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Roskes L, Chamzas A, Ma B, Medina AE, Gopalakrishnan M, Viscardi RM, Sundararajan S. Early human milk feeding: Relationship to intestinal barrier maturation and postnatal growth. Pediatr Res 2024:10.1038/s41390-024-03622-5. [PMID: 39397156 DOI: 10.1038/s41390-024-03622-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/15/2024] [Accepted: 09/09/2024] [Indexed: 10/15/2024]
Abstract
OBJECTIVES Early exposure to mother's own milk (MOM) promotes intestinal barrier maturation in preterm infants. We hypothesized (1) donor human milk (DHM) supplementation reduces intestinal permeability (IP) similar to exclusive MOM and (2) early HM exposure and low IP at 7-10 days postnatal age (PNA) are associated with improved growth outcomes. METHODS IP was measured by the standard sugar absorption test (SAT) in infants <33 weeks gestation between 7-10 days PNA. Nutritional and anthropometric data were recorded. Postnatal growth failure (PNGF) was defined as a decrease in weight z-score >1 from birth to discharge to home. RESULTS Of 158 preterm infants, the mean (SD) gestational age was 29.9(2.3) weeks and birthweight 1388(424) g. Diet prior to SAT was exclusive MOM [N = 55(35%)], DHM ± MOM [N = 52(33%)], or preterm formula±MOM [N = 51(32%)]. The mean Lactulose(La)/Rhamnose(Rh) ratio was lower in the exclusive MOM [0.06(0.07)] and DBM ± MOM [0.05(0.07)] groups compared to the preterm formula±MOM group [0.11(0.11)], p < 0.01). Cumulative intake >150 ml/kg MOM ± DHM, but not preterm formula within 7-10 days PNA was associated with early intestinal barrier maturation. Low IP was not associated with lower risk of PNGF at discharge. CONCLUSIONS Low IP is associated with cumulative intake of MOM alone or supplemented with DHM > 150 ml/kg within 7-10 days PNA. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov NCT01756040 ; web link to study on registry: https://clinicaltrials.gov/study/NCT01756040 . IMPACT Key message Early intestinal barrier maturation is associated with cumulative intake of exclusive MOM alone or supplemented with DHM > 150 ml/kg within 7-10 days after birth, but is not associated with lower risk of PNGF at time of discharge. What it adds to existing literature? This observational study is the first study to demonstrate that supplemental DHM promotes intestinal barrier maturation similar to MOM alone. What is the impact? The findings underscore the importance of early introduction of human milk feeds as MOM or MOM supplemented with DHM in sufficient volume to promote early intestinal barrier maturation.
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Affiliation(s)
- Lisa Roskes
- Department of Pediatrics, University of Maryland School of Medicine, 22 S, Greene St, Baltimore, Maryland, 21201, USA
| | - Athanasios Chamzas
- Center for Translational Medicine, University of Maryland School of Pharmacy, S Greene St, Baltimore, Maryland, 21201, USA
| | - Bing Ma
- Institute for Genome Sciences, Department of Microbiology and Immunology, University of Maryland School of Medicine, 22 S Greene St, Baltimore, Maryland, 21201, USA
| | - Alexandre E Medina
- Department of Pediatrics, University of Maryland School of Medicine, 22 S, Greene St, Baltimore, Maryland, 21201, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, S Greene St, Baltimore, Maryland, 21201, USA
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland School of Medicine, 22 S, Greene St, Baltimore, Maryland, 21201, USA
| | - Sripriya Sundararajan
- Department of Pediatrics, University of Maryland School of Medicine, 22 S, Greene St, Baltimore, Maryland, 21201, USA.
