Fortified human milk: nature's way to feed premature infants

Peptides Released from Foremilk and Hindmilk Proteins by Breast Milk Proteases Are Highly Similar

Human milk contains active proteases that initiate hydrolysis of milk proteins within the mammary gland. Milk expressed at the beginning of feeding is known as foremilk and that at the end of feeding is known as hindmilk. As hindmilk contains higher fat, vitamins A and E, and higher calories than foremilk, feeding only hindmilk initially and reserving foremilk for later are practiced in some neonatal intensive care units. This study investigated the difference in peptide profiles, predicted milk protease activities, and bioactive peptides between foremilk and hindmilk. Bioactive peptides are short fragments of proteins that influence biological processes. Four mothers pumped 10 mL of their foremilk and 10 mL of their hindmilk into iced containers prepared with antiproteases and the samples were immediately frozen. The peptide profile of each sample was analyzed by liquid chromatography nano-electrospray ionization Orbitrap Fusion tandem mass spectrometry. Peptide abundance (sum of ion intensities) and count (number of unique peptide sequences) in each milk sample were determined from this analysis. The specific enzymes that participated in peptide release were predicted based on the amino acids positioned at each cleavage site. Peptide bioactivity was predicted based on homology to a known functional peptide database and two bioactivity prediction algorithms. Hindmilk contained a higher count of peptides than foremilk. The higher number of unique peptide sequences in hindmilk was related to hydrolysis of β-casein, osteopontin, α_s1-casein and mucin-1 via plasmin and elastase cleavage, and possible aminopeptidase and carboxypeptidase activities. Though hindmilk contained a greater number of peptides than foremilk, the overall peptide abundance did not differ and most of the total peptide abundance derived from peptide sequences that were present in both milk types. The presence of higher numbers of predicted bioactive peptides in the hindmilk could indicate that the practice of providing hindmilk rather than foremilk to premature infants could positively impact health outcomes; however, as there are few differences in overall peptide abundance, the overall effect is likely limited.

Volume of foremilk, hindmilk, and total milk produced by mothers of very preterm infants born at less than 28 weeks of gestation

The purpose of this study is to describe foremilk volume (milk produced in the first 3 minutes of pumping), hindmilk volume (remainder of milk produced), and total milk volume produced by mothers of very preterm infants at 3 weeks postpartum and associated factors. Mothers (n = 24) mechanically pump their breasts a median (minimum, maximum) of 7 times (5, 9 times) per 24 hours for a total of 15 minutes (9.4, 23.9 minutes) each time. Foremilk, hindmilk, and total milk volumes are 183 mL per 24 hours (80, 810), 318 mL per 24 hours (98, 1007), and 545 mL per 24 hours (224, 1817), respectively. Milk volumes are not associated with mother's age, race or ethnic background, education, parity, reported prepregnancy body mass index, previous breastfeeding experience, frequency of milk pumping, longest time between pumps, infant birth weight, or multiple births. The degree of pre-maturity (<26 weeks vs 26(0/7)-27(6/7) weeks) is significantly related to the relative proportion of foremilk/hindmilk volumes (45:55 vs 36:65, respectively).

Nutrient composition of hindmilk produced by mothers of very low birth weight infants born at less than 28 weeks' gestation

The objectives of this study were to describe and compare retinol, alpha-tocopherol and gamma-tocopherol, fat, energy, and nitrogen concentrations between the foremilk and hindmilk fractions of 24-hour milk collected by 24 mothers of very preterm (< 28 weeks' gestation) infants and to relate milk vitamins A and E content to maternal vitamin intake. Concentrations of retinol were significantly higher in hindmilk than in foremilk (1.6-fold), as were concentrations of alpha-tocopherol (1.6-fold), gamma-tocopherol (1.5-fold), fat (1.7-fold), energy (1.3-fold), and nitrogen (1.05-fold). Retinol, alpha-tocopherol, and gamma-tocopherol were positively related (P < .05) to milk fat and energy but not to maternal intake. Estimates of vitamins A and E intakes of infants fed hindmilk with added human milk fortifier surpassed current recommended upper level of intakes. The higher fat-soluble vitamin content of hindmilk produced by mothers of very low birth weight infants needs to be considered in the design and recommendations for use of human milk fortifier.

Breast milk composition in a cohort of pre-term infants' mothers followed in an ambulatory programme in Colombia

OBJECTIVES

Describing preterm breast milk evolution and composition according to gestational age (GA) and postnatal age (PNA) in a cohort of mothers cared for in an ambulatory Kangaroo Mother Care Program (KMCP) in a developing country.

METHODS

A cohort involving 113 mothers who delivered 'healthy' preterms adequate for GA was assembled. Mothers received intensive breastfeeding support before discharge. Samples of both fore- and hind milk were obtained at entry into KMCP and weekly thereafter, until term. Composition was described according to PNA and postconceptional age (PCA).

RESULTS

Protein concentration varied inversely with both PCA and PNA. Fat concentration was consistently higher in hind milk than in fore milk samples of the same feed. Lactose increased steadily with PCA. Calcium/phosphorus ratios were stable, close to 2:1 and content of both was similar in samples of different PCA and PNA.

CONCLUSION

Minerals concentration could be inadequate for preterms. Protein concentration decreases steadily to mature milk levels by the third week of PNA, regardless of birth GA. Therefore, from the third week of PNA onwards, protein content could be insufficient to satisfy needs of preterms born at 32 weeks or less. Feeding hind milk could increase caloric density and fat intake to better meet preterms' nutritional needs.

Breastfeeding: making the difference in the development, health and nutrition of term and preterm newborns

Breastfeeding is the natural and safe way of feeding small infants, providing nutritional, immunological, psychological and economic recognized and unquestionable advantages. These qualities are especially important in premature infants, because of their vulnerability. Despite highly desirable, there is, in general, little success in breastfeeding preterm infants, especially in special care neonatal units. There are evidences that a high supportive hospital environment, with an interdisciplinary team, makes possible to these infants to be breastfed. In this article, the authors present an up-to-date review about the components of human milk and its unique characteristics, as well as describes aspects that make the breast milk particularly suitable for feeding the premature newborn.

Recipient prioritization and use of human milk in the hospital setting

Donor human milk is used to treat and protect the health and development of preterm and term infants, and occasionally to treat illnesses in older children and adults. When donor human milk is in short supply nationally, decisions must be made with regard to the priority of recipients. This article reviews the importance of donor human milk in the hospital setting, describes the factors that are considered by the Human Milk Banking Association of North America when prioritizing eligible recipients if there is a shortage of donor milk, and discusses how human milk should be stored and handled in the hospital setting.

Breastfeeding the high risk infant: implications for midwifery management

The mother of a high risk infant is confronted with numerous parenting challenges, not the least of which is the decision about how to nourish her vulnerable newborn. Successful breastfeeding depends on overcoming obstacles posed by infant condition, maternal health, and the neonatal intensive care environment. These obstacles include maternal separation from the nursing infant during hospitalization, delayed initiation of the expression of breast milk due to maternal illness and/or surgery, the inability to suckle her infant or feed on demand, and the lack of sufficient maternal follow-up after discharge. This article reviews the benefits of providing breast milk to high risk infants, problems that may be encountered by mothers of high risk infants, and the interventions that may be used by the midwife to facilitate the breastfeeding process.