Human milk for preterm infants: why, what, when and how?

A Review: The Effect of Bovine Colostrum on Immunity in People of All Ages

Bovine colostrum provides newborn calves with strong passive immunity, which will further affect the immunity of their offspring. Compared with other commercial dairy products, bovine colostrum emphasizes the limit of aflatoxin M1, pathogenic bacteria, microorganisms, antibiotics, stimulants, and other items, so it is safe to use. There are many reports that the use of bovine colostrum as a breast milk fortifier for preterm infants provides necessary immune support for premature infants, but the selection of bovine colostrum products chosen must be free of Bacillus cereus because they are very dangerous for premature infants. This also emphasizes that for the bovine colostrum that is used in preterm infants, more clinical research support is needed. At the same time, it should also be emphasized that the composition of BC is different from that of human colostrum, in particular, the main protein of BC is casein, while the main protein in breast milk is whey protein, especially α-lactalbumin, which together with ovalbumin is still the reference protein with the best biological value, especially for muscles. Therefore, bovine colostrum is currently not a complete substitute for breast milk. In recent years, in addition to reports of bovine colostrum use in preterm infants, studies have also found that bovine colostrum has immunomodulatory and promoting effects in adolescents, adults, and the elderly. This suggests that bovine colostrum has the potential to provide appropriate immune support for people of all ages. Therefore, this study aimed to evaluate the quality of nutritional characteristics of bovine colostrum on three dimensions. The effects of bovine colostrum on people of all ages is a narrative review of the effects of bovine colostrum on immunity in people of all ages. This review identified several classes of immunoactive substances in bovine colostrum, including immunoglobulins, cytokines, and enzymes, and compared the nutritional composition of bovine colostrum with mature milk, colostrum and mature milk in full-term breast milk, and colostrum and mature milk in preterm breast milk, to demonstrate that bovine colostrum provides a rich range of immunoactive components. In addition, the influencing factors affecting the quality of bovine colostrum (immunoglobulin) were reviewed, and it was found that individual differences, environmental factors, and processing methods had a great impact on the quality of BC. More importantly, the immunomodulatory effects of bovine colostrum in people of all ages were reviewed in detail (with an emphasis on preterm infants and immunocompromised children in neonates) as evidence to support the immunity effects of colostrum in people of all ages. This review hopes to use the above evidence to make people understand the health role of bovine colostrum as having a human immunomodulatory effect, and at the same time, when seeing the potential value of bovine colostrum in the future, the limitations of its application should also be deeply re-explored, such as lactose intolerance, allergies, etc., to provide effective solutions for the wide application of bovine colostrum.

Associations between Parental Engagement in the Neonatal Intensive Care Unit and Neighborhood-Level Socioeconomic Status

OBJECTIVE

 This study aimed to (1) determine the effect of neighborhood-level socioeconomic status (SES), which considers the social and physical environment where a person lives, on parental engagement in the Neonatal Intensive Care Unit (NICU) and (2) compare the relationships between parental engagement and individual versus neighborhood-level measures of SES.

STUDY DESIGN

 In this cohort study, parents (n = 45) of premature neonates ≤34 weeks' gestation were assessed at 2 and 6 weeks after birth from December 2017 to October 2019. Neighborhood-level SES was determined using census data per the Association of Maternal and Child Health Programs' methodology, and parents self-reported their education level as an individual-level measure of SES. Data on frequency of engagement in NICU activities, including telephone updates, visitation, providing expressed breastmilk, and participating in kangaroo care, were collected from the electronic medical record. Parent psychosocial factors were assessed using validated surveys. Statistical analysis was performed using Fisher's exact test, t-test, and logistic regression.

RESULTS

 In multivariate regression analysis, disadvantaged neighborhood-level SES was associated with decreased odds of kangaroo care (OR = 0.16, 95% CI: [0.03-0.89]) and visitation (OR = 0.14, 95% CI: [0.02-0.87]), while lower individual-level SES was not significantly associated with kangaroo care, visiting, calling, or pumping (p > 0.05).

CONCLUSION

 Parental engagement was more consistently and significantly associated with neighborhood-level SES than with individual-level SES. Therefore, neighborhood-level SES measures may be more explanatory than individual-level SES measures. Further studies and targeted interventions are needed to address disparities in the frequency of kangaroo care and visitation according to SES.

KEY POINTS

· Parents from disadvantaged neighborhoods are less likely to do kangaroo care and visit the NICU.. · Parent engagement was more significantly associated with neighborhood than with parent education.. · Neighborhood-level SES measures may be more explanatory than individual-level SES measures.. · Interventions are needed to address SES-related disparities in NICU kangaroo care and visitation..

Antisecretory factor in breastmilk is associated with reduced incidence of sepsis in preterm infants

BACKGROUND

Antisecretory Factor (AF) is a protein present in breastmilk that regulates inflammatory processes. We aimed to investigate the level of AF in mothers' own milk (MOM) in relation to sepsis and other neonatal morbidities in preterm infants.

METHODS

Samples of breastmilk and infant plasma were collected at 1, 4, and 12 weeks after birth from 38 mothers and their 49 infants born before 30 weeks gestation. AF-compleasome in MOM was determined by a sandwich enzyme-linked immunosorbent assay (ELISA) and inflammatory markers in infant plasma by a panel of 92 inflammatory proteins. Neonatal treatments and outcomes were recorded.

RESULTS

The level of AF in MOM week 1 was lower for infants with later sepsis compared to no sepsis (p = 0.005). Corrected for nutritional intake of MOM, higher levels of AF decreased the risk for sepsis, OR 0.24. AF in MOM week 1 was negatively correlated to inflammatory proteins in infant plasma week 4, markedly IL-8, which was also associated with infant sepsis. Overall, higher AF levels in MOM was associated with fewer major morbidities of prematurity.

CONCLUSION

Mother's milk containing high levels of antisecretory factor is associated with reduced risk for sepsis and inflammation in preterm infants.

IMPACT

High level of antisecretory factor (AF) in mothers' own milk is associated with less risk for later sepsis in preterm infants. Receiving mothers' milk with low AF levels during the first week after birth is correlated with more inflammatory proteins in infant's plasma 2-4 weeks later. Human breastmilk has anti-inflammatory properties, and antisecretory factor in mothers' own milk is a component of potential importance for infants born preterm. The findings suggest that food supplementation with AF to mothers of preterm infants to increase AF-levels in breastmilk may be a means to decrease the risk of inflammatory morbidities of prematurity.

High-Pressure Processing of Human Milk: A Balance between Microbial Inactivation and Bioactive Protein Preservation

BACKGROUND

Donor human milk banks use Holder pasteurization (HoP; 62.5°C, 30 min) to reduce pathogens in donor human milk, but this process damages some bioactive milk proteins.

OBJECTIVES

We aimed to determine minimal parameters for high-pressure processing (HPP) to achieve >5-log reductions of relevant bacteria in human milk and how these parameters affect an array of bioactive proteins.

METHODS

Pooled raw human milk inoculated with relevant pathogens (Enterococcus faecium, Staphylococcus aureus, Listeria monocytogenes, Cronobacter sakazakii) or microbial quality indicators (Bacillus subtilis and Paenibacillus spp. spores) at 7 log CFU/mL was processed at 300-500 MPa at 16-19°C (due to adiabatic heating) for 1-9 min. Surviving microbes were enumerated using standard plate counting methods. For raw milk, and HPP-treated and HoP-treated milk, the immunoreactivity of an array of bioactive proteins was assessed via ELISA and the activity of bile salt-stimulated lipase (BSSL) was determined via a colorimetric substrate assay.