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Girard M, Janvier A, Barrington KJ, Myhal G, St-Pierre C, Fournier D, Chouinard MC, Lewin A, Renaud C. Donor Milk Expression Habits: Can we Favor Hindmilk Banking for Extremely Preterm Infants? Breastfeed Med 2024. [PMID: 39183713 DOI: 10.1089/bfm.2024.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Background: Extremely preterm infants often receive donor milk. Hindmilk, which is released more than 3 minutes after letdown, could be advantageous due to its elevated levels of fat and calorie density. Donor milk expression habits may influence milk composition but have not yet been investigated. This study aims to assess the practices of milk donors and the feasibility of hindmilk expression. Methods: Active milk donors in Québec were questioned using an online survey about their milk expression habits and whether hindmilk donation would be acceptable to them. Answers were analyzed using mixed methods. Results: Of 181 donors, 126 fully completed the questionnaire (70%); 57% reported expressing donated milk between breastfeeds; 15% reported simultaneously breastfeeding while expressing donated milk from the other breast; 12% reported breastfeeding their baby on each breast, then expressing donated milk (hindmilk). The majority (66%) would be willing to change their habits most or all the time to provide hindmilk for preterm infants. The main themes invoked by respondents in open-ended answers were altruism and gratitude for being able to help others. However, 15% commented on the complexity of milk expression or that adding further complexity might discourage them from donating. Conclusions: Expression practices are variable, which may lead to variability in donor milk composition. Most donors would agree to change their expression habits in favor of giving hindmilk to help the most fragile infants. More information is needed on how changing recommendations for milk expression might impact the supply and composition of donor milk.
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Affiliation(s)
- Mélissa Girard
- Medical Affairs and Innovation, Héma-Québec, Quebec, Canada
- Department of Microbiology-Infectious Diseases and Immunology, Faculty of Medicine, Laval University, Quebec, Canada
| | - Annie Janvier
- Department of Pediatrics, CHU Sainte-Justine, University of Montréal, Montréal, Canada
- Division of Neonatology, Research Center, Unité d'éthique clinique, Unité de soins palliatifs, Bureau du Partenariat Patients-Familles-Soignants; CHU Sainte-Justine, Montréal, Canada
| | - Keith J Barrington
- Department of Pediatrics, CHU Sainte-Justine, University of Montréal, Montréal, Canada
| | - Geneviève Myhal
- Customer Experience and Communications, Héma-Québec, Quebec, Canada
| | | | | | | | - Antoine Lewin
- Medical Affairs and Innovation, Héma-Québec, Quebec, Canada
| | - Christian Renaud
- Medical Affairs and Innovation, Héma-Québec, Quebec, Canada
- Department of Pediatrics, CHU Sainte-Justine, University of Montréal, Montréal, Canada
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Simonsen MB, Kappel SS, Aunsholt L, Möller S, Sangild PT, Zachariassen G. Mineral supplementation for very preterm infants fed fortified human milk. J Pediatr Gastroenterol Nutr 2024; 78:1389-1397. [PMID: 38587119 DOI: 10.1002/jpn3.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/23/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024]
Abstract
OBJECTIVES The safety and feasibility of human milk fortification with bovine colostrum (BC) were investigated in very preterm infants (FortiColos trial, NCT03537365). The BC product contained lower calcium, phosphate, and iron levels compared to the conventional fortifier (CF). We tested whether fortification with BC plus extra phosphate was sufficient to support the infants' mineral status assessed by blood biochemistry. METHODS In a randomised controlled trial (FortiColos, NCT03537365), mineral status was compared after fortification with BC versus CF. Blood calcium, phosphate, and haemoglobin were determined before and up to 3 weeks after the start of fortification (at the mean age of 8-9 days). The maximum supplemental doses of calcium, phosphate, and iron given were retrieved from patient medical records. Results were adjusted for gestational age, birth weight, and enteral nutrition with the mother's own milk and/or donor human milk. RESULTS Blood values of calcium, phosphate, and haemoglobin were similar between groups. Infants in both groups required supplementation with calcium and phosphate, but infants fed BC required higher maximum doses of phosphate and calcium (p < 0.05) to maintain acceptable blood values. Regardless of fortification groups, the most immature (<29 weeks of gestation) and small for gestational age infants showed a higher risk for requiring additional phosphate (odds ratio [OR]: 3.9, p < 0.001; OR: 2.14, p = 0.07, respectively). CONCLUSIONS The use of BC as a fortifier for human milk requires additional phosphate and calcium relative to a CF. Regardless of the fortification product, the most immature and small infants require additional mineral supplementation.
