1
|
Vernekar SS, Somji S, Msimuko K, Yogeshkumar S, Nayak RB, Nabapure S, Kusagur VB, Saidi F, Phiri M, Kafansiyanji E, Sudfeld CR, Kisenge R, Moshiro R, Tuller DE, Vesel L, Semrau KEA, Dhaded SM, Bellad RM, Mvalo T, Manji K. Lessons learned in implementing the Low Birthweight Infant Feeding Exploration study: A large, multi-site observational study. BJOG 2023; 130 Suppl 3:99-106. [PMID: 37470090 DOI: 10.1111/1471-0528.17603] [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: 03/20/2023] [Accepted: 06/24/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Globally, early and optimal feeding practices and strategies for small and vulnerable infants are limited. We aim to share the challenges faced and implementation lessons learned from a complex, mixed methods research study on infant feeding. DESIGN A formative, multi-site, observational cohort study using convergent parallel, mixed-methods design. SETTING Twelve tertiary/secondary, public/private hospitals in India, Malawi and Tanzania. POPULATION OR SAMPLE Moderately low birthweight infants (MLBW; 1.50-2.49 kg). METHODS We assessed infant feeding and care practices through: (1) assessment of in-facility documentation of 603 MLBW patient charts; (2) intensive observation of 148 MLBW infants during facility admission; and (3) prospective 1-year follow-up of 1114 MLBW infants. Focus group discussions and in-depth interviews gathered perspectives on infant feeding among clinicians, families, and key stakeholders. MAIN OUTCOME MEASURES The outcomes of the primary study were: (1) To understand the current practices and standard of care for feeding LBW infants; (2) To define and document the key outcomes (including growth, morbidity, and lack of success on mother's own milk) for LBW infants under current practices; (3) To assess the acceptability and feasibility of a system-level Infant and Young Child Feeding (IYCF) intervention and the proposed infant feeding options for LBW infants. RESULTS Hospital-level guidelines and provision of care for MLBW infants varied across and within countries. In all, 89% of charts had missing data on time to first feed and 56% lacked discharge weights. Among 148 infants observed in-facility, 18.5% were discharged prior to meeting stated weight goals. Despite challenges during COVID, 90% of the prospective cohort was followed until 12 months of age. CONCLUSIONS Enrolment and follow-up of this vulnerable population required additional effort from researchers and the community. Using a mixed-methods exploratory study allowed for a comprehensive understanding of MLBW health and evidence-based planning of targeted large-scale interventions. Multi-site partnerships in global health research, which require active and equal engagement, are instrumental in avoiding duplication and building a stronger, generalisable evidence base.
Collapse
Affiliation(s)
- Sunil S Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Sarah Somji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kingsly Msimuko
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - S Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | | | - Shilpa Nabapure
- S S Institute of Medical Sciences & Research Centre, Davangere, Karnataka, India
| | | | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rodrick Kisenge
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Robert Moshiro
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Danielle E Tuller
- Ariadne Labs, Harvard T.H. Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Linda Vesel
- Ariadne Labs, Harvard T.H. Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine E A Semrau
- Ariadne Labs, Harvard T.H. Chan School of Public Health/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sangappa M Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Roopa M Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| |
Collapse
|
2
|
Semrau KEA, Mokhtar RR, Manji K, Goudar SS, Mvalo T, Sudfeld CR, Young MF, Caruso BA, Duggan CP, Somji SS, Lee ACC, Bakari M, Lugangira K, Kisenge R, Adair LS, Hoffman IF, Saidi F, Phiri M, Msimuko K, Nyirenda F, Michalak M, Dhaded SM, Bellad RM, Misra S, Panda S, Vernekar SS, Herekar V, Sommannavar M, Nayak RB, Yogeshkumar S, Welling S, North K, Israel-Ballard K, Mansen KL, Martin SL, Fleming K, Miller K, Pote A, Spigel L, Tuller DE, Vesel L. Facility-based care for moderately low birthweight infants in India, Malawi, and Tanzania. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001789. [PMID: 37075019 PMCID: PMC10115266 DOI: 10.1371/journal.pgph.0001789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 03/13/2023] [Indexed: 04/20/2023]
Abstract
