trials were generally small and methodologically weak. Meta-analyses provided low- to moderate-certainty evidence showing that multi-nutrient fortification of human milk increases in-hospital rate of weight gain (MD 1.76 g/kg/d, 95% confidence interval (CI) 1.30 to 2.22), body length (MD 0.11 cm/week, 95% CI 0.08 to 0.15), or head circumference (MD 0.06 cm/week, 95% CI 0.03 to 0.08) among preterm infants. Few data on growth and developmental outcomes assessed beyond infancy are available, and these do not show effects of multi-nutrient fortification. The data do not suggest other benefits or harms and provide low-certainty evidence suggesting effects of multi-nutrient fortification on the risk of necrotising enterocolitis in preterm infants (typical RR 1.37, 95% CI 0.72 to 2.63; 13 studies, 1110 infants). AUTHORS' CONCLUSIONS Feeding preterm infants with multi-nutrient fortified human breast milk compared with unfortified human breast milk is associated with modest increases in in-hospital growth rates. Evidence is insufficient to show whether multi-nutrient fortification has any effect on long-term growth or neurodevelopment.
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Affiliation(s)
- Jennifer Ve Brown
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Luling Lin
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Nicholas D Embleton
- Newcastle Neonatal Service, Newcastle Hospitals NHS Foundation Trust and University of Newcastle, Newcastle upon Tyne, UK
| | - Jane E Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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Premkumar MH, Massieu LA, Anderson DM, Gokulakrishnan G. Human Milk Supplements: Principles, Practices, and Current Controversies. Clin Perinatol 2020; 47:355-368. [PMID: 32439116 DOI: 10.1016/j.clp.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Human milk is the most optimal source of nutrition for preterm and term infants. However, in most preterm infants, breast milk fails to meet the energy needs of the newborn infant. Overwhelming evidence supports the fortification of breast milk in preterm infants to facilitate better short-term outcomes. Several single-nutrient and multinutrient breast milk supplements and fortifiers are used to improve the macronutrient and micronutrient content of breast milk. An individualized fortification strategy has the potential to offer better results compared with standard fortification strategies. Human milk-derived fortification is promising, but the benefits in exclusively human milk-fed preterm infants are unclear.
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Affiliation(s)
- Muralidhar H Premkumar
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | | | - Diane M Anderson
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Ganga Gokulakrishnan
- Division of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Lucas A, Boscardin J, Abrams SA. Preterm Infants Fed Cow's Milk-Derived Fortifier Had Adverse Outcomes Despite a Base Diet of Only Mother's Own Milk. Breastfeed Med 2020; 15:297-303. [PMID: 32239968 PMCID: PMC7232708 DOI: 10.1089/bfm.2019.0133] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: An increasingly common practice is to feed preterm infants a base diet comprising only human milk (HM), usually fortified with a cow's milk (CM)-derived fortifier (CMDF). We evaluated the safety of CMDF in a diet of 100% mother's own milk (MOM) against a HM-derived fortifier (HMDF). To date, this has received little research attention. Study Design: We reanalyzed a 12-center randomized trial, originally comparing exclusive HM feeding, including MOM, donor milk (DM), and HMDF, versus a CM exposed group fed MOM, preterm formula (PTF), and CMDF1. However, for the current study, we performed a subgroup analysis (n = 114) selecting only infants receiving 100% MOM base diet plus fortification, and fed no DM or PTF. This allowed for an isolated comparison of fortifier type: CMDF versus HMDF to evaluate the primary outcomes: necrotizing enterocolitis (NEC) and a severe morbidity index of NEC surgery or death; and several secondary outcomes. Results: CMDF and HMDF groups had similar baseline characteristics. CMDF was associated with higher risk of NEC; relative risk (RR) 4.2 (p = 0.038), NEC surgery or death (RR 5.1, p = 0.014); and reduced head circumference gain (p = 0.04). Conclusions: In neonates fed, as currently recommended with a MOM-based diet, the safety of CMDF when compared to HMDF has been little researched. We conclude that available evidence points to an increase in adverse outcomes with CMDF, including NEC and severe morbidity comprising NEC surgery or death.
