Home use of breast milk fortifier to promote postdischarge growth and breast feeding in preterm infants: a quality improvement project

Human Milk Fortifier After Neonatal Intensive Care Unit Discharge Improves Human Milk Usage Rates for Preterm Infants

BACKGROUND

A common neonatal intensive care unit (NICU) discharge feeding strategy for preterm infants with growth failure who are fed exclusively expressed human milk (EHM) has been to enrich mother's own milk with formula powder or supplement 2-3 feeds per day with formula. However, this strategy displaces human milk from the diet. Our NICU recently adopted the standard practice of adding commercial human milk fortifier (HMF) to human milk feedings after discharge.

OBJECTIVES

We aimed to compare breastfeeding rates and growth using the aforementioned 2 strategies.

METHODS

Preterm infants (<34 wk of gestation at birth) exclusively feeding EHM fortified with HMF at 2 weeks before discharge were included in this retrospective study. The HMF group (n = 92) continued fortifying with HMF at home, whereas the historical comparison group (n = 35) received our previous guidance to enrich or supplement using postdischarge formula.

RESULTS

Rates of human milk exclusivity after discharge decreased significantly less in the HMF group than those in the historical comparison group (to 83% compared with 39% at the first outpatient visit and 27% compared with 6%, respectively, at the second outpatient visit). Rates of any EHM feedings were also significantly higher in the HMF group. Fenton z-scores for weight, length, and head circumference were not significantly different between the groups.

CONCLUSIONS

Continuing EHM fortification with HMF after NICU discharge, rather than enriching or supplementing with postdischarge infant formula, increases rates of feeding EHM for ≥3 mo but does not affect growth.

Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot

Background

Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system.

Aim

To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies.

Method

We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study.

Results

Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth.

Conclusion

A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.

Influence of Full Oral Feeding Acquisition on Growth of Premature Infants

OBJECTIVE

The main objective was to describe the impact of full oral feeding achievement in very low birth weight infants on weight, length, and head circumference, measured as the change in z-score from 32 weeks to discharge, the time at which full oral feeding occurs.

METHODS

This was a longitudinal retrospective observational study on infants younger than 30 weeks of gestational age, admitted to the Neonatology Unit of La Paz University Hospital, Madrid (Spain), from January 1, 2019 to December 31, 2019. The infant's anthropometric characteristics (weight, height, and head circumference) were compared at birth, at 32, 34, and 36 weeks of gestational age, at the time of full oral feeding, and at discharge from the unit.

RESULTS

A total of 66 infants were included, gestational age at birth range from 24 to 30. Full oral intake occurred at 37.1 ± 2.1 weeks postmenstrual age (PMA). We found an inverse correlation between gestational age at birth and birth weight with PMA at which full oral feeding (FOF) is achieved. PMA at discharge was 38.6 ± 2.5 weeks. Age of full oral intake and discharge occurred later in infants who had patent ductus arteriosus, retinopathy of prematurity, and sepsis or received a blood transfusion. A positive correlation was found between days of oxygen and both parameters. However, we found no relationship between necrotizing enterocolitis or intraventricular hemorrhage with age at full oral feeding or age at discharge.

CONCLUSIONS

The transition from gastric tube to oral intake did not affect growth. We found a close relationship between preterm infants birth, earlier younger than 30 weeks of gestational age, and low birth weight, with a delay in full oral feeding achievement that correlated with age at discharge.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

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.

The Role of Nutrition in the Prevention and Management of Bronchopulmonary Dysplasia: A Literature Review and Clinical Approach

Bronchopulmonary dysplasia (BPD) remains the most common severe complication of preterm birth, and nutrition plays a crucial role in lung growth and repair. A practical nutritional approach for infants at risk of BPD or with established BPD is provided based on a comprehensive literature review. Ideally, infants with BPD should receive a fluid intake of not more than 135-150 mL/kg/day and an energy intake of 120-150 kcal/kg/day. Providing high energy in low volume remains a challenge and is the main cause of growth restriction in these infants. They need a nutritional strategy that encompasses early aggressive parenteral nutrition and the initiation of concentrated feedings of energy and nutrients. The order of priority is fortified mother's own milk, followed by fortified donor milk and preterm enriched formulas. Functional nutrient supplements with a potential protective role against BPD are revisited, despite the limited evidence of their efficacy. Specialized nutritional strategies may be necessary to overcome difficulties common in BPD infants, such as gastroesophageal reflux and poorly coordinated feeding. Planning nutrition support after discharge requires a multidisciplinary approach to deal with multiple potential problems. Regular monitoring based on anthropometry and biochemical markers is needed to guide the nutritional intervention.