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Affiliation(s)
- Marie Bendix Simonsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Susanne Soendergaard Kappel
- Section of Comparative Paediatrics and Nutrition, University of Copenhagen, Frederiksberg, Denmark
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lise Aunsholt
- Section of Comparative Paediatrics and Nutrition, University of Copenhagen, Frederiksberg, Denmark
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Per Torp Sangild
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Section of Comparative Paediatrics and Nutrition, University of Copenhagen, Frederiksberg, Denmark
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Zachariassen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
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4
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Holgersen K, Rasmussen MB, Zamir I, Aunsholt L, Zachariassen G, Sangild PT. Glucose-regulatory hormones and growth in very preterm infants fed fortified human milk. Pediatr Res 2024:10.1038/s41390-024-03166-8. [PMID: 38580842 DOI: 10.1038/s41390-024-03166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 03/01/2024] [Accepted: 03/15/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Bovine colostrum (BC) contains a range of milk bioactive components, and it is unknown how human milk fortification with BC affects glucose-regulatory hormones in very preterm infants (VPIs). This study aimed to investigate the associations between hormone concentrations and fortification type, birth weight (appropriate/small for gestational age, AGA/SGA), milk intake, postnatal age, and body growth. METHODS 225 VPIs were randomized to fortification with BC or conventional fortifier (CF). Plasma hormones were measured before, one and two weeks after start of fortification. ΔZ-scores from birth to 35 weeks postmenstrual age were calculated. RESULTS Compared with CF, infants fortified with BC had higher plasma GLP-1, GIP, glucagon, and leptin concentrations after start of fortification. Prior to fortification, leptin concentrations were negatively associated with growth, while IGF-1 concentrations associated positively with growth during fortification. In AGA infants, hormone concentrations generally increased after one week of fortification. Relative to AGA infants, SGA infants showed reduced IGF-1 and leptin concentrations. CONCLUSION Fortification with BC increased the plasma concentrations of several glucose-regulatory hormones. Concentrations of IGF-1 were positively, and leptin negatively, associated with growth. Glucose-regulatory hormone levels were affected by birth weight, milk intake and postnatal age, but not closely associated with growth in VPIs. IMPACT Little is known about the variation in glucose-regulatory hormones in the early life of very preterm infants (VPIs). This study shows that the levels of glucose-regulatory hormones in plasma of VPIs are highly variable and modified by birth weight (appropriate or small for gestational age, AGA or SGA), the type of fortifier, enteral nutritional intake, and advancing postnatal age. The results confirm that IGF-1 levels are positively associated with early postnatal growth in VPIs, yet the levels of both IGF-1 and other glucose-regulatory hormones appeared to explain only a small part of the overall variation in growth rates.