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Affiliation(s)
- Alan Lucas
- Institute of Child Health, University College, London, United Kingdom
| | - John Boscardin
- Department of Medicine and University of California, San Francisco, California, USA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California, USA
| | - Steven A. Abrams
- Department of Pediatrics, Dell Medical School, The University of Texas, Austin, Texas, USA
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Darrow CJ, Bai-Tong SS, Kang EM, Thompson CL, Walsh MC. Use of acidified versus non-acidified liquid human milk fortifier in very low birth weight infants: A retrospective comparison of clinical outcomes. J Neonatal Perinatal Med 2020; 13:71-79. [PMID: 31771077 DOI: 10.3233/npm-180188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Use of human milk is recommended for low birth weight (VLBW) infants, but must be safety fortified with sterile liquid fortifiers to be nutritionally sufficient. Due to clinical concern for a high incidence of metabolic acidosis among VLBW infants fed human milk fortified with acidified liquid human milk fortifier (ALHMF), we aimed to retrospectively compare the outcomes of infants fed ALHMF to those fortified with non-acidified liquid HMF (NLHMF). METHODS Medical records of VLBW neonates admitted to our institution's neonatal intensive care unit from July 1st, 2013 to June 30th, 2014 were reviewed. 129 patients were included in the study, 61 of which received ALHMF and 68 received NLHMF. Metabolic, nutritional and clinical outcomes, including growth, were compared between the two cohorts. RESULTS Of the infants who received ALHMF, 70.5% developed metabolic acidosis compared to only 11.8% in the NLHMF group (p < 0.001). In addition, infants who received NLHMF had a 10% greater growth velocity during the period of fortification (p = 0.01). During the full course of hospitalization, no difference in growth velocity was seen between the groups and greater length gains were found in the ALHMF group. CONCLUSIONS The use of human milk fortified with ALHMF was associated with an increased incidence of metabolic acidosis and poorer growth during the period of fortification when compared to NLHMF-fortified feedings. These growth effects were not apparent when the duration of hospitalization was considered, suggesting a need for further study to better characterize the advantages and disadvantages of each fortifier.
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Affiliation(s)
- C J Darrow
- Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, MD, USA
- 18th Medical Operations Squadron, Kadena AB, Okinawa, Japan
| | - S S Bai-Tong
- Division of Neonatology, UC San Diego Medical Center and Rady Children's Hospital, San Diego, CA, USA
| | - E M Kang
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - C L Thompson
- Department of Nutrition, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - M C Walsh
- Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
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Abstract
Human milk provides not only ideal nutrition for infant development but also immunologic factors to protect from infection and inflammation. For the newborn preterm infant, the natural delivery of milk is not attainable, and instead pumped maternal milk, donor human milk, and human milk fortification are mainstays of clinical care. Current research demonstrates a decreased risk of necrotizing enterocolitis with maternal milk and donor human milk when individually compared to formula and with a complete human milk diet of maternal milk supplemented with donor human milk. The incidence of severe retinopathy of prematurity is decreased with an exclusive human milk diet, and this decrease is more pronounced with human milk-based compared to bovine milk-based human milk fortifier. The incidence of other morbidities such as late-onset sepsis and bronchopulmonary dysplasia is decreased with higher dose of human milk though significant differences are not apparent in exclusive human milk diet studies.
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Affiliation(s)
- Sarah N Taylor
- Yale School of Medicine, PO Box 208064, New Haven, Connecticut, 06520-8064, USA.