RESULTS

Treatment at 500 MPa for 9 min resulted in >5-log reductions of all vegetative bacteria, but <1-log reduction in B. subtilis and Paenibacillus spores. HoP decreased immunoglobulin A (IgA), immunoglobulin M (IgM), immunoglobulin G, lactoferrin, elastase and polymeric immunoglobulin receptor (PIGR) concentrations, and BSSL activity. The treatment at 500 MPa for 9 min preserved more IgA, IgM, elastase, lactoferrin, PIGR, and BSSL than HoP. HoP and HPP treatments up to 500 MPa for 9 min caused no losses in osteopontin, lysozyme, α-lactalbumin and vascular endothelial growth factor.

CONCLUSION

Compared with HoP, HPP at 500 MPa for 9 min provides >5-log reduction of tested vegetative neonatal pathogens with improved retention of IgA, IgM, lactoferrin, elastase, PIGR, and BSSL in human milk.

Early Life Programming of Skeletal Health

PURPOSE OF REVIEW

Increasing bone mineral accrual during childhood might delay the onset of osteoporosis. We discuss the scientific evidence for early life approaches to optimising skeletal health.

RECENT FINDINGS

There is an ever-growing body of evidence from observational studies suggesting associations between early life exposures, particularly during foetal development, and bone mineral density (BMD). The findings of such studies are often heterogeneous, and for some exposures, for example, maternal smoking and alcohol intake in pregnancy or age at conception, intervention studies are not feasible. The most frequently studied exposures in intervention studies are calcium or vitamin D supplementation in pregnancy, which overall suggest positive effects on offspring childhood BMD. Maternal calcium and/or vitamin D supplementation during pregnancy appear to have positive effects on offspring BMD during early childhood, but further long-term follow-up is required to demonstrate persistence of the effect into later life.

Effects of Sepsis on Immune Response, Microbiome and Oxidative Metabolism in Preterm Infants

This is a narrative review about the mechanisms involved in bacterial sepsis in preterm infants, which is an illness with a high incidence, morbidity, and mortality. The role of the innate immune response and its relationship with oxidative stress in the pathogenesis are described as well as their potential implementation as early biomarkers. Moreover, we address the impact that all the mechanisms triggered by sepsis have on the dysbiosis and the changes on neonatal microbiota.

Knowledge of Breastfeeding Mothers Regarding Caries Prevention in Toddlers

Mothers' awareness regarding the risk factors for the development of early childhood caries is crucial. The current study aims to examine the knowledge of breastfeeding mothers about their baby's dental health and prevention of ECC while comparing primiparous mothers to multiparous mothers. A total of 165 mothers aged 20-49 y/o participated in the study by completing questionnaires that assessed the knowledge and attitudes of mothers toward their infants' oral health. Results showed that (1) mothers were found to be highly knowledgeable regarding the oral hygiene of their infants and the recommended breastfeeding best practices (71%); (2) mothers with lower education showed poor knowledge regarding the recommended practices of infant oral health; (3) a large proportion of the mothers in the sample (62%) reported that they usually tasted the food before giving it to their baby, in a way they could transmit bacteria to infants; (4) most of the mothers (68%) were not aware that their dental health during pregnancy affects the infants' dental health; and (5) multiparous mothers were more knowledgeable regarding artificial baby milk composition (96%) in comparison with mothers with only a single child (60%). According to the results, there is a need to improve the knowledge of breastfeeding mothers, especially mothers who have one child and mothers with a lower education about their baby's dental health. The results of this study shed light on the knowledge of breastfeeding mothers on this important topic and could serve policymakers to improve practices toward advancing better oral health for infants, without sacrificing the benefits of breastfeeding, which are so crucial for infant health and development.

Emotional journey of Asian mothers of premature infants who received pasteurised donor human milk: a qualitative study

OBJECTIVE

To explore the effect of donor human milk usage on the emotional experience of mothers with premature infants in a multiracial Asian population.

DESIGN

A qualitative descriptive study. Semistructured individual interviews were audio-recorded, transcribed and analysed using Braun and Clarke's process of thematic analysis.

SETTING AND PATIENTS

Seventeen mothers whose premature infants received donor human milk in a level III neonatal intensive care unit.

MAIN OUTCOME MEASURES

Perceptions of mothers whose premature infants received donor human milk.

RESULTS

Mothers described their experience as a journey of acceptance with three sequential themes. 'Resistance to receiving somebody else's milk' was a process of overcoming initial hesitation and concerns. 'Recognising maternal limitations and baby's needs' depicted the mothers' struggles in reconciling their infant's milk demand and their low milk supply. 'Embracing benefits of donor human milk and acceptance with gratitude' illustrated the mothers' joy and gratitude to milk donors as they embraced benefits of donor human milk usage. Although participants had agreed to use of donor human milk after counselling, many still struggled with negative emotions of anxiety and guilt. Mothers of Muslim faith had additional concerns about milk kinship and religious permissibility of donor human milk.

CONCLUSION

Mothers undergo a spectrum of complex emotions from initial hesitation to acceptance with gratitude, when their premature infants receive donor human milk. Some continue to struggle with negative emotions and require more support. By recognising their emotional responses, healthcare providers can support mothers in their breastfeeding journey with targeted counselling.

How much does a liter of donor human milk cost? Cost analysis of operating a human milk bank in Italy

BACKGROUND

To date, 40 Human Milk Banks (HMB) have been established in Italy; however, recent cost analysis data for operating an HMB in Italy are not available in the literature.

METHODS

This study was a cross-sectional study performed at "Bambino Gesù" Children's Hospital in Rome, Italy in 2019. We assessed the one-year operational costs and, the per liter unit costs at our HMB.

RESULTS

During the 2019 year we collected 771 l of human milk supplied by 128 donors. The total cost was € 178,287.00 and the average cost was € 231.00 per liter. € 188,716.00 would have been spent had the maximum capacity for 904 l been reached. We found a significant difference (€ 231.00 vs € 209.00 per liter, p = 0.016) comparing the cost for collected liters in the year 2019 and the cost for the maximum capacity of the bank for that year of activity. Analyzing each cost item that determines the charge of donor human milk (DHM), the highest costs are the salaries of medical and paramedical staff, and then the costs related to transporting. If the HMB works at maximum capacity and manages a greater number of liters of milk, this can represent an important saving. Conversely, the price of consumables is modest (i.e., the price of a single-use kit for breast pumps was € 0.22 per unit).

CONCLUSION

The costs for a liter of DHM are quite high, but they must be related to the benefits, especially for preterm infants. Comparing the cost for collected liters in 2019 and the costs for the 2019 maximum capacity of the HMB, we calculated how much fixed costs of collection and distribution of DHM can be reduced, by increasing the volume of milk collected. To the best of our knowledge, this is the first complete cost analysis for an Italian Milk Bank. A thorough analysis could help to abate fixed costs and reduce the cost of a liter of DHM. The centralization of DHM can allow savings, rather than creating small HMBs scattered throughout the territory that would operate with lower milk volumes.

A Randomized, Controlled Study to Investigate How Bovine Colostrum Fortification of Human Milk Affects Bowel Habits in Preterm Infants (FortiColos Study)

Background: Human milk does not meet the nutritional needs to support optimal growth of very preterm infants during the first weeks of life. Nutrient fortifiers are therefore added to human milk, though these products are suspected to increase gut dysmotility. The objective was to evaluate whether fortification with bovine colostrum (BC) improves bowel habits compared to a conventional fortifier (CF) in very preterm infants. Methods: In an unblinded, randomized study, 242 preterm infants (26−31 weeks of gestation) were randomized to receive BC (BC, Biofiber Damino, Gesten, Denmark) or CF (FM85 PreNAN, Nestlé, Vevey, Switzerland) as a fortifier. Stools (Amsterdam Stool Scale), bowel gas restlessness, stomach appearance score, volume, and frequency of gastric residuals were recorded before each meal until 35 weeks post-menstrual age. Results: As intake of fortifiers increased, stools became harder in both groups (p < 0.01) though less in BC infants (p < 0.05). The incidence of bowel gas restlessness increased with laxative treatments and days of fortification in both groups (p < 0.01), but laxatives were prescribed later in BC infants (p < 0.01). With advancing age, stomach appearance scores improved, but more so in BC infants (p < 0.01). Conclusions: Although there are limitations, a minimally processed, bioactive milk product such as BC induced similar or slightly improved bowel habits in preterm infants.