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Affiliation(s)
- Kristine Holgersen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Martin Bo Rasmussen
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Itay Zamir
- Department of Clinical Sciences, Pediatrics unit, Umeå University, Umeå, Sweden
| | - Lise Aunsholt
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Gitte Zachariassen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network, Region of Southern Denmark, Odense, Denmark
| | - Per Torp Sangild
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
- Comparative Pediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Walter L, Clifford V, Sulfaro C, Brown R, Ribeiro D, Welvaert M, Shuttleworth G, Klein LD. Macronutrient content of pasteurised donor human milk: Variability between batches from single-donor pools at an Australian milk bank. J Paediatr Child Health 2023; 59:1281-1288. [PMID: 37880918 DOI: 10.1111/jpc.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/09/2023] [Accepted: 09/08/2023] [Indexed: 10/27/2023]
Abstract
AIM This study aimed to characterise the between-batch variability of pasteurised donor human milk (PDHM) produced from single-donor pools at Australian Red Cross Lifeblood's milk bank and identify key donor characteristics that predict macronutrient content. METHODS Macronutrient content from 200 batches of PDHM was measured using a mid-infrared human milk analyser (Miris, Uppsala, Sweden). Linear mixed models were used to study the impact of stage of lactation and gestational age on macronutrient content. Coefficients of determination (R2 ) were calculated to estimate the impact of the individual donor on overall variability. RESULTS Macronutrient content of PDHM varied considerably, with between-batch variations of 2.8 and 6.4-fold for protein and fat content, respectively. Mean crude protein content was 1.16 g/100 mL, ranging from 0.7 to 1.96 g/100 mL. Mean fat content was 3.85 g/100 mL, ranging from 1.46 to 9.39 g/100 mL. Stage of lactation was identified as a predictor for protein content and gestational age at birth for fat content. Individual donor effect explained 55 and 35% of the variance for fat and protein content, respectively. CONCLUSIONS This study highlights the variation in macronutrient content in PDHM at an Australian milk bank. Variability could be reduced through the implementation of targeted multiple-donor pooling using the key donor characteristics identified in this study along with the measurement of macronutrient content of individual donors at the time of first donation. However, the clinical benefit of a reduction in between-batch variation, achieved through multiple-donor pooling, would need to be assessed to justify additional efforts associated with PDHM processing changes.
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Affiliation(s)
- Leonie Walter
- Strategy and Growth, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia
| | - Vanessa Clifford
- Pathology and Clinical Governance, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia
- Laboratory Services, Royal Children's Hospital, Melbourne, Victoria, Australia
- Infection and Immunity, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Christine Sulfaro
- Strategy and Growth, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia
| | - Richard Brown
- Strategy and Growth, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia
| | - Daniel Ribeiro
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Marijke Welvaert
- Pathology and Clinical Governance, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia
| | - Glen Shuttleworth
- Pathology and Clinical Governance, Australian Red Cross Lifeblood, Melbourne, Victoria, Australia
| | - Laura D Klein
- Strategy and Growth, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia
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Tanaka M, Date M, Miura K, Ito M, Mizuno N, Mizuno K. Protein and Immune Component Content of Donor Human Milk in Japan: Variation with Gestational and Postpartum Age. Nutrients 2023; 15:2278. [PMID: 37242161 PMCID: PMC10221383 DOI: 10.3390/nu15102278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Donor human milk (DHM) is the second-best nutrition for preterm infants when their own mother's milk is unavailable. The nutrient content of human milk is influenced by various factors, including gestational and postpartum age, but there are no data regarding DHM composition in Japan. The aim of this study was to determine the protein and immune component content of DHM in Japan and to elucidate the effects of gestational and postpartum age on nutrient composition. From September 2021 to May 2022, 134 DHM samples were collected from 92 mothers of preterm and term infants. Protein concentrations in preterm DHM (n = 41) and term DHM (n = 93) were analyzed using a Miris Human Milk Analyzer. The concentrations of secretory immunoglobulin A (sIgA) and lactoferrin, major immune components, were measured using enzyme-linked immunosorbent assays. Preterm DHM exhibited higher protein content than term DHM (1.2 g/dL and 1.0 g/dL, respectively, p < 0.001), whereas sIgA content was higher in term DHM than in preterm DHM (110 μg/mL and 68.4 μg/mL, respectively, p < 0.001). Gestational age was negatively correlated with protein levels and positively correlated with sIgA and lactoferrin levels. Furthermore, a negative correlation was found between postpartum week and protein, sIgA, and lactoferrin concentrations. Our data suggest that gestational and postpartum age affects protein, sIgA, and lactoferrin concentrations in DHM. These results indicate the importance of nutritional analysis for the appropriate use of DHM in preterm infants.