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26
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Ellis ZM, Tan HSG, Embleton ND, Sangild PT, van Elburg RM. Milk feed osmolality and adverse events in newborn infants and animals: a systematic review. Arch Dis Child Fetal Neonatal Ed 2019; 104:F333-F340. [PMID: 30523072 PMCID: PMC6764252 DOI: 10.1136/archdischild-2018-315946] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/12/2018] [Accepted: 11/05/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND High feed osmolality (or osmolarity) is often suggested to be linked with adverse gastrointestinal events in preterm infants. AIM To systematically review the literature on milk feed osmolality and adverse gastrointestinal events in newborn and low birthweight infants and animals. METHODS MEDLINE, Embase, CAB Abstracts, Current Contents, BIOSIS Previews and SciSearch were searched from inception to May 2018 to identify potentially relevant studies. INCLUSION CRITERIA randomised controlled or observational studies of newborn and low birthweight infants or animals investigating the effects of milk-based feeds with different osmolalities. Only full-text, English-language papers were included. RESULTS Ten human and six animal studies met the inclusion criteria. Of human studies, seven reported no differences in adverse events with varying feed osmolalities; one reported delayed gastric emptying with feed osmolarity of 539 mOsm/L compared with lower levels; one reported higher necrotising enterocolitis (NEC) incidence with feed osmolarity of 650 mOsm/L compared with 359 mOsm/L; one found higher NEC incidence with the lowest feed osmolality (326 mOsm/kg compared with 385 mOsm/kg). Of animal studies, two reported delayed gastric emptying with feed osmolarity >624 mOsm/L, one reported decreased survival due to dehydration with dietary osmolarities ≥765 mOsmol/L and none reported increased NEC incidence with differing feed osmolalities. No clear mechanisms were found, and diet composition differences limited the interpretations regarding the independent impact of osmolality. CONCLUSIONS There is no consistent evidence that differences in feed osmolality in the range 300-500 mOsm/kg are associated with adverse gastrointestinal symptoms in neonates.
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Affiliation(s)
| | | | - Nicolas D Embleton
- Newcastle Neonatal Service, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle, UK
| | - Per Torp Sangild
- Section of Comparative Pediatrics and Nutrition, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,Rigshospitalet, Copenhagen, Denmark, Department of Pediatrics and Adolescent Medicine, Copenhagen, Denmark
| | - Ruurd M van Elburg
- Danone Nutricia Research, Utrecht, The Netherlands,Emma Children’s Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Schanler RJ, Groh-Wargo SL, Barrett-Reis B, White RD, Ahmad KA, Oliver J, Baggs G, Williams L, Adamkin D. Improved Outcomes in Preterm Infants Fed a Nonacidified Liquid Human Milk Fortifier: A Prospective Randomized Clinical Trial. J Pediatr 2018; 202:31-37.e2. [PMID: 30195561 DOI: 10.1016/j.jpeds.2018.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 06/26/2018] [Accepted: 07/02/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To compare growth, feeding tolerance, and clinical and biochemical evaluations in human milk-fed preterm infants randomized to receive either an acidified or a nonacidified liquid human milk fortifier. STUDY DESIGN This prospective, controlled, parallel, multicenter growth and tolerance study included 164 preterm infants (≤32 weeks of gestation, birth weight 700-1500 g) who were randomized to acidified or nonacidified liquid human milk fortifier from study day 1, the first day of fortification, through study day 29 or until hospital discharge. RESULTS There was no difference in the primary outcome of weight gain from study days 1 to 29 (acidified liquid human milk fortifier, 16.4 ± 0.4 g/kg/day; nonacidified liquid human milk fortifier, 16.9 ± 0.4 g/kg/day). However, in both the intention-to-treat and the protocol evaluable analyses, infants fed nonacidified liquid human milk fortifier had significantly greater weight gain from study days 1 to 15 (17.9 g/kg/day vs 15.2 g/kg/day; P = .001). Infants fed with acidified liquid human milk fortifier received more protein (4.26 vs g/kg/day 4.11 g/kg/day, P = .0099) yet had lower blood urea nitrogen values (P = .010). The group fed acidified liquid human milk fortifier had more vomiting (10.3% vs 2.4%; P = .018), gastric residuals (12.8% vs 3.7%; P = .022), and metabolic acidosis (27% vs 5%; P < .001) in the intention-to-treat analysis and more abdominal distension (14.0% vs 1.7%; P = .015) in the protocol evaluable analysis. CONCLUSIONS Infants fed an acidified liquid human milk fortifier had higher rates of metabolic acidosis and poor feeding tolerance compared with infants fed a nonacidified liquid human milk fortifier. Initial weight gain was poorer with the acidified liquid human milk fortifier. TRIAL REGISTRATION ClinicalTrials.gov: NCT02307760.