Gut priming with bovine colostrum and T regulatory cells in preterm neonates: a randomized controlled trial

BACKGROUND

Necrotizing enterocolitis (NEC) and neonatal sepsis are still considered major problems, especially in formula-fed preterm neonates. This study aimed to investigate the effect of bovine colostrum on T regulatory cells, NEC, and late-onset sepsis in preterm neonates ≤34 weeks.

METHODS

This prospective double-blind randomized controlled trial was conducted on 80 preterm infants who were randomly assigned to either the bovine colostrum group (n = 32) or control group (n = 48). T lymphocytes and their subsets, necrotizing enterocolitis, late-onset sepsis (LOS) and its severity, feeding tolerance, growth, length of hospital stay, and mortality were documented.

RESULTS

The bovine colostrum group showed higher follow-up levels of CD4+CD25+ FOXP3+ T lymphocyte % (FOXP3 Tregs). FOXP3 Tregs and its difference in change levels between baseline and follow-up were considered as the most related factors to the bovine colostrum. Bovine colostrum group showed positive trends for reduction of sepsis severity and mortality with no significant difference in the incidence of NEC, LOS, and length of hospital stay.

CONCLUSIONS

Preterm neonates who received bovine colostrum showed a higher FOXP3 Treg level.

IMPACT

Bovine colostrum has no significant effect on the incidence of necrotizing enterocolitis. FOXP3 T regulatory cells and their increased level between baseline and follow-up is considered as the most influencing factors related to the bovine colostrum. Positive trends were noted for reduction of sepsis severity and concomitant mortality, but the study lacked the power to assess these outcomes.

Gut colonization in preterm infants supplemented with bovine colostrum in the first week of life: An explorative pilot study

BACKGROUND

In the first weeks after birth, enteral feeding and bacterial colonization interact to influence gut maturation in preterm infants. Bovine colostrum (BC) has been suggested as a relevant supplementary diet when own mother's milk (MM) is insufficient or absent. This pilot trial tests whether the supplement type, BC or donor human milk (DM), affects gut colonization in preterm infants during the first week of life.

METHODS

On day 7, fecal samples were collected from preterm infants (n = 24) fed BC or DM as a supplement to MM. The gut microbiome (GM) was analyzed by 16S ribosomal RNA amplicon sequencing. Correlations between the relative abundance of specific bacterial taxa and blood chemistry variables, including amino acids, were explored.

RESULTS

BC-supplemented infants showed a lower relative abundance of the families Lactobacillaceae and Enterococcaceae than DM infants. Planococcaceae were more abundant in infants delivered by cesarean birth vs vaginally. The relative abundance of bacterial families, specifically Enterobacteriaceae, correlated negatively with plasma levels of multiple essential and nonessential amino acids (valine, isoleucine, lysine, histidine, and arginine).

CONCLUSION

The nature of nutrition supplements (BC or DM) just after birth may affect GM development and nutrient metabolism in the neonatal period of preterm infants. The exploratory nature of our study calls for confirmation of these results and their possible long-term clinical implications for preterm infants.

Frozen Mother's Own Milk Can Be Used Effectively to Personalize Donor Human Milk

Feeding preterm infants mother's own milk (MOM) lowers rates of sepsis, decreases necrotizing enterocolitis, and shortens hospital stay. In the absence of freshly expressed MOM, frozen MOM (FMOM) is provided. When MOM is unavailable, preterm infants are often fed pasteurized donor human milk (DHM), rendering it devoid of beneficial bacteria. We have previously reported that when MOM is inoculated into DHM to restore the live microbiota [restored milk (RM)], a similar microbial diversity to MOM can be achieved. Yet, it is unknown if a similar diversity to MOM can be obtained when FMOM is inoculated into DHM. The goal of this study was to determine whether a similar microbial composition to MOM could be obtained when FMOM is used to personalize DHM. To this end, a fresh sample of MOM was obtained and divided into fresh and frozen fractions. MOM and FMOM were inoculated into DHM at different dilutions: MOM/FMOM 10% (RM/FRM10) and MOM/FMOM 30% (RM/FRM30) and incubated at 37°C. At different timepoints, culture-dependent and culture-independent techniques were performed. Similar microbiota expansion and alpha diversity were observed in MOM, RM10, and RM30 whether fresh or frozen milk was used as the inoculum. To evaluate if microbial expansion would result in an abnormal activation on the innate immune system, Caco-2 epithelial cells were exposed to RM/FRM to compare interleukin 8 levels with Caco-2 cells exposed to MOM or DHM. It was found that RM samples did not elicit a significant increase in IL-8 levels when compared to MOM or FMOM. These results suggest that FMOM can be used to inoculate DHM if fresh MOM is unavailable or limited in supply, allowing both fresh MOM and FMOM to be viable options in a microbial restoration strategy.

Human milk pasteurisation reduces pre-lipolysis but not digestive lipolysis and moderately decreases intestinal lipid uptake in a combination of preterm infant in vitro models

Donor human milk, pasteurised for safety reasons, is the first alternative for feeding preterm infants when mothers' own milk is unavailable. Breastmilk pasteurisation impact on lipid digestion and absorption was evaluated by a static in vitro digestion model for preterm infants coupled with intestinal absorption using Caco-2/TC7 cells. Lipid absorption was quantified by digital image analysis of lipid droplets, by measurement of basolateral triglyceride concentration and by analysing the expression of major genes involved. After in vitro digestion, lipolysis extent was 13% lower in pasteurised human milk (PHM) than in raw human milk (RHM). In Caco-2/TC7 cells, the number of lipid droplets was identical for both milk types, while the mean droplet area was 17% smaller with PHM. Altogether, pasteurisation decreased the pre-lipolysis of human milk. This initial difference in free fatty acid amount was only partially buffered by the subsequent processes of in vitro digestion and cellular lipid absorption.

Breastfeeding in hospitalised preterm infants: A survey from 18 tertiary neonatal intensive care units across mainland China

AIM

To understand the use of breast milk and breastfeeding in preterm infants in neonatal intensive care units (NICUs) in mainland China.

METHODS

An online questionnaire survey of reported practices was conducted among 18 tertiary NICUs distributed across all seven districts in mainland China. The items of the questionnaire consisted of the following areas: breastfeeding rate of preterm infants (<37 weeks' gestation) at discharge, the standards used for guiding the clinical practice and the use of breast milk and breastfeeding.

RESULTS

On average, across all hospitals, breastfeeding rate for preterm infants at discharge was 65%, with 41% preterm infants being exclusively breastfed during the hospitalisation prior to discharge. Sixteen (89%) NICUs had policies designating breast milk as the preferred first feed for preterm infants. Donor milk was available in 3 of 18 (17%) NICUs. Kangaroo care was provided in 11 of 18 (61%) NICUs, and 14 of 18 (78%) allowed parental access to the hospitalised preterm infants. A large variation was found in clinical practices around the breast milk testing, breast milk storage and transportation and breast milk fortification methods among different NICUs.

CONCLUSIONS

The use of breast milk in hospitalised preterm infants has increased greatly but still needs to be further improved. A recommendation is made to conduct high-quality original trials to find evidence of the controversial problems, develop evidence-based guidelines, promote the best implementation of the guidelines and provide updated breastfeeding education to health-care providers in order to standardise the use of breast milk and breastfeeding in hospitalised preterm infants.