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Affiliation(s)
- Miori Tanaka
- The Nippon Foundation Human Milk Bank, 17-10 Nihonbashi-koamicho, Chuo-ku, Tokyo 103-0016, Japan; (M.D.); (K.M.); (M.I.); (K.M.)
| | - Midori Date
- The Nippon Foundation Human Milk Bank, 17-10 Nihonbashi-koamicho, Chuo-ku, Tokyo 103-0016, Japan; (M.D.); (K.M.); (M.I.); (K.M.)
| | - Kumiko Miura
- The Nippon Foundation Human Milk Bank, 17-10 Nihonbashi-koamicho, Chuo-ku, Tokyo 103-0016, Japan; (M.D.); (K.M.); (M.I.); (K.M.)
- Faculty of Medicine, Oita University, 1-1 Hasamamachiidaigaoka, Yufu-shi, Oita 879-5593, Japan
| | - Mizuho Ito
- The Nippon Foundation Human Milk Bank, 17-10 Nihonbashi-koamicho, Chuo-ku, Tokyo 103-0016, Japan; (M.D.); (K.M.); (M.I.); (K.M.)
- School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Noriko Mizuno
- Japan Human Milk Bank Association, 4-4 Nihonbashi-hisamatsucho, Chuo-ku, Tokyo 103-8480, Japan;
| | - Katsumi Mizuno
- The Nippon Foundation Human Milk Bank, 17-10 Nihonbashi-koamicho, Chuo-ku, Tokyo 103-0016, Japan; (M.D.); (K.M.); (M.I.); (K.M.)
- Japan Human Milk Bank Association, 4-4 Nihonbashi-hisamatsucho, Chuo-ku, Tokyo 103-8480, Japan;
- Department of Pediatrics, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
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Tabasso C, Piemontese P, Pesenti N, Perrone M, Menis C, Liotto N, Amato O, Orsi A, Mallardi D, Mosca F, Roggero P. Pooling Strategies to Modify Macronutrient Content of Pasteurized Donor Human Milk. Breastfeed Med 2023; 18:370-376. [PMID: 37098175 DOI: 10.1089/bfm.2023.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Background: Donor human milk (DHM) is the recommended feeding for preterm infants when mother's own milk is unavailable or insufficient. DHM macronutrient's variability may have significant implications on preterm growth. Different pooling strategies could be used to improve the macronutrient content, facilitating the achievement of nutritional requirements of preterm. Objective: The aim was to compare the impact of random pooling (RP) and target pooling (TP) strategies on the macronutrient content of DHM and to identify which RP practice allows the achievement of a macronutrient composition as similar as possible to that achievable with TP. Methods: The macronutrient content of 1,169 single-donor pools was analyzed, and a TP strategy combining 2,3,4, or 5 single-donor pools was adopted. On the bases of single-donor pools' analyses, a simulation of 10,000 randomly selected pools for each configuration of donor considered and for different milk volume proportions was performed. Results: Regardless of the type of strategy and milk volume, as the number of donor per pool increases, the percentage of pools with a macronutrient content equal or higher than the reference values for human milk increases. Conclusion: When a TP strategy is not feasible, a RP strategy combining at least five donors should be performed to obtain a better macronutrient content of DHM.