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Affiliation(s)
- Richard J Schanler
- Neonatal-Perinatal Medicine, Cohen Children's Medical Center, New Hyde Park, NY.
| | | | | | - Robert D White
- Pediatrix Medical Group, Memorial Hospital of South Bend, South Bend, IN
| | - Kaashif A Ahmad
- Baylor College of Medicine, Pediatrix Medical Group, North Central Baptist Hospital, San Antonio, TX
| | | | | | | | - David Adamkin
- Department of Pediatrics, University of Louisville, Louisville, KY
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Shakeel F, Newkirk M, Altoubah T, Martinez D, Amankwah EK. Tolerance of Hydrolyzed Liquid Protein Fortified Human Milk and Effect on Growth in Premature Infants. Nutr Clin Pract 2018; 34:450-458. [PMID: 30320413 DOI: 10.1002/ncp.10193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND We evaluated tolerance of hydrolyzed liquid protein (LP) supplement added to fortified human milk (HM) to optimize protein intake in preterm infants. METHODS A prospective observational study of 31 subjects compared with 31 historic controls, receiving mothers own milk (MOM) and/or donor milk (DM) to assess LP tolerance, growth, and risk for morbidities was conducted. Milk was analyzed for nutrient content. Feeding intolerance, defined as cessation of feedings for ≥48 hours, abdominal distension and/or residuals, necrotizing enterocolitis (NEC), and metabolic acidosis were used to assess safety, while weight and head circumference (HC) were used to evaluate growth. RESULTS LP added to powder-fortified HM had no impact on feeding intolerance and NEC. Biochemical parameters showed no metabolic acidosis: blood urea nitrogen levels (first week: median, 13 mg/dL; interquartile range [IQR], 9-16; last week: median, 13 mg/dL; IQR, 10.3-14; P = .94), bicarbonate levels (first week: median, 26.3 mEq/L; IQR, 24-28; last week: median, 28 mEq/L; IQR, 26.3-29.8; P = .10), and pH levels (first week: median, 7.4; IQR, 7.3-7.4; last week: median, 7.4; IQR, 7.37-7.40; P = .5). Weight and HC were not statistically significant. HM analysis showed lower protein and caloric content, respectively (MOM: 0.88 vs DM: 0.77 g/100 mL; P < .0001 and MOM: 18.68 vs DM: 17.96 kcal/oz; P = .02). CONCLUSIONS Hydrolyzed LP is well tolerated in preterm infants with no difference in growth rates. Clinicians should focus on the need to maximize both protein and energy to optimize growth.
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Affiliation(s)
- Fauzia Shakeel
- Department of Neonatology, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Melanie Newkirk
- Department of Nutritional Services, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Taymeyah Altoubah
- Department of Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Denise Martinez
- Department of Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Ernest K Amankwah
- Department of Clinical and Translational Research Organization, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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29
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Evaluation of A Concentrated Preterm Formula as a Liquid Human Milk Fortifier in Preterm Babies at Increased Risk of Feed Intolerance. Nutrients 2018; 10:nu10101433. [PMID: 30287775 PMCID: PMC6213423 DOI: 10.3390/nu10101433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/29/2018] [Accepted: 10/02/2018] [Indexed: 11/25/2022] Open
Abstract
There are concerns around safety and tolerance of powder human milk fortifiers to optimize nutrition in preterm infants. The purpose of this study was to evaluate the tolerance and safety of a concentrated preterm formula (CPF) as a liquid human milk fortifier (HMF) for premature infants at increased risk of feeding intolerance. We prospectively enrolled preterm infants over an 18-month period, for whom a clinical decision had been made to add CPF to human milk due to concerns regarding tolerance of powder HMF. Data on feed tolerance, anthropometry, and serum biochemistry values were recorded. Serious adverse events, such as mortality, necrotizing enterocolitis (NEC), and sepsis, were monitored. A total of 29 babies received CPF fortified milk during the study period. The most common indication for starting CPF was previous intolerance to powder HMF. Feeding intolerance was noted in 4 infants on CPF. The growth velocity of infants was satisfactory (15.9 g/kg/day) after addition of CPF to feeds. The use of CPF as a fortifier in preterm babies considered at increased risk for feed intolerance seems well tolerated and facilitates adequate growth. Under close nutrition monitoring, this provides an additional option for human milk fortification in this challenging subgroup of preterm babies, especially in settings with limited human milk fortifier options.