Growth and Clinical Outcomes of Very Low-Birth-Weight Infants Receiving Acidified vs Nonacidified Liquid Human Milk Fortifiers

BACKGROUND

Liquid human milk fortifiers are used commonly in neonatal intensive care. Use of an acidified HMF (A-HMF) is associated with transient metabolic acidosis, but whether growth outcomes differ between infants fed A-HMF vs nonacidified HMF (NA-HMF) remains unknown.

METHODS

Retrospective cohort study of 255 infants born at <33 weeks' gestation and ≤1500 g who were receiving ≥75% fortified human milk on day of life 14, in a level III neonatal intensive care unit (NICU) from May 2015 to December 2018. Infants born before October 2017 (n = 165) received A-HMF, whereas infants born after October 2017 (n = 90) received NA-HMF. We used logistic regression to estimate odds of metabolic acidosis (serum bicarbonate <16 mEq/L in the first 21 days of life) in infants receiving A-HMF vs NA-HMF and linear mixed models to compare the mean size at discharge (weight, length, head z-scores) by HMF type. We adjusted models for confounders and accounted for the nonindependence of multiple births.

RESULTS

Median gestational age was 28.7 weeks (range, 22.6-32.9) and birth weight 1.1 kg (range, 0.4-1.5). Infants receiving A-HMF had higher adjusted odds of metabolic acidosis than infants receiving NA-HMF (adjusted odds ratio, 2.7; 95% CI, 1.2-6.2). There were no differences between groups in size z-scores at discharge.

CONCLUSIONS

In human-milkfed, very-low-birthweight infants, fortification with liquid A-HMF may contribute to metabolic acidosis in the first month of life, but this practice does not appear to impair growth through NICU discharge, compared with fortification with NA-HMF.

Bovine Colostrum Before or After Formula Feeding Improves Systemic Immune Protection and Gut Function in Newborn Preterm Pigs

Objectives: Maternal milk is often absent or in limited supply just after preterm birth. Many preterm infants are therefore fed infant formula as their first enteral feed despite an increased risk of feeding intolerance, necrotizing enterocolitis (NEC), and infection. Using preterm pigs as a model for preterm infants, we hypothesized that bovine colostrum given before or after formula feeding would alleviate formula-induced detrimental effects during the first days after preterm birth.

Methods: A total of 74 preterm pigs received gradually increasing volumes of formula (F) or bovine colostrum (C) until day 5, when they were euthanized or transitioned to either C or F for another 4 days, resulting in six groups: C or F until day 5 (C5, F5, n = 11 each), C or F until day 9 (CC, FF n = 12–13 each), C followed by F (CF, n = 14), and F followed by C (FC, n = 13).

Results: Systemically, colostrum feeding stimulated circulating neutrophil recruitment on day 5 (C5 vs. F5, P < 0.05). Relative to initial formula feeding, initial colostrum feeding promoted the development of systemic immune protection as indicated by a decreased T-helper cell population and an increased regulatory T-cell population (CC + CF vs. FC + FF, P < 0.01). In the gut, colostrum feeding improved intestinal parameters such as villus heights, enzymes, hexose absorption, colonic goblet cell density, and decreased the incidence of severe NEC (27 vs. 64%), diarrhea (16 vs. 49%), and gut permeability on day 5, coupled with lowered expression of LBP, MYD88, IL8, HIF1A, and CASP3 (C5 vs. F5, all P < 0.05). On day 9, the incidence of severe NEC was similarly low across groups (15–21%), but diarrhea resistance and intestinal parameters were further improved by colostrum feeding, relative to exclusive formula feeding (CC, CF, or FC vs. FF, respectively, all P < 0.05). The expression of MYD88 and CASP3 remained downregulated by exclusive colostrum feeding (CC vs. FF, P < 0.01) and colostrum before or after formula feeding down regulated HIF1A and CASP3 expression marginally.

Conclusion: Colostrum feeding ameliorated detrimental effects of formula feeding on systemic immunity and gut health in preterm newborns, especially when given immediately after birth.

Use of acidified versus non-acidified liquid human milk fortifier in very low birth weight infants: A retrospective comparison of clinical outcomes

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.

Donated human milk use and subsequent feeding pattern in neonatal units

Background

Donated human milk (DHM) is a safe alternative in the absence of mother’s own milk (MOM); however, specific clinical indications for DHM use and its impact on subsequent feeding practice remain unclear. We aimed to audit local DHM use and explore the impact of the introduction of DHM as the first enteral feed on subsequent MOM availability.

Methods

We retrospectively audited DHM recipients nursed in Royal Hospital for Children, Glasgow from 2014 to 2016 against local guidelines. Data were collected from an operational electronic database. Descriptive data analysis was performed to describe DHM use. To explore the association between the first human milk feed with subsequent MOM availability Kruskal Wallis test was used. Adjustments for confounding variables were performed using analysis of variance (ANOVA).

Results

A total of 165 recipients of DHM (5.3% of all admission to RHC) were identified. The majority of recipients (69%) were born < 32 weeks of gestation. The main indication for DHM was prematurity, other indications included congenital anomalies of bowel and heart. The local guideline was adhered to in 87% of cases. The median interquartile range (IQR) at DHM introduction was 6 days (3, 17) and the duration of use was 12 days (6, 22). In those born < 32 weeks of gestation the type of human milk (DHM and/ or MOM) used as first feed did not influence the subsequent median IQR days of feeding with any MOM [DHM 40 (9, 51); MOM 28 (17, 49), MOM & DHM 17 (10, 26) p value = 0.465] after adjusting for birthweight and length of hospital stay.

Conclusions

In our unit, DHM is mainly used in preterm neonates in accordance with existing local guidance. Using DHM as first milk feed did not affect subsequent MOM availability.

Electronic supplementary material

The online version of this article (10.1186/s13006-019-0233-x) contains supplementary material, which is available to authorized users.

Longitudinal Analysis of Macronutrient Composition in Preterm and Term Human Milk: A Prospective Cohort Study

Background: Mother’s own milk is the optimal source of nutrients and provides numerous health advantages for mothers and infants. As they have supplementary nutritional needs, very preterm infants may require fortification of human milk (HM). Addressing HM composition and variations is essential to optimize HM fortification strategies for these vulnerable infants. Aims: To analyze and compare macronutrient composition in HM of mothers lactating very preterm (PT) (28 0/7 to 32 6/7 weeks of gestational age, GA) and term (T) infants (37 0/7 to 41 6/7 weeks of GA) over time, both at similar postnatal and postmenstrual ages, and to investigate other potential factors of variations. Methods: Milk samples from 27 mothers of the PT infants and 34 mothers of the T infants were collected longitudinally at 12 points in time during four months for the PT HM and eight points in time during two months for the T HM. Macronutrient composition (proteins, fat, and lactose) and energy were measured using a mid-infrared milk analyzer, corrected by bicinchoninic acid (BCA) assay for total protein content. Results: Analysis of 500 HM samples revealed large inter- and intra-subject variations in both groups. Proteins decreased from birth to four months in the PT and the T HM without significant differences at any postnatal time point, while it was lower around term equivalent age in PT HM. Lactose content remained stable and comparable over time. The PT HM contained significantly more fat and tended to be more caloric in the first two weeks of lactation, while the T HM revealed higher fat and higher energy content later during lactation (three to eight weeks). In both groups, male gender was associated with more fat and energy content. The gender association was stronger in the PT group, and it remained significant after adjustments. Conclusion: Longitudinal measurements of macronutrients compositions of the PT and the T HM showed only small differences at similar postnatal stages in our population. However, numerous differences exist at similar postmenstrual ages. Male gender seems to be associated with a higher content in fat, especially in the PT HM. This study provides original information on macronutrient composition and variations of HM, which is important to consider for the optimization of nutrition and growth of PT infants.