Globally, increasing rates of facility-based childbirth enable early intervention for small vulnerable newborns. We describe health system-level inputs, current feeding, and discharge practices for moderately low birthweight (MLBW) infants (1500-<2500g) in resource-constrained settings. The Low Birthweight Infant Feeding Exploration study is a mixed methods observational study in 12 secondary- and tertiary-level facilities in India, Malawi, and Tanzania. We analyzed data from baseline facility assessments and a prospective cohort of 148 MLBW infants from birth to discharge. Anthropometric measuring equipment (e.g., head circumference tapes, length boards), key medications (e.g., surfactant, parenteral nutrition), milk expression tools, and human milk alternatives (e.g., donor milk, formula) were not universally available. MLBW infants were preterm appropriate-for-gestational age (38.5%), preterm large-for-gestational age (3.4%), preterm small-for-gestational age (SGA) (11.5%), and term SGA (46.6%). The median length of stay was 3.1 days (IQR: 1.5, 5.7); 32.4% of infants were NICU-admitted and 67.6% were separated from mothers at least once. Exclusive breastfeeding was high (93.2%). Generalized group lactation support was provided; 81.8% of mother-infant dyads received at least one session and 56.1% had 2+ sessions. At the time of discharge, 5.1% of infants weighed >10% less than their birthweight; 18.8% of infants were discharged with weights below facility-specific policy [1800g in India, 1500g in Malawi, and 2000g in Tanzania]. Based on descriptive analysis, we found constraints in health system inputs which have the potential to hinder high quality care for MLBW infants. Targeted LBW-specific lactation support, discharge at appropriate weight, and access to feeding alternatives would position MLBW for successful feeding and growth post-discharge.
Collapse
Affiliation(s)
- Katherine E. A. Semrau
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rana R. Mokhtar
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Shivaprasad S. Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Christopher R. Sudfeld
- Department of Global Health and Population and Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Melissa F. Young
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Christopher P. Duggan
- Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sarah S. Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anne C. C. Lee
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kristina Lugangira
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Linda S. Adair
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Irving F. Hoffman
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Kingsly Msimuko
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Fadire Nyirenda
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | - Sangappa M. Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Roopa M. Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Sujata Misra
- Department of Obstetrics and Gynaecology, SCB Medical College and Hospital, Cuttack, Odisha, India
- Department of Obstetrics and Gynaecology, FM Medical College, Balasore, Odisha, India
| | - Sanghamitra Panda
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
- Department of Obstetrics and Gynaecology, City Hospital, Cuttack, Odisha, India
| | - Sunil S. Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Veena Herekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Manjunath Sommannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Rashmita B. Nayak
- Department of Paediatrics, SCB Medical College and Hospital, Cuttack, Odisha, India
| | - S. Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Saraswati Welling
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Krysten North
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kiersten Israel-Ballard
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, United States of America
| | - Kimberly L. Mansen
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, United States of America
| | - Stephanie L. Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Katelyn Fleming
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Katharine Miller
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Arthur Pote
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lauren Spigel
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Danielle E. Tuller
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Linda Vesel
- Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | |
Collapse
|
3
|
Vesel L, Bellad RM, Manji K, Saidi F, Velasquez E, Sudfeld CR, Miller K, Bakari M, Lugangira K, Kisenge R, Salim N, Somji S, Hoffman I, Msimuko K, Mvalo T, Nyirenda F, Phiri M, Das L, Dhaded S, Goudar SS, Herekar V, Kumar Y, Koujalagi MB, Guruprasad G, Panda S, Shamanur LG, Somannavar M, Vernekar SS, Misra S, Adair L, Bell G, Caruso BA, Duggan C, Fleming K, Israel-Ballard K, Fishman E, Lee ACC, Lipsitz S, Mansen KL, Martin SL, Mokhtar RR, North K, Pote A, Spigel L, Tuller DE, Young M, Semrau KEA. Feeding practices and growth patterns of moderately low birthweight infants in resource-limited settings: results from a multisite, longitudinal observational study. BMJ Open 2023; 13:e067316. [PMID: 36792338 PMCID: PMC9933750 DOI: 10.1136/bmjopen-2022-067316] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES To describe the feeding profile of low birthweight (LBW) infants in the first half of infancy; and to examine growth patterns and early risk factors of poor 6-month growth outcomes. DESIGN Prospective observational cohort study. SETTING AND PARTICIPANTS Stable, moderately LBW (1.50 to <2.50 kg) infants were enrolled at birth from 12 secondary/tertiary facilities in India, Malawi and Tanzania and visited nine times over 6 months. VARIABLES OF INTEREST Key variables of interest included birth weight, LBW type (combination of preterm/term status and size-for-gestational age at birth), lactation practices and support, feeding profile, birthweight regain by 2 weeks of age and poor 6-month growth outcomes. RESULTS Between 13 September 2019 and 27 January 2021, 1114 infants were enrolled, comprising 4 LBW types. 