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30
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Reid J, Makrides M, McPhee AJ, Stark MJ, Miller J, Collins CT. The Effect of Increasing the Protein Content of Human Milk Fortifier to 1.8 g/100 mL on Growth in Preterm Infants: A Randomised Controlled Trial. Nutrients 2018; 10:nu10050634. [PMID: 29772833 PMCID: PMC5986513 DOI: 10.3390/nu10050634] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/11/2018] [Accepted: 05/15/2018] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to assess the effect of feeding high protein human milk fortifier (HMF) on growth in preterm infants. In this single-centre randomised trial, 60 infants born 28–32 weeks’ gestation were randomised to receive a higher protein HMF providing 1.8 g protein (n = 31) or standard HMF providing 1 g protein per 100 mL expressed breast milk (EBM) (n = 29). The primary outcome was rate of weight gain. Baseline characteristics were similar between groups. There was no difference between high and standard HMF groups for weight gain (mean difference (MD) −14 g/week; 95% CI −32, 4; p = 0.12), length gain (MD −0.01 cm/week; 95% CI −0.06, 0.03; p = 0.45) or head circumference gain (MD 0.007 cm/week; 95% CI −0.05, 0.06; p = 0.79), despite achieving a 0.7 g/kg/day increase in protein intake in the high protein group. Infants in the high protein group had a higher proportion of lean body mass at trial entry; however, there was no group by time effect on lean mass gains over the study. Increasing HMF protein content to 1.8 g per 100 mL EBM does not improve growth in preterm infants born 28–32 weeks’ gestation.
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Affiliation(s)
- Jessica Reid
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia.
| | - Maria Makrides
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia.
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, SA 5006, Australia.
| | - Andrew J McPhee
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia.
- Neonatal Medicine, Women's and Children's Hospital, Adelaide, SA 5006, Australia.
| | - Michael J Stark
- Neonatal Medicine, Women's and Children's Hospital, Adelaide, SA 5006, Australia.
- The Robinson Research Institute, The University of Adelaide, Adelaide, SA 5006, Australia.
| | - Jacqueline Miller
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia.
- Nutrition and Dietetics, Flinders University, Adelaide, SA 5006, Australia.
| | - Carmel T Collins
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia.
- Adelaide Medical School, Discipline of Paediatrics, The University of Adelaide, Adelaide, SA 5006, Australia.
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31
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Highly Concentrated Preterm Formula as an Alternative to Powdered Human Milk Fortifier: A Randomized Controlled Trial. J Pediatr Gastroenterol Nutr 2017; 65:574-578. [PMID: 29064929 DOI: 10.1097/mpg.0000000000001638] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to assess clinical feasibility and tolerance of concentrated preterm formula at 30 kcal/oz (CPF30) to fortify human milk to a caloric density of 24 kcal/oz, compared to conventional powdered human milk fortifier (PHMF). STUDY DESIGN Very low birth weight neonates were stratified by birth weight and randomized to receive human milk fortification using CPF30 or PHMF. Infants were monitored from first introduction of human milk fortification, until fortified feeds were well tolerated. Primary outcome was weight gain; secondary outcomes included other measures of feeding intolerance (residual gastric aspirates, feeds held, prokinetic therapy), sepsis, and death. The clinical and study personnel were blinded to the intervention. RESULTS No significant differences in weight gain or other measures of feeding tolerance were demonstrated between CPF30 and PHMF. Macronutrient intake was similar between both groups. Infants with a birth weight of ≥ 1000 g who received CPF30, experienced fewer days NPO (nil per os; nothing per mouth) and a trend toward lower incidence of NEC, compared with those who received PHMF.. The amount of human milk consumed was significantly lower in the CPF30 group. CONCLUSIONS Both fortifiers were similarly well tolerated. Fortification of human milk with CPF30 is a safe and feasible alternative to conventional PHMF.