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Affiliation(s)
- Chiara Tabasso
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pasqua Piemontese
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Pesenti
- Division of Biostatistics, Epidemiology, and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Michela Perrone
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Camilla Menis
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nadia Liotto
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Orsola Amato
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Orsi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Domenica Mallardi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Paola Roggero
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Cardoso M, Virella D, Papoila AL, Alves M, Macedo I, E Silva D, Pereira-da-Silva L. Individualized Fortification Based on Measured Macronutrient Content of Human Milk Improves Growth and Body Composition in Infants Born Less than 33 Weeks: A Mixed-Cohort Study. Nutrients 2023; 15:nu15061533. [PMID: 36986263 PMCID: PMC10052754 DOI: 10.3390/nu15061533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
The optimal method for human milk (HM) fortification has not yet been determined. This study assessed whether fortification relying on measured HM macronutrient content (Miris AB analyzer, Upsala, Sweden) composition is superior to fortification based on assumed HM macronutrient content, to optimize the nutrition support, growth, and body composition in infants born at <33 weeks' gestation. In a mixed-cohort study, 57 infants fed fortified HM based on its measured content were compared with 58 infants fed fortified HM based on its assumed content, for a median of 28 and 23 exposure days, respectively. The ESPGHAN 2010 guidelines for preterm enteral nutrition were followed. Growth assessment was based on body weight, length, and head circumference Δ z-scores, and the respective growth velocities until discharge. Body composition was assessed using air displacement plethysmography. Fortification based on measured HM content provided significantly higher energy, fat, and carbohydrate intakes, although with a lower protein intake in infants weighing ≥ 1 kg and lower protein-to-energy ratio in infants weighing < 1 kg. Infants fed fortified HM based on its measured content were discharged with significantly better weight gain, length, and head growth. These infants had significantly lower adiposity and greater lean mass near term-equivalent age, despite receiving higher in-hospital energy and fat intakes, with a mean fat intake higher than the maximum recommended and a median protein-to-energy ratio intake (in infants weighing < 1 kg) lower than the minimum recommended.
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Affiliation(s)
- Manuela Cardoso
- Nutrition Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 2890-495 Lisbon, Portugal
| | - Daniel Virella
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
| | - Ana Luísa Papoila
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Centre of Statistics and Its Applications, University of Lisbon, 1749-016 Lisbon, Portugal
| | - Marta Alves
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Centre of Statistics and Its Applications, University of Lisbon, 1749-016 Lisbon, Portugal
| | - Israel Macedo
- Neonatal Intensive Care Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 2890-495 Lisbon, Portugal
| | - Diana E Silva
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - Luís Pereira-da-Silva
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Nutrition Lab, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Medicine of Woman, Childhood and Adolescence Academic Area, NOVA Medical School, Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal
- CHRC-Comprehensive Health Research Centre, Nutrition Group, NOVA Medical School, Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal
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9
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Growth after implementing a donor breast milk program in neonates <33 weeks gestational age or birthweight <1500 grams: Retrospective cohort study. J Perinatol 2023; 43:608-615. [PMID: 36737571 PMCID: PMC9897884 DOI: 10.1038/s41372-023-01627-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Donor breast milk (DBM) feeding has been associated with less growth than formula in preterm infants. Zinc content in DBM is insufficient to support growth in preterm infants. OBJECTIVE To compare growth from birth to discharge, macro- and micronutrient intake and the frequency of poor growth before (Epoch-1) and after (Epoch-2) implementing a DBM program. METHODS Retrospective cohort study of 1069 infants born at < 33 weeks' gestational age or birthweight < 1500 g and fed using our adjustable feeding protocol with accurate serial length measurements. Growth was assessed by changes in Z-scores of weight, length and fronto-occipital circumference from birth to discharge. RESULTS Growth did not decrease significantly in Epoch-2. However, energy and protein intake increased by 5% and frequency of zinc and vitamin D supplementation increased by >30%. CONCLUSIONS DBM implementation did not significantly decrease growth from birth to discharge using our adjustable feeding protocol.