363 (37.3%) infants initiated early breast feeding and 425 (43.8%) were exclusively breastfed to 6 months. 231 (22.3%) did not regain birthweight by 2 weeks; at 6 months, 280 (32.6%) were stunted, 222 (25.8%) underweight and 88 (10.2%) wasted. Preterm-small-for-gestational age (SGA) infants had 1.89 (95% CI 1.37 to 2.62) and 2.32 (95% CI 1.48 to 3.62) times greater risks of being stunted and underweight at 6 months compared with preterm-appropriate-for-gestational age (AGA) infants. Term-SGA infants had 2.33 (95% CI 1.77 to 3.08), 2.89 (95% CI 1.97 to 4.24) and 1.99 (95% CI 1.13 to 3.51) times higher risks of being stunted, underweight and wasted compared with preterm-AGA infants. Those not regaining their birthweight by 2 weeks had 1.51 (95% CI 1.23 to 1.85) and 1.55 (95% CI 1.21 to 1.99) times greater risks of being stunted and underweight compared with infants regaining. CONCLUSION LBW type, particularly SGA regardless of preterm or term status, and lack of birthweight regain by 2 weeks are important risk identification parameters. Early interventions are needed that include optimal feeding support, action-oriented growth monitoring and understanding of the needs and growth patterns of SGA infants to enable appropriate weight gain and proactive management of vulnerable infants. TRIAL REGISTRATION NUMBER NCT04002908.
Collapse
Affiliation(s)
- Linda Vesel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Roopa M Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Esther Velasquez
- Department of Epidemiology and Population Health, Stanford University, Palo Alto, California, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Katharine Miller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kristina Lugangira
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nahya Salim
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Kingsly Msimuko
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Fadire Nyirenda
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Leena Das
- Department of Paediatrics, SCB Medical College & Hospital, Cuttack, Orissa, India
| | - Sangappa Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Veena Herekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Yogesh Kumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - M B Koujalagi
- Department of Paediatrics, JJM Medical College, Davangere, Karnataka, India
| | - Gowdar Guruprasad
- Department of Paediatrics, JJM Medical College, Davangere, Karnataka, India
| | | | - Latha G Shamanur
- Department of Paediatrics, SS Institute of Medical Sciences and Research Center, Davangere, Karnataka, India
| | - Manjunath Somannavar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Sunil S Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Sujata Misra
- Department of Paediatrics, SCB Medical College & Hospital, Cuttack, Orissa, India
| | - Linda Adair
- Department of Nutrition, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Griffith Bell
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bethany A Caruso
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Christopher Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katelyn Fleming
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eliza Fishman
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne C C Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stuart Lipsitz
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kimberly L Mansen
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, USA
| | - Stephanie L Martin
- Department of Nutrition, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Rana R Mokhtar
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Krysten North
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Arthur Pote
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren Spigel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Danielle E Tuller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Melissa Young
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Katherine E A Semrau