FortiColos - a multicentre study using bovine colostrum as a fortifier to human milk in very preterm infants: study protocol for a randomised controlled pilot trial

BACKGROUND

Very preterm infants (< 32 weeks gestation) have a relatively high nutrient requirement for growth and development. The composition of human milk is often inadequate to ensure optimal growth so it is common to fortify human milk for very preterm infants with nutrient fortifiers based on bovine milk. However, there are concerns that bovine milk-based fortifiers may increase the risk of feeding intolerance, necrotizing enterocolitis and late-onset sepsis. We hypothesize that a bovine colostrum-based product is a suitable alternative to bovine milk-based products when used as a fortifier to human milk in very preterm infants.

METHODS/DESIGN

In an open-label multicentre randomised controlled pilot trial, 200 very preterm infants (26 + 0 to 30 + 6 weeks gestation at birth) will be randomly allocated to a bovine colostrum-based or a bovine milk-based fortifier added to mother's own milk and/or human donor milk. Outcomes are growth rate, incidence of necrotizing enterocolitis and late-onset sepsis, a series of paraclinical endpoints, and practical feasibility of using the novel fortifier for very preterm infants.

DISCUSSION

The optimal enteral diet and feeding regimen for very preterm infants remain debated; this clinical trial will document the feasibility, safety and preliminary efficacy of using bovine colostrum, rich in nutrients and bioactive factors, as a novel fortifier for human milk to very preterm infants. Data on infant growth, metabolism, gut function and immunity will be assessed from clinical data as well as blood and stool samples.

TRIAL REGISTRATION

Registered retrospectively 25 May 2018 at ClinicalTrials.gov: NCT03537365 .

Preterm birth in evolutionary context: a predictive adaptive response?

Preterm birth is a significant public health problem worldwide, leading to substantial mortality in the newborn period, and a considerable burden of complications longer term, for affected infants and their carers. The fact that it is so common, and rates vary between different populations, raising the question of whether in some circumstances it might be an adaptive trait. In this review, we outline some of the evolutionary explanations put forward for preterm birth. We specifically address the hypothesis of the predictive adaptive response, setting it in the context of the Developmental Origins of Health and Disease, and explore the predictions that this hypothesis makes for the potential causes and consequences of preterm birth. We describe how preterm birth can be triggered by a range of adverse environmental factors, including nutrition, stress and relative socioeconomic status. Examining the literature for any associated longer-term phenotypic changes, we find no strong evidence for a marked temporal shift in the reproductive life-history trajectory, but more persuasive evidence for a re-programming of the cardiovascular and endocrine system, and a range of effects on neurodevelopment. Distinguishing between preterm birth as a predictive, rather than immediate adaptive response will depend on the demonstration of a positive effect of these alterations in developmental trajectories on reproductive fitness. This article is part of the theme issue 'Developing differences: early-life effects and evolutionary medicine'.

Fifteen-minute consultation: Breastfeeding in the first 2 weeks of life-a hospital perspective

The beneficial health and economic impacts of breastfeeding are considerable. However the majority of babies in the UK are not exclusively breastfeeding by 6 weeks of age. The first few weeks of life are therefore a critical period to facilitate breastfeeding. Health professionals must have a thorough knowledge of normal breastfeeding patterns in order to minimise unnecessary interference, and an understanding of how to protect the breastfeeding relationship when medical problems occur.

Exploring the Gap Between Needs and Practice in Facilitating Breastfeeding Within the Neonatal Intensive Care Setting: An Italian Survey on Organizational Factors

Introduction: The system-level factors of the neonatal intensive care unit work environment contribute to breastfeeding promotion in the preterm population. The aim of this study was to investigate the operative policies related to breastfeeding support in a sample of Italian Neonatal Intensive Care Units. Materials and Methods: A multicenter cross-sectional survey was conducted, including a sample of 17 head nurses. The items of the questionnaire investigated the following areas: breastfeeding policies, staff education, family centered care, and breastfeeding promotion and support both in the neonatal intensive care units and after discharge. Results: Written breastfeeding policies were available for staff in all the neonatal intensive care units, most commonly addressing procedures related to skin-to-skin contact, human milk expression, and preterm infant breastfeeding. Most of the neonatal intensive care units correctly advised the mothers to initiate milk expression within 6 h from delivery and to pump milk at least 6 times/days. Breastfeeding training for the nursing staff was planned in the majority of the neonatal intensive care units although according to different schedules. With regard to the family centered care implementation, time restrictions were present in seven neonatal intensive care units, mostly occurring during the night shift, and the morning hours concomitantly with medical rounds. Moreover, in the majority of the investigated neonatal intensive care units, the parents were asked to leave the ward when their infant underwent a major invasive procedure or during the nurse/physician shift change report. With regard to breastfeeding promotion and support, eight neonatal care units had a multidisciplinary team with several health care professionals and 10 provided information about community-based support services. Most of the units assessed breastfeeding after discharge. Conclusion: Based on the present findings, enrolled Neonatal Intensive Care Units appear to provide breastfeeding-supportive environments with special regard to breastfeeding policies, milk expression practices, interprofessional collaboration, and continuity of care. Health care professionals should exert efforts to ensure continuous and updated breastfeeding staff education and promote parent-infant closeness and family centered care.

A New High Hydrostatic Pressure Process to Assure the Microbial Safety of Human Milk While Preserving the Biological Activity of Its Main Components

Background: The main process used to pasteurize human milk is the low-temperature, long-time Holder method. More recently, the high-temperature, short-time method has been investigated. Both processes lead to the appropriate inactivation of vegetative bacterial forms but are ineffective against bacterial spores. Research Aims/Questions: We aimed to accomplish two main objectives: inactivation of all pathogens, including spores; and preservation of the activity of milk components. Design/Methods: Recently, a novel high-hydrostatic pressure process has been developed by HPBioTECH. Using the same raw human milk samples, we compared the effects of this method with those of the Holder method on vegetative and spore forms of pathogens and on bioactive components (lipase activity, immunoproteins). Results: Two main microbial strains were selected: Staphylococcus aureus (as a reference for vegetative forms) and Bacillus cereus (as a reference for spores). Use of the high-hydrostatic pressure process led to microbial decontamination of 6 log for both S. aureus and B. cereus. Additionally, the bioactivity of the main components of human milk was preserved, with activities of lipase, α-lactalbumin, casein, lysozyme, lactoferrin, and sIgA of ~80, 96-99, 98-100, 95-100, 93-97, and 63-64%, respectively. Conclusions: Use of this novel high-hydrostatic pressure process to generate microbiologically safe human milk may provide important benefits for preterm infants, including improved assimilation of human milk (leading increased weight gain) and improved resistance to infections. Because 10% of all human milk collected is contaminated by B. cereus, use of this method will also prevent waste.

Maternal views on facilitators of and barriers to breastfeeding preterm infants

Background

The supply of breast milk to preterm infants tends to occur at a lower rate than that recorded among term infants. We aimed to investigate the facilitators of and barriers to breastfeeding during hospital stay according to the experiences of mothers that gave birth to premature infants requiring admission to neonatal intensive care unit.

Methods

A cross-sectional questionnaire survey was conducted. Mothers who had delivered a newborn with a gestational age ≤33 weeks requiring intensive care, entered the study. Basic subjects’ characteristics and infant feeding practices were also recorded.

Results

A total of 64 mothers were enrolled, leading to a total of 81 infants. At discharge, any breastfeeding was recorded in 66% of infants, with 27% of those infants being exclusively breastfed. Any infant was exclusively fed directly at the breast. Most mothers experienced adequate support during their infant’s hospitalization and reported satisfaction with breastfeeding. Almost all mothers felt that feeding their infant human milk was beneficial for the infant’s health. Thirty percent of the mothers reported that they had experienced some obstacles to breastfeeding. Specifically, infants born to mothers who experienced difficulties in pumping breast milk (OR = 4.6; CI 1.5–13.9) or in providing an adequate amount of milk to the infant (OR = 3.57; CI 1.1–11.5) were at higher risk of being fed with formula at discharge.