The role of breast milk fortifier in the post-discharge nutrition of preterm infants

Infants born prematurely are often discharged from hospital before 37 weeks post-menstrual age. While breastfeeding will meet all the nutritional requirements of full-term infants, these preterm infants may need enhanced levels of protein, minerals and possibly energy to ensure optimum growth, bone mineralisation and neurological development. To meet these additional nutrient needs in the neonatal unit, it is currently recommended that multinutrient breast milk fortifier is added to maternal breast milk. There may also be benefits in continuing to provide fortified milk after discharge, potentially including improved growth and preserving breastfeeding, and this is increasingly becoming a recognised practice in some neonatal units. This article presents the discussion and consensus of a multidisciplinary panel of neonatologists, neonatal dietitians, a GP and a neonatal outreach sister. The aim is to develop guidance on providing safe and effective nutritional supplementation for preterm infants after discharge in order to maintain optimal growth. This guidance is aimed at community healthcare staff and is based on the limited evidence available, using shared best practice and expertise.

Effect of the Addition of Human Milk Fortifier to Breast Milk on the Early Recovery of Infants After Congenital Cardiac Surgery

Objective: This article studied the effect of breast milk supplemented with human milk fortifier (HMF) on the early recovery of infants after congenital cardiac surgery. Methods: Infants undergoing congenital cardiac surgery were randomly divided into an intervention group (n = 27) and a control group (n = 27). Infants in the intervention group received HMF, and those in the control group were exclusively breastfed. The nutritional indicators at discharge, the postoperative recovery status, and nutritional-related complications were recorded. Results: Compared with the control group at the time of discharge, the weight and albumin and prealbumin levels of the intervention group were significantly increased (P < 0.05). The length of hospital stay of the intervention group was significantly reduced compared with that of the control group (P < 0.05). Although the length of ICU stay for the intervention group was shorter than that of the control group, the difference was not significant (P > 0.05). No significant difference in the incidence of postoperative nutrition-related complications was noted between the two groups (P > 0.05). Conclusion: Compared with breastfeeding alone, with HMF can improve postoperative weight gains, reduce the length of stay, and promote infants' early recovery after congenital cardiac surgery.

The use of Breast Milk Fortifier in Preterm Infants by paediatric dietitians in the UK

BACKGROUND

Breast milk is the feed of choice for premature infants, although its nutritional composition is not always sufficient to meet their raised nutritional requirements. The addition of a multi-nutrient breast milk fortifier (BMF) to breastmilk is recommended; however, international guidelines on the use of BMF are inconsistent. The present study aimed to explore the use of BMF in preterm infants by paediatric dietitians in the UK.

METHODS

A questionnaire was designed and sent to members of the British Dietetic Association neonatal specialist group (n = 100) using a secure online platform. Descriptive statistics were calculated.

RESULTS

Forty dietitians completed the survey, all of whom used BMF. Local hospital BMF guidelines were available to 77.5% (n = 31). The most commonly used criteria for commencing BMF were: tolerating a feed volume of 150 mL kg^-1  day^-1 (72.5%, n = 29), a gestational age <34 weeks (67.5%, n = 27) and a birth weight <1500 g (60%, n = 24). The primary contraindication for the use of BMF was necrotising enterocolitis (NEC). The majority of respondents used standard fortification, with individualised fortification available to only 12.5% (n = 5). The most common indicators for discontinuing BMF were on discharge home (67.5%, n = 27), satisfactory growth (65%, n = 26) or feeding directly from the breast (62.5%, n = 25).

CONCLUSIONS

Although BMF is used more proactively in UK neonatal units than previously, variation in practice remains. Individualised fortification is very uncommon and caution remains regarding risk of NEC. The development of national guidelines on the use of BMF would help to standardise nutritional care in neonatal units.

Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification

Evidence indicates that human milk (HM) is the best form of nutrition uniquely suited not only to term but also to preterm infants conferring health benefits in both the short and long-term. However, HM does not provide sufficient nutrition for the very low birth weight (VLBW) infant when fed at the usual feeding volumes leading to slow growth with the risk of neurocognitive impairment and other poor health outcomes such as retinopathy and bronchopulmonary dysplasia. HM should be supplemented (fortified) with the nutrients in short supply, particularly with protein, calcium, and phosphate to meet the high requirements of this group of babies. In this paper the European Milk Bank Association (EMBA) Working Group on HM Fortification discusses the existing evidence in this field, gives an overview of different fortification approaches and definitions, outlines the gaps in knowledge and gives recommendations for practice and suggestions for future research. EMBA recognizes that "Standard Fortification," which is currently the most utilized regimen in neonatal intensive care units, still falls short in supplying sufficient protein for some VLBW infants. EMBA encourages the use of "Individualized Fortification" to optimize nutrient intake. "Adjustable Fortification" and "Targeted Fortification" are 2 methods of individualized fortification. The quality and source of human milk fortifiers constitute another important topic. There is work looking at human milk derived fortifiers, but it is still too early to draw precise conclusions about their use. The pros and cons are discussed in this Commentary in addition to the evidence around use of fortifiers post discharge.