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Effect of an exclusive human milk diet on feeding tolerance in preterm infants. J Perinatol 2022; 42:1070-1075. [PMID: 35184144 DOI: 10.1038/s41372-022-01348-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/13/2022] [Accepted: 02/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare the time to full enteral feeds in preterm infants fed exclusive human milk (EHM) - mother's own milk (MOM) fortified with human milk-based fortifier (HMBF), to those who received partial human milk (PHM) - MOM fortified with bovine milk-based fortifier (BMBF), and exclusive formula. STUDY DESIGN A single-center retrospective study of infants with birth weight <1250 g from 2013 to 2018. Data on feeding, growth and other short-term neonatal morbidities were collected. RESULTS On regression analysis, time to full enteral feeds was significantly higher in PHM compared to EHM group (β-coefficient 4.14, 95% CI 0.00-8.29) and formula-fed group compared to EHM (β-coefficient 4.3, 95% CI 0.32-8.20). No significant differences in growth velocity, length of stay and other morbidities were found between the groups. CONCLUSION Infants in EHM had better feeding tolerance and reached their enteral feed goals sooner compared to PHM and formula-fed groups.
Collapse
|
5
|
Beggs MR, Bando N, Unger S, O'Connor DL. State of the evidence from clinical trials on human milk fortification for preterm infants. Acta Paediatr 2022; 111:1115-1120. [PMID: 35143058 DOI: 10.1111/apa.16283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/08/2022] [Indexed: 12/22/2022]
Abstract
Infants born preterm or low birth weight are at risk for morbidity, mortality and later neuroimpairment. Appropriate early post-natal growth is associated with better outcomes in-hospital and post-discharge. Therefore, nutritional strategies that support growth may improve the long-term health of this population. Mother's milk with donor milk as a supplement are preferred sources of nutrition for these infants but may not always support growth, especially amongst infants born of very low birth weight (<1500 g) and or those with a major morbidity. Systematic reviews of randomised controlled trials to date demonstrate that multi-nutrient fortification of human milk improves in-hospital growth of preterm infants although data on long-term neurodevelopment are lacking. Further, individualised approaches to fortification based on milk analysis or the infant's metabolic response may improve growth over standard fortification. The evidence is insufficient to inform the timing of introducing fortifier, routine fortification of feeds post-discharge or routine use of fortifiers made from human instead of bovine milk. Importantly, there is insufficient data to determine if these fortification practices improve relevant clinical or neurodevelopmental outcomes. In sum, there is an urgent need for well-designed clinical trials to assess potential benefits and risks of fortification practices and at what cost.
Collapse
Affiliation(s)
- Megan R. Beggs
- Translational Medicine Program The Hospital for Sick Children Toronto Ontario Canada
| | - Nicole Bando
- Translational Medicine Program The Hospital for Sick Children Toronto Ontario Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
| | - Sharon Unger
- Department of Nutritional Sciences, Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
- Department of Pediatrics Sinai Health Toronto Ontario Canada
| | - Deborah L. O'Connor
- Translational Medicine Program The Hospital for Sick Children Toronto Ontario Canada
- Department of Nutritional Sciences, Temerty Faculty of Medicine University of Toronto Toronto Ontario Canada
- Department of Pediatrics Sinai Health Toronto Ontario Canada
| |
Collapse
|
6
|
Zhu J, Liu M, Xing Y. Preterm birth and human milk proteome: are we ready for individualized fortification? Curr Opin Clin Nutr Metab Care 2022; 25:216-222. [PMID: 35199659 DOI: 10.1097/mco.0000000000000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Preterm birth is one of the most pressing clinical problems in obstetrics and neonatology worldwide. One of the most sophisticated components of human milk is the proteome and a better understanding of it can lead to precision guides for feeding preterm infants. In this review, we will examine recent research focused on the human milk proteome and individualized protein fortification of human milk. RECENT FINDINGS In both preterm and term birth, the protein content in mother's own milk dropped rapidly in the early postnatal period. Preterm milk had a higher protein content and contained different protein and endogenous peptide compositions compared with term milk. The peptides in gastrointestinal fluids of preterm infants still need further investigation. Individualized fortification is more superior to standard fortification, but it only focuses on the total protein amount. There is no data concerning the composition and posttranslational modifications of proteins and endogenous peptides with fortification and their longterm effects. SUMMARY Comprehensive identification and characterization of the human milk proteome have led to the targeted breast milk fortification theory of preterm infant feeding and has also been enriched by clinical trials. However, to achieve fortification of key proteins and/or endogenous peptides, as standard clinical practice, requires additional studies. Future research should explore the long-term effect of protein fortification and pay more attention to quality rather than quantity in relation to infant body composition and growth outcomes.