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Walker RE, Harvatine KJ, Ross AC, Wagner EA, Riddle SW, Gernand AD, Nommsen-Rivers LA. Fatty Acid Transfer from Blood to Milk Is Disrupted in Mothers with Low Milk Production, Obesity, and Inflammation. J Nutr 2023; 152:2716-2726. [PMID: 36208911 PMCID: PMC9840005 DOI: 10.1093/jn/nxac220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/26/2022] [Accepted: 09/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Obesity is associated with chronic inflammation and is a risk factor for insufficient milk production. Inflammation-mediated suppression of LPL could inhibit mammary uptake of long-chain fatty acids (LCFAs; >16 carbons). OBJECTIVES In an ancillary case-control analysis, we investigated whether women with low milk production despite regular breast emptying have elevated inflammation and disrupted transfer of LCFAs from plasma into milk. METHODS Data and specimens from a low milk supply study and an exclusively breastfeeding control group were analyzed, with milk production measured by 24-h test-weighing at 2-10 wk postpartum. Low milk supply groups were defined as very low (VL; <300 mL/d; n = 23) or moderate (MOD; ≥300 mL/d; n = 20) milk production, and compared with controls (≥699 mL/d; n = 18). Serum and milk fatty acids (weight% of total) were measured by GC, serum and milk TNF-α by ELISA, and serum high-sensitivity C-reactive protein (hsCRP) by clinical analyzer. Group differences were assessed by linear regression models, chi-square exact tests, and Kruskal-Wallis nonparametric tests. RESULTS VL cases, as compared with MOD cases and controls, had higher prevalence of elevated serum hsCRP (>5 mg/L; 57%, 15%, and 22%, respectively; P = 0.004), detectable milk TNF-α (67%, 32%, and 33%, respectively; P = 0.04), and obesity (78%, 40%, and 22%, respectively; P = 0.003). VL cases had lower mean ± SD LCFAs in milk (60% ± 3%) than MOD cases (65% ± 4%) and controls (66% ± 5%) (P < 0.001). Milk and serum LCFAs were strongly correlated in controls (r = 0.82, P < 0.001), but not in the MOD (r = 0.25, P = 0.30) or VL (r = 0.20, P = 0.41) groups (Pint < 0.001). CONCLUSIONS Mothers with very low milk production have significantly higher obesity and inflammatory biomarkers, lower LCFAs in milk, and disrupted association between plasma and milk LCFAs. These data support the hypothesis that inflammation disrupts normal mammary gland fatty acid uptake. Further research should address impacts of inflammation and obesity on mammary fatty acid uptake for milk production.
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Affiliation(s)
- Rachel E Walker
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Kevin J Harvatine
- Department of Animal Science, The Pennsylvania State University, University Park, PA, USA
| | - A Catharine Ross
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
| | - Erin A Wagner
- College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Sarah W Riddle
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Alison D Gernand
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA, USA
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11
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Fatty acid transfer from blood to milk is disrupted in mothers with low milk production, obesity, and inflammation. J Nutr 2022. [DOI: 10.1016/j.tjnut.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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12
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Gomez J, Wardell D. Nurse-Driven Interventions for Improving ELBW Neurodevelopmental Outcomes. J Perinat Neonatal Nurs 2022; 36:362-370. [PMID: 36288443 DOI: 10.1097/jpn.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Survival rates for extremely low-birth-weight (ELBW) infants are improving as neurodevelopmental impairment (NDI) rates stay stable, thereby increasing the overall number of infants with NDI. Although there are many determinants of NDI in this population, nutritional factors are of interest because they are readily modifiable in the clinical setting. Nurses can influence nutritional factors such as improving access to human milk feeding, using growth monitoring, establishing feeding policies, implementing oral care with colostrum, facilitating kangaroo care, and providing lactation education for the mother. All of these measures assist in leading to a decrease in NDI rates among ELBW infants.