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32
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Hay WW, Hendrickson KC. Preterm formula use in the preterm very low birth weight infant. Semin Fetal Neonatal Med 2017; 22:15-22. [PMID: 27595621 DOI: 10.1016/j.siny.2016.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Whereas human milk is the recommended diet for all infants, preterm formulas are indicated for enteral feeding of preterm very low birth weight infants when sufficient maternal breast milk and donor human milk are not available. Feeding with preterm formulas helps to ensure consistent delivery of nutrients. The balance of risks and benefits of feeding preterm formulas versus supplemented maternal and donor breast milk for preterm infants, however, is uncertain. Numerous studies and extensive practice have shown improved growth with preterm formulas, but there is concern for increased risks of necrotizing enterocolitis, possibly from cow milk antigen in the formulas or from different gut microbiomes, increased duration of total parenteral nutrition, and increased rates of sepsis in infants receiving preterm formulas. Furthermore, whereas preterm formulas improve neurodevelopmental outcomes compared to term formulas and unfortified donor milk, they do not produce neurodevelopmental outcomes better than fortified human milk, again indicating that maternal milk has unique properties that formulas need to mimic as closely as possible.
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Affiliation(s)
- William W Hay
- University of Colorado School of Medicine and University of Colorado Hospital, Aurora, CO, USA.
| | - Kendra C Hendrickson
- University of Colorado School of Medicine and University of Colorado Hospital, Aurora, CO, USA
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33
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Lainwala S, Kosyakova N, Spizzoucco AM, Herson V, Brownell EA. Clinical and nutritional outcomes of two liquid human milk fortifiers for premature infants. J Neonatal Perinatal Med 2017; 10:393-401. [PMID: 29286933 DOI: 10.3233/npm-16164] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND In preterm infants fortification of human milk with human milk fortifiers (HMF) to optimize nutrition and growth is standard practice. We compared clinical, nutrition and growth outcomes in infants receiving two types of liquid HMF (LHMF). METHODS Clinical, nutrition and growth outcomes were compared between infants admitted to a level IV NICU, and born with birth weight less than or equal to 1800 grams, between 10/1/2014-12/31/2014 and received human milk with acidified LHMF (ALHMF) and between 1/1/2015-4/31/2015 and received human milk with heat treated LHMF (HTLHMF). RESULTS Of the 85 qualifying infants, 67 received human milk and LHMF. ALHMF group had significantly higher incidence of metabolic acidosis and lower bicarbonate and base excess levels relative to infants receiving HTLHMF (P < 0.001). There were no significant differences by LHMF status in other clinical outcomes and nutrition and growth outcomes. In multivariate analyses, ALHMF use was associated with metabolic acidosis, and lower base excess and bicarbonate levels. CONCLUSION In our study, the clinical, nutrition and growth outcomes between the two LHMF groups were similar. However, use of ALHMF in preterm infants was associated with increased incidence of metabolic acidosis in our cohort. Further randomized control trials are warranted to evaluate these findings.
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Affiliation(s)
- Shabnam Lainwala
- Division of Neonatology, Connecticut Children's Medical Center, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Ann Marie Spizzoucco
- Department of Nutrition, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Victor Herson
- Division of Neonatology, Connecticut Children's Medical Center, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Elizabeth A Brownell
- Division of Neonatology, Connecticut Children's Medical Center, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
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34
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Shulhan J, Dicken B, Hartling L, Larsen BM. Current Knowledge of Necrotizing Enterocolitis in Preterm Infants and the Impact of Different Types of Enteral Nutrition Products. Adv Nutr 2017; 8:80-91. [PMID: 28096129 PMCID: PMC5227976 DOI: 10.3945/an.116.013193] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Preterm infants are extremely vulnerable to a range of morbidities and mortality. Underdeveloped cardiac, respiratory, gastrointestinal, and immune systems in the preterm period increase the risk of necrotizing enterocolitis (NEC), a serious disease of the gut. NEC affects 5-12% of very-low birth-weight infants, leads to surgery in 20-40% of cases, and is fatal in 25-50% of cases. There are multiple factors that may contribute to NEC, but the exact cause is not yet fully understood. Severe cases can result in intestinal resection or death, and the health care costs average >$300,000/infant when surgical management is required. Different types of nutrition may affect the onset or progression of NEC. Several studies have indicated that bovine milk-based infant formulas lead to a higher incidence of NEC in preterm infants than does human milk (HM). However, it is not clear why HM is linked to a lower incidence of NEC or why some infants fed an exclusively HM diet still develop NEC. An area that has not been thoroughly explored is the use of semielemental or elemental formulas. These specialty formulas are easy to digest and absorb in the gut and may be an effective nutritional intervention for reducing the risk of NEC. This review summarizes what is known about the factors that contribute to the onset and progression of NEC, discusses its health care cost implications, and explores the impact that different formulas and HM have on this disease.