Conclusions

On the basis of the present results, health care professionals should target their efforts to optimize breastfeeding support for mothers of premature infants admitted to level III care, especially by improving breast milk production and endorsing direct breastfeeding.

The experience of breastfeeding infants affected by congenital diaphragmatic hernia or esophageal atresia

Background

Newborns with congenital diaphragmatic hernia (CDH) and esophageal atresia (EA) might experience breastfeeding difficulties. The aim of this study was to detect the prevalence of breastfeeding in newborns with CDH and EA at different time points.

Methods

We performed an epidemiological study and retrospective survey on the prevalence of breastfeeding in CDH and EA affected newborns. We identified 40 CDH and 25 EA newborns who were fed through breastfeeding procedures according to WHO categorized definitions, and compared the breastfeeding procedures at the beginning of hospitalization and at three months of life.

Results

Although all the mothers attempted breastfeeding after birth, only 44 (67.7%) were still breastfeeding at the time of discharge. Exclusive breastfeeding was successful for only 19 (29%) mothers. The rate of exclusive breastfeeding at three months of life did not differ statistically from discharge and between the two groups of study.

Conclusion

A large percentage of mothers of children with CDH and EA who breastfed at the beginning of hospitalization did not continue at three months. It would be important to increase the breastfeeding rate in CDH and EA affected newborns by following specific steps for vulnerable infants and sustaining breastfeeding after discharge.

Application of industrial treatments to donor human milk: influence of pasteurization treatments, storage temperature, and time on human milk gangliosides

Donor milk is the best option when mother’s own milk is unavailable. Heat treatments are applied to ensure donor milk safety. The effects of heat treatments on milk gangliosides—bioactive compounds with beneficial antibacterial, anti-inflammatory, and prebiotic roles—have not been studied. The most abundant gangliosides in non-homogenized human milk were characterized and quantified by liquid chromatography–mass spectrometry (LC–MS)/MS before and after pasteurization treatments mimicking industrial conditions (63 °C/30 min, 72 °C/15 s, 127 °C/5 s, and 140 °C/6 s). Ganglioside stability over a 3-month period was assessed following the storage at 4 and 23 °C. Independent of the heat treatment applied, gangliosides were stable after 3 months of storage at 4 or 23 °C, with only minor variations in individual ganglioside structures. These findings will help to define the ideal processing and storage conditions for donor milk to maximize the preservation of the structure of bioactive compounds to enhance the health of fragile newborns. Moreover, these results highlight the need for, and provide a basis for, a standardized language enabling biological and food companies, regulatory agencies, and other food stakeholders to both annotate and compute the ways in which production, processing, and storage conditions alter or maintain the nutritive, bioactive, and organoleptic properties of ingredients and foods, as well as the qualitative effects these foods and ingredients may have on conferring phenotype in the consuming organism.

Donor human milk, the best alternative to mother’s own milk, usually needs to be pasteurized before use out of safety concerns. Daniela Barile at University of California Davis, USA, and colleagues studied the effects of heat treatment and storage temperature and time on milk gangliosides, a class of sugar-derived compounds important for neural and brain development of newborns, among other bioactivities. They found that, while there were minor structural changes during mimicked industrial pasteurization processes, gangliosides remain stable for at least three months either in the refrigerator or at room temperature. These results may help standardize the processing protocols and storage conditions for donor milk, and the methods can be extended to other bioactive components.

Bovine Colostrum for Preterm Infants in the First Days of Life: A Randomized Controlled Pilot Trial

OBJECTIVES

Mother's own milk (MM) is the best nutrition for newborn preterm infants, but is often limited in supply just after birth. Pasteurized human donor milk (DM), and especially preterm infant formula (IF) are less optimal diets than MM. We hypothesized that it is feasible to use bovine colostrum (BC), the first milk from cows, as a supplement to MM, during the first weeks after preterm birth.

METHODS

In an open-label, randomized, controlled pilot safety trial, supplementation of MM with BC was compared with DM supplementation (Danish unit) or IF supplementation (Chinese unit). If MM was limited or lacking, BC, DM or IF were given according to local feeding guidelines during the first 14 days of life.

RESULTS

Forty infants were included and randomized in Denmark and in China, with gestational ages 29.9 ± 0.4 and 31.1 ± 0.2 weeks, respectively. Infants supplemented with BC received more enteral protein (P < 0.05) and tended to reach full enteral feeding earlier (China only). Eight infants fed BC showed a temporary elevation in plasma tyrosine on day 7, versus 2 infants in the DM/IF groups. There were no differences between diet groups in feeding intolerance or clinical adverse events.

CONCLUSIONS

Our results indicate that it is feasible to use BC as a supplement to MM during the first weeks of life to increase enteral protein intake in preterm infants. Plasma tyrosine levels may be a good marker for excessive protein intake. A larger randomized trial is required to test the safety and possible short- and long-term clinical benefits of BC supplementation during the first weeks of life for preterm infants.

Feeding Practices in Very Preterm and Very Low Birth Weight Infants in an Area Where a Network of Human Milk Banks Is in Place

Background: Great variability in enteral feeding practices for very preterm (<32 weeks gestational age-GA) and very low birth weight infants (VLBW; ≤1,500 g) have been reported. We aimed to describe data on enteral feeding in Tuscany (Italy), where a network of 6 donor milk banks is in place. Methods: A 4-years (2012-2015) observational study was performed analyzing the database "TIN Toscane online" on very preterm and VLBW infants. The database covers all 25 hospitals with a neonatal unit. Results: Data concerning the beginning of enteral nutrition were available for 1,302 newborns with a mean (standard deviation) GA of 29.3 (2.9) weeks, while information at the time of full enteral nutrition was available for 1,235 and at discharge for 1,140. Most infants (74.1%) started enteral feeding during the first 24 h of life. Overall, 80.1% of newborns were fed exclusive human milk, donor milk having the larger prevalence of use (66.8%). Few infants (13.3%) started with exclusive mother's milk. Full enteral feeding was achieved using exclusive human milk in most cases (80%). Full enteral feeding was reached earlier in newborns who were fed human milk than in those fed formula, regardless of GA. Sixty-four percent of infants were still fed with any human milk at discharge. When data at the achievement of full enteral nutrition and at discharge were analyzed stratified by the type of milk used to start enteral feeding, newborns initially fed donor milk presented the highest prevalence (91.3%) of exclusive human milk at full enteral feeding, an important period to prevent necrotizing enterocolitis, while no differences were observed at discharge. Conclusions: Donor milk was widely used for newborns during the first hours of life, when mother's milk availability may be quite challenging. Starting enteral nutrition with donor milk was associated with early start of enteral feeding and early achievement of full enteral nutrition without affecting mother lactation. The overall prevalence of human milk at discharge (when donor milk is not available anymore) was high (64%), irrespective of the type of milk used to start nutrition.

Bioactive Whey Protein Concentrate and Lactose Stimulate Gut Function in Formula-fed Preterm Pigs

OBJECTIVE

Formula feeding is associated with compromised intestinal health in preterm neonates compared with maternal milk, but the mechanisms behind this are unclear. We hypothesized that the use of maltodextrin and whey protein concentrates (WPCs) with reduced bioactivity owing to thermal processing are important factors.

METHOD

Ninety-two cesarean-delivered preterm pigs were fed increasing doses of formulas for 5 days (24-120 mL · kg · day). In experiment 1, 4 groups of pigs (n = 15-16) were fed lactose- or maltodextrin-dominant formulas (lactose/maltodextrin ratios 3:1 or 1:3, respectively), containing WPC with either high or low levels of IgG (WPC1 or WPC2, respectively). In experiment 2, 2 groups of pigs (n = 15-16) were fed lactose-dominant formulas with either a bioactive WPC (BioWPC, produced by reduced thermal-processing) or a conventional WPC (ConWPC).