Collapse
Affiliation(s)
- Jing Zhu
- Beijing Institute of Nutritional Resources, Beijing Academy of Science and Technology
| | - Mengyuan Liu
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| |
Collapse
|
7
|
Vesel L, Spigel L, Behera JN, Bellad RM, Das L, Dhaded S, Goudar SS, Guruprasad G, Misra S, Panda S, Shamanur LG, Vernekar SS, Hoffman IF, Mvalo T, Phiri M, Saidi F, Kisenge R, Manji K, Salim N, Somji S, Sudfeld CR, Adair L, Caruso BA, Duggan C, Israel-Ballard K, Lee AC, Martin SL, Mansen KL, North K, Young M, Benotti E, Marx Delaney M, Fishman E, Fleming K, Henrich N, Miller K, Subramanian L, Tuller DE, Semrau KE. Mixed-methods, descriptive and observational cohort study examining feeding and growth patterns among low birthweight infants in India, Malawi and Tanzania: the LIFE study protocol. BMJ Open 2021; 11:e048216. [PMID: 34857554 PMCID: PMC8640640 DOI: 10.1136/bmjopen-2020-048216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 10/28/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Ending preventable deaths of newborns and children under 5 will not be possible without evidence-based strategies addressing the health and care of low birthweight (LBW, <2.5 kg) infants. The majority of LBW infants are born in low- and middle-income countries (LMICs) and account for more than 60%-80% of newborn deaths. Feeding promotion tailored to meet the nutritional needs of LBW infants in LMICs may serve a crucial role in curbing newborn mortality rates and promoting growth. The Low Birthweight Infant Feeding Exploration (LIFE) study aims to establish foundational knowledge regarding optimal feeding options for LBW infants in low-resource settings throughout infancy. METHODS AND ANALYSIS LIFE is a formative, multisite, observational cohort study involving 12 study facilities in India, Malawi and Tanzania, and using a convergent parallel, mixed-methods design. We assess feeding patterns, growth indicators, morbidity, mortality, child development and health system inputs that facilitate or hinder care and survival of LBW infants. ETHICS AND DISSEMINATION This study was approved by 11 ethics committees in India, Malawi, Tanzania and the USA. The results will be disseminated through peer-reviewed publications and presentations targeting the global and local research, clinical, programme implementation and policy communities. TRIAL REGISTRATION NUMBERS NCT04002908 and CTRI/2019/02/017475.