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Affiliation(s)
- Jocelyn Shulhan
- Departments of Pediatrics and
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Bryan Dicken
- Surgery, Faculty of Medicine and Dentistry, and
- Stollery Children's Hospital, Edmonton, Canada; and
| | - Lisa Hartling
- Departments of Pediatrics and
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Bodil Mk Larsen
- Departments of Pediatrics and
- Stollery Children's Hospital, Edmonton, Canada; and
- Nutrition Services, Alberta Health Services, Edmonton, Canada
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35
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Moya F. Comments to Article by Thoene M et al., Nutrients 2016, 8, 451. Nutrients 2016; 8:nu8120821. [PMID: 27999273 PMCID: PMC5188474 DOI: 10.3390/nu8120821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/08/2016] [Indexed: 11/16/2022] Open
Affiliation(s)
- Fernando Moya
- Betty Cameron Children's Hospital, 2131 S 17th St, Wilmington, NC 28401, USA.
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36
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Rosas R, Sanz MP, Fernández-Calle P, Alcaide MJ, Montes MT, Pastrana N, Segovia C, Omeñaca F, Sáenz de Pipaón M. Experimental study showed that adding fortifier and extra-hydrolysed proteins to preterm infant mothers' milk increased osmolality. Acta Paediatr 2016; 105:e555-e560. [PMID: 27392326 DOI: 10.1111/apa.13522] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/04/2016] [Accepted: 07/06/2016] [Indexed: 12/18/2022]
Abstract
AIM Measuring milk osmolality after adjustable fortification is clinically relevant, as values exceeding recommended safety thresholds might result in gastrointestinal consequences. The aim of this study was to evaluate the effect of four fortification levels and storage time on the osmolality of human milk. METHODS This was an experimental study using 71 spare samples of fresh breastmilk collected from 31 mothers of preterm infants. Osmolality was measured before and after adding commercial human milk fortifier containing dextrinomaltose and hydrolysed proteins at four different concentrations. Measurements were performed at various points during the 23 hours after fortification. RESULTS The mean basal osmolality of the 71 human milk samples was 296 ± 14 milliosmoles (mOsm)/kg, and these remained stable over a period of 23 hours. Just after fortification, the four fortified formulas showed higher osmolalities than the nonfortified human milk, ranging between 384 ± 14 and 486 ± 15 mOsm/kg, respectively (p < 0.01). This osmolality increased significantly from 20 minutes to 23 hours after fortification (p < 0.05). CONCLUSION Adding fortifier and extra-hydrolysed proteins to human preterm milk increased osmolality, and these osmolality levels also increased with time. We recommend evaluating the risk of hyperosmolality when a higher fortification level is needed, to avoid gastrointestinal problems.
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Affiliation(s)
- R Rosas
- Department of Laboratory Medicine; La Paz University Hospital; Madrid Spain
| | - MP Sanz
- Department of Laboratory Medicine; La Paz University Hospital; Madrid Spain
| | - P Fernández-Calle
- Department of Laboratory Medicine; La Paz University Hospital; Madrid Spain
| | - MJ Alcaide
- Department of Laboratory Medicine; La Paz University Hospital; Madrid Spain
| | - MT Montes
- Department of Neonatology; La Paz University Hospital; Madrid Spain
| | - N Pastrana
- Department of Neonatology; La Paz University Hospital; Madrid Spain
| | - C Segovia
- Department of Neonatology; La Paz University Hospital; Madrid Spain
| | - F Omeñaca
- Department of Neonatology; La Paz University Hospital; Madrid Spain
- Instituto de Salud Carlos III; Red de Salud Materno Infantil y Desarrollo-SAMID; Madrid Spain
- Department of Pediatrics; Autonomous University of Madrid; Madrid Spain
| | - M Sáenz de Pipaón
- Department of Neonatology; La Paz University Hospital; Madrid Spain
- Instituto de Salud Carlos III; Red de Salud Materno Infantil y Desarrollo-SAMID; Madrid Spain
- Department of Pediatrics; Autonomous University of Madrid; Madrid Spain
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