RESULTS

In experiment 1, pigs fed formula with WPC1 had higher villi, hexose absorption, and lactase activity in small intestine, relative to WPC2, but predominantly with the lactose-dominant formula (all P < 0.05). In experiment 2, the BioWPC product had higher bioactivity, as indicated by higher IgG, lactoferrin, and TGF-β2 levels, and better enterocyte proliferation in vitro. Pigs fed the BioWPC formula showed better feeding tolerance and higher intestinal villi and lactase activity (all P < 0.05). The BioWPC formula-fed pigs also had greater physical activity (P < 0.05 on day 4) and tended to show improved hexose absorption and decreased gut permeability (both P ≤ 0.09).

CONCLUSIONS

Infant formulas containing lactose as the main carbohydrate, and WPC with reduced thermal processing, may support gut maturation and health in sensitive, preterm neonates.

Cost and Cost-Effectiveness of Donor Human Milk to Prevent Necrotizing Enterocolitis: Systematic Review

BACKGROUND

Necrotizing enterocolitis (NEC) is a costly gastrointestinal disorder that mainly affects preterm and low-birth-weight infants and can lead to considerable morbidity and mortality. Mother's own milk is protective against NEC but is not always available. In such cases, donor human milk has also been shown to be protective (although to a lesser extent) compared with formula milk, but it is more expensive. This systematic review aimed at evaluating the cost of donor milk, the cost of treating NEC, and the cost-effectiveness of exclusive donor milk versus formula milk feeding to reduce the short-term health and treatment costs of NEC.

MATERIALS AND METHODS

We systematically searched five relevant databases to find studies with verifiable costs or charges of donor milk and/or treatment of NEC and any economic evaluations comparing exclusive donor milk with exclusive formula milk feeding. All search results were double screened.

RESULTS

Seven studies with verifiable donor milk costs and 17 with verifiable NEC treatment costs were included. The types of cost or charge included varied considerably across studies, so quantitative synthesis was not attempted. Estimates of the incremental length of stay associated with NEC were ∼18 days for medical NEC and 50 days for surgical NEC. Two studies claimed to report economic evaluations but did not do so in practice.

CONCLUSIONS

It is likely that donor milk provides short-term cost savings by reducing the incidence of NEC. Future studies should provide more details on cost components included and a full economic evaluation, including long-term outcomes, should be undertaken.

Personalization of the Microbiota of Donor Human Milk with Mother's Own Milk

The American Academy of Pediatrics recommends that extremely preterm infants receive mother's own milk (MOM) when available or pasteurized donor breast milk (DBM) when MOM is unavailable. The goal of this study was to determine whether DBM could be inoculated with MOM from mothers of preterm infants to restore the live microbiota (RM). Culture dependent and culture independent methods were used to analyze the fluctuations in the overall population and microbiome, respectively, of DBM, MOM, and RM samples over time. Using MOM at time = 0 (T0) as the target for the restoration process, this level was reached in the 10% (RM-10) and 30% (RM-30) mixtures after 4 h of incubation at 37°C, whereas, the larger dilutions of 1% (RM-1) and 5% (RM-5) after 8 h. The diversity indexes were similar between MOM and DBM samples, however, different genera were prevalent in each group. Interestingly, 40% of the bacterial families were able to expand in DBM after 4 h of incubation indicating that a large percentage of the bacterial load present in MOM can grow when transferred to DBM, however, no core microbiome was identified. In summary, the microbiome analyses indicated that each mother has a unique microbiota and that live microbial reestablishment of DBM may provide these microbes to individual mothers' infants. The agreement between the results obtained from the viable bacterial counts and the microbiome analyses indicate that DBM incubated with 10-30% v/v of the MOM for 4 h is a reasonable restoration strategy.

Pasteurization Procedures for Donor Human Milk Affect Body Growth, Intestinal Structure, and Resistance against Bacterial Infections in Preterm Pigs

Background: Holder pasteurization (HP) destroys multiple bioactive factors in donor human milk (DM), and UV-C irradiation (UVC) is potentially a gentler method for pasteurizing DM for preterm infants.Objective: We investigated whether UVC-treated DM improves gut maturation and resistance toward bacterial infections relative to HP-treated DM.Methods: Bacteria, selected bioactive components, and markers of antioxidant capacity were measured in unpasteurized donor milk (UP), HP-treated milk, and UVC-treated milk (all from the same DM pool). Fifty-seven cesarean-delivered preterm pigs (91% gestation; ratio of males to females, 30:27) received decreasing volumes of parental nutrition (average 69 mL · kg^-1 · d^-1) and increasing volumes of the 3 DM diets (n = 19 each, average 89 mL · kg^-1 · d^-1) for 8-9 d. Body growth, gut structure and function, and systemic bacterial infection were evaluated.Results: A high bacterial load in the UP (6×10⁵ colony forming units/mL) was eliminated similarly by HP and UVC treatments. Relative to HP-treated milk, both UVC-treated milk and UP showed greater activities of lipase and alkaline phosphatase and concentrations of lactoferrin, secretory immunoglobulin A, xanthine dehydrogenase, and some antioxidant markers (all P < 0.05). The pigs fed UVC-treated milk and pigs fed UP showed higher relative weight gain than pigs fed HP-treated milk (5.4% and 3.5%), and fewer pigs fed UVC-treated milk had positive bacterial cultures in the bone marrow (28%) than pigs fed HP-treated milk (68%) (P < 0.05). Intestinal health was also improved in pigs fed UVC-treated milk compared with those fed HP-treated milk as indicated by a higher plasma citrulline concentration (36%) and villus height (38%) (P < 0.05) and a tendency for higher aminopeptidase N (48%) and claudin-4 (26%) concentrations in the distal intestine (P < 0.08). The gut microbiota composition was similar among groups except for greater proportions of Enterococcus in pigs fed UVC-treated milk than in pigs fed UP and those fed HP-treated milk in both cecum contents (20% and 10%) and distal intestinal mucosa (24% and 20%) (all P < 0.05).Conclusions: UVC is better than HP treatment in preserving bioactive factors in DM. UVC-treated milk may induce better weight gain, intestinal health, and resistance against bacterial infections as shown in preterm pigs as a model for DM-fed preterm infants.

Pumping Practices and Characteristics of Mothers With Preterm Babies Going to the Neonatal Intensive Care Unit

Introduction: The benefits of mothers own milk on premature and ill infants’ nutritional, immunological, and developmental needs have been shown. This article aims to provide insights regarding pumping practices and characteristics of mothers with preterm babies in the neonatal intensive care unit (NICU).

Methods: Data on the milk production of women who gave birth to preterm babies at a tertiary teaching hospital was collected between 2010 and 2013. Mothers logged their pumping sessions, and milk was brought to the NICU in accordance with hospital policies.

Results: Eighty-one mothers were enrolled in the study. Thirteen (16%) who did not return any logs were excluded from the data analysis. Of the remaining 68 mothers, 16 (24%) began pumping within 6 hours of the birth, whereas 52 (77%) did not. On Day 1, the average daily volume of breast milk pumped was 6 ml (SD = 10, range 0–63 ml). By Day 5, the average daily volume pumped increased to 285 ml (SD = 221, range 0–823 ml).

Conclusion: There is a wide range in milk production for mothers of preterm infants, thus highlighting the need for evidence-based information and continuous encouragement of mothers to provide this valuable resource to the very vulnerable preterm infants.