Collapse
Affiliation(s)
- Linda Vesel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren Spigel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Roopa M Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Leena Das
- Department of Paediatrics, SCB Medical College and Hospital, Cuttack, Orissa, India
| | - Sangappa Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Gowdar Guruprasad
- Department of Neonatology, JJM Medical College, Davangere, Karnataka, India
| | - Sujata Misra
- Department of Paediatrics, SCB Medical College and Hospital, Cuttack, Orissa, India
| | - Sanghamitra Panda
- Department of Obstetrics and Gynaecology, City Hospital, Cuttack, Orissa, India
| | - Latha G Shamanur
- Department of Paediatrics, SS Institute of Medical Sciences and Research Center, Davangere, Karnataka, India
| | - Sunil S Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Irving F Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Tisungane Mvalo
- Department of Pediatrics, University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Melda Phiri
- Department of Pediatrics, University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Friday Saidi
- Department of Pediatrics, University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Nahya Salim
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Linda Adair
- Department of Nutrition, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Bethany A Caruso
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Christopher Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Anne Cc Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephanie L Martin
- Department of Nutrition, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Kimberly L Mansen
- Maternal, Newborn, Child Health and Nutrition Program, PATH, Seattle, Washington, USA
| | - Krysten North
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Melissa Young
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, USA
| | - Emily Benotti
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan Marx Delaney
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Eliza Fishman
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katelyn Fleming
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Natalie Henrich
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kate Miller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Laura Subramanian
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Danielle E Tuller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katherine Ea Semrau
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants. Nutrients 2021; 13:nu13124307. [PMID: 34959859 PMCID: PMC8704746 DOI: 10.3390/nu13124307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/29/2022] Open
Abstract
Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.
Collapse
|
9
|
North K, Marx Delaney M, Bose C, Lee ACC, Vesel L, Adair L, Semrau K. The effect of milk type and fortification on the growth of low-birthweight infants: An umbrella review of systematic reviews and meta-analyses. MATERNAL & CHILD NUTRITION 2021; 17:e13176. [PMID: 33733580 PMCID: PMC8189224 DOI: 10.1111/mcn.13176] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 01/29/2021] [Accepted: 02/16/2021] [Indexed: 01/08/2023]
Abstract
Approximately 15% of infants worldwide are born with low birthweight (<2500 g). These children are at risk for growth failure. The aim of this umbrella review is to assess the relationship between infant milk type, fortification and growth in low-birthweight infants, with particular focus on low- and lower middle-income countries. We conducted a systematic review in PubMed, CINAHL, Embase and Web of Science comparing infant milk options and growth, grading the strength of evidence based on standard umbrella review criteria. Twenty-six systematic reviews qualified for inclusion. They predominantly focused on infants with very low birthweight (<1500 g) in high-income countries. We found the strongest evidence for (1) the addition of energy and protein fortification to human milk (donor or mother's milk) leading to increased weight gain (mean difference [MD] 1.81 g/kg/day; 95% confidence interval [CI] 1.23, 2.40), linear growth (MD 0.18 cm/week; 95% CI 0.10, 0.26) and head growth (MD 0.08 cm/week; 95% CI 0.04, 0.12) and (2) formula compared with donor human milk leading to increased weight gain (MD 2.51 g/kg/day; 95% CI 1.93, 3.08), linear growth (MD 1.21 mm/week; 95% CI 0.77, 1.65) and head growth (MD 0.85 mm/week; 95% CI 0.47, 1.23). We also found evidence of improved growth when protein is added to both human milk and formula. Fat supplementation did not seem to affect growth. More research is needed for infants with birthweight 1500-2500 g in low- and lower middle-income countries.
Collapse
Affiliation(s)
- Krysten North
- Department of PediatricsUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Megan Marx Delaney
- Ariadne LabsBrigham Women's Hospital and Harvard TH Chan School of Public HealthBostonMassachusettsUSA
| | - Carl Bose
- Department of PediatricsUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Anne C. C. Lee
- Department of Pediatric Newborn MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Linda Vesel
- Ariadne LabsBrigham Women's Hospital and Harvard TH Chan School of Public HealthBostonMassachusettsUSA
| | - Linda Adair
- Department of Nutrition, Carolina Population Center, Gillings School of Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Katherine Semrau
- Ariadne LabsBrigham Women's Hospital and Harvard TH Chan School of Public HealthBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|