A Stepwise, Pilot Study of Bovine Colostrum to Supplement the First Enteral Feeding in Preterm Infants (Precolos): Study Protocol and Initial Results

STUDY PROTOCOL

The optimal feeding for preterm infants during the first weeks is still debated, especially when mother's own milk is lacking or limited. Intact bovine colostrum (BC) contains high amounts of protein, growth factors, and immuno-regulatory components that may benefit protein intake and gut maturation. We designed a pilot study to investigate the feasibility and tolerability of BC as the first nutrition for preterm infants. The study was designed into three phases (A, B, and C) and recruited infants with birth weights of 1,000-1,800 g (China) or gestational ages (GAs) of 27 + 0 to 32 + 6 weeks (Denmark). In phase A, three infants were recruited consecutively to receive BC as a supplement to standard feeding. In phase B, seven infants were recruited in parallel. In phase C (not yet complete), 40 infants will be randomized to BC or standard feeding. Feeding intolerance, growth, time to full enteral feeding, serious infections/NEC, plasma amino acid profile, blood biochemistry, and intestinal functions are assessed. This paper presents the study protocol and results from phases A and B.

RESULTS

Seven Danish and five Chinese infants received 22 ± 11 and 22 ± 6 ml·kg^-1·day^-1 BC for a mean of 7 ± 3 and 7 ± 1 days which provided 1.81 ± 0.89 and 1.83 ± 0.52 g·kg^-1·day^-1 protein, respectively. Growth rates until 37 weeks or discharge were in the normal range (11.8 ± 0.9 and 12.9 ± 2.7 g·kg^-1·day^-1 in Denmark and China, respectively). No clinical adverse effects were observed. Five infants showed a transient hypertyrosinemia on day 7 of life.

DISCUSSION AND CONCLUSION

The three-phased study design was used to proceed with caution as this is the first trial to investigate intact BC as the first feed for preterm infants. BC supplementation appeared well tolerated and resulted in high enteral protein intake. Based on the safety evaluation of phases A and B, the randomized phase C has been initiated. When complete, the Precolos trial will document whether it is feasible to use BC as a novel, bioactive milk diet for preterm infants. Our trial paves the way for a larger randomized controlled trial on using BC as the first feed for preterm infants with insufficient access to mother's own milk.

Probiotics for Preterm Infants: A Premature or Overdue Necrotizing Enterocolitis Prevention Strategy?

Common among preterm, very low birth weight (VLBW) and extremely low birth weight (ELBW) infants, necrotizing enterocolitis (NEC) is a gastrointestinal, infectious disease that remains a leading cause of morbidity and mortality among this high-risk population. To combat this devastating condition, research efforts have been redirected from treatment toward prevention strategies. Although there are several proposed risk-reduction strategies, one intervention gaining support is the administration of prophylactic enteral probiotics. Regardless of growing evidentiary support and a benign safety profile, neonatal providers have yet to embrace this therapy. This article provides an overview of the proposed benefits of probiotics, focusing on their role as a NEC prevention strategy. A review of several sentinel research studies targeting preterm, VLBW, and ELBW infants is provided. Considerations for ongoing research are reviewed. Finally, two evidence-based NEC prevention probiotics protocols are presented.

Introducing Donor Milk in a Neonatal Intensive Care Unit: A Developing Country's Perspective

OBJECTIVE

To replace 75 % of formula feeds by donor human milk (DHM) feeds in the first three days of life in neonates admitted to the neonatal intensive care unit (NICU).

METHODS

It was a prospective observational study in the NICU in a resource-limited set up in India. All neonates admitted during December 2013 and August 2014, were included in the study without any exclusion. Expressed DHM was administered within 2-3 h of manual expression without refrigeration or pasteurization. It was left standing at room temperature in a covered stainless steel container prior to use. Prospective entries of 2 hourly neonatal feeds, for first 3 d of life, (36 entries) were made in the charts. Main outcome was the desired percentage replacement of formula feeds.

RESULTS

Total 168 neonates were admitted to the NICU over the study period. Their median [Interquartile range (IQR); Range] gestation and birth weight was 37 (36, 38; 24-42) wk and 2300 (2100, 2700; 500-2950) g respectively. A total of 4136/6027 (68.6 %) charted feeds were of human milk and 1891(31.4 %) were of formula milk. Thus, 68.6 % of formula feeds were replaced by DHM. Neonates weighing ≤2 kg were at a lower risk of getting >25 % formula feeds.

CONCLUSIONS

A simple low cost method was effective in replacing a significant proportion of formula feeds by DHM in the first three days of life for neonates in a resource poor set up.

Early versus Delayed Human Milk Fortification in Very Low Birth Weight Infants-A Randomized Controlled Trial

OBJECTIVE

To compare the effect of initiating human milk fortification at 2 different feeding volumes on feeding intolerance and the time to reach full feeding volume.

STUDY DESIGN

Very low birth weight infants (n = 100) were prospectively randomized to early fortification (EF) (beginning at a feeding volume of 20 mL/kg/d) or delayed fortification (at a feeding volume of 100 mL/kg/d). We employed a standardized feeding protocol and parenteral nutrition guidelines for the nutritional management of all study infants.

RESULTS

The median days to reach full feeding volumes were equivalent in the 2 groups (20 vs 20, P = .45). No significant difference was observed in the total number of episodes of feeding intolerance (58 vs 57). Two cases of necrotizing enterocolitis (Bell stage ≥2) and deaths occurred in each group. Median daily protein intake (g/kg/d) was higher in EF group in week 1 (3.3 [3.2, 3.5] vs 3.1 [2.9, 3.3], P < .001), week 2 (3.6 [3.5, 3.8] vs 3.2 [2.9, 3.4], P < .001), and week 3 (3.7 [3.4, 3.9] vs 3.5 [2.8, 3.8], P = .006). Cumulative protein intake (g/kg) in the first 4 weeks of life was higher in EF group (98.6 [93.8, 104] vs 89.6 [84.2, 96.4], P < .001).

CONCLUSIONS

Very early human milk fortification may improve early protein intake in very low birth weight infants without increasing frequencies of adverse events.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01988792.

Clinical Benefits of Milk Fat Globule Membranes for Infants and Children

The milk fat globule membrane (MFGM) in breast milk contains many bioactive components. Infant formulas traditionally have been devoid of the MFGM fraction, but dairy technology now has made the addition of bovine MFGM technically feasible. We identified 6 double-blinded randomized controlled trials exploring the effects of MFGM supplementation on the diets of infants or children. Results suggest that supplementation is safe and indicate positive effects on both neurodevelopment and defense against infections. MFGM supplementation of infant formula may narrow the gap in cognitive performance and infection rates between breastfed and formula-fed infants. Because of the small number of studies and the heterogeneity of interventions, more high-quality double-blinded randomized controlled trials are needed, with well characterized and clearly defined MFGM fractions, before firm conclusions on the effects of MFGM supplementation on the health and development of infants can be drawn.

Outbreak of extended-spectrum β-lactamase-producing Escherichia coli transmitted through breast milk sharing in a neonatal intensive care unit

BACKGROUND

Routine surveillance in a neonatal intensive care unit (NICU) showed an increased detection of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) in August 2012, following nearly a year without detection.

AIM

To describe the investigation and interventions by a hospital infection control team of an outbreak of ESBL-E. coli in a NICU.

METHODS

Six neonates with positive cultures of ESBL-E. coli (five with respiratory colonization, one with a urinary tract infection), control infants who were negative for ESBL-E. coli during the study period, and mothers who donated their breast milk were included. A case-control study was performed to identify possible risk factors for positive ESBL-E. coli cultures and molecular typing of isolated strains by pulsed-field gel electrophoresis.

FINDINGS

The odds ratio for ESBL-E. coli infection after receiving shared unpasteurized breast milk during the study period was 49.17 (95% confidence interval: 6.02-354.68; P < 0.05). The pulsed-field gel electrophoresis pattern showed that all strains were identical, and the same pathogen was detected in freshly expressed milk of a particular donor. After ceasing the breast milk sharing, the outbreak was successfully terminated.

CONCLUSION

This outbreak indicates that contamination of milk packs can result in transmission of a drug-resistant pathogen to newborn infants. Providers of human breast milk need to be aware of the necessity for low-temperature pasteurization and bacterial cultures, which should be conducted before and after freezing, before prescribing to infants.