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Affiliation(s)
- Jessica Gomez
- Section of Neonatology, Department of Pediatrics, The University of Texas Health Science Center at Houston, Houston (Ms Gomez); and Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston (Dr Wardell)
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13
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Asbury MR, Shama S, Sa JY, Bando N, Butcher J, Comelli EM, Copeland JK, Forte V, Kiss A, Sherman PM, Stintzi A, Taibi A, Tomlinson C, Unger S, Wang PW, O'Connor DL. Human milk nutrient fortifiers alter the developing gastrointestinal microbiota of very-low-birth-weight infants. Cell Host Microbe 2022; 30:1328-1339.e5. [PMID: 35987195 DOI: 10.1016/j.chom.2022.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/14/2022] [Accepted: 07/15/2022] [Indexed: 11/30/2022]
Abstract
Nutrient fortifiers are added to human milk to support the development of very-low-birth-weight infants. Currently, bovine-milk-based fortifiers (BMBFs) are predominantly administered, with increasing interest in adopting human-milk-based fortifiers (HMBFs). Although beneficial for growth, their effects on the gastrointestinal microbiota are unclear. This triple-blind, randomized clinical trial (NCT02137473) tested how nutrient-enriching human milk with HMBF versus BMBF affects the gastrointestinal microbiota of infants born < 1,250 g during hospitalization. HMBF-fed infants (n = 63, n = 269 stools) showed lower microbial diversity, altered microbial community structure, and changes in predicted microbial functions compared with BMBF-fed infants (n = 56, n = 239 stools). HMBF-fed infants had higher relative and normalized abundances of unclassified Enterobacteriaceae and lower abundances of Clostridium sensu stricto. Post hoc analyses identified dose-dependent relationships between individual feed components (volumes of mother's milk, donor milk, and fortifiers) and the microbiota. These results highlight how nutrient fortifiers impact the microbiota of very-low-birth-weight infants during a critical developmental window.
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Affiliation(s)
- Michelle R Asbury
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Sara Shama
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Jong Yup Sa
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Nicole Bando
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - James Butcher
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON K1N 6N5, Canada; Ottawa Institute of Systems Biology, University of Ottawa, Ottawa ON, K1H 8M5, Canada
| | - Elena M Comelli
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Julia K Copeland
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, ON M5S 3B2, Canada
| | - Victoria Forte
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Alex Kiss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada; Evaluative and Clinical Sciences, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
| | - Philip M Sherman
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Cell Biology Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada; Faculty of Dentistry, University of Toronto, Toronto, ON M5G 1X3, Canada
| | - Alain Stintzi
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, ON K1N 6N5, Canada; Ottawa Institute of Systems Biology, University of Ottawa, Ottawa ON, K1H 8M5, Canada
| | - Amel Taibi
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Christopher Tomlinson
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada; Division of Neonatology, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada; Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada; Rogers Hixon Ontario Human Milk Bank, Toronto, ON M5G 1X5, Canada
| | - Pauline W Wang
- Centre for the Analysis of Genome Evolution and Function, University of Toronto, Toronto, ON M5S 3B2, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada; Translational Medicine Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, Toronto, ON M5S 1A8, Canada; Department of Pediatrics, Sinai Health, Toronto, ON M5G 1X5, Canada; Rogers Hixon Ontario Human Milk Bank, Toronto, ON M5G 1X5, Canada.
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Maternal dietary intake, nutritional status and macronutrient composition of human breast milk: systematic review. Br J Nutr 2022; 127:1796-1820. [PMID: 34294167 DOI: 10.1017/s0007114521002786] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Human breast milk (BM) is the best source of nutrition in early life, particularly during the first 6 months. Nevertheless, human BM composition is variable, and more insight in the exact factors contributing to this variability is warranted. In this review, we explored the impact of maternal dietary intake and nutritional status (e.g. anthropometric measures, BMI, bioimpedance) on human milk macronutrient composition. PubMed, Scopus and Cochrane were systematically searched till November 2019. In total, 4946 publications underwent title-abstract screening; 101 publications underwent full-text screening. Eventually, fifty publications were included in this review, investigating either associations between maternal dietary intake (n 29) and/or maternal nutritional status (n 29), and macronutrient composition of human BM. Reported energy composition ranged from 213 to 301 kJ/100 ml, and 67 % and 54 % of the studies reported associations between with maternal nutritional intake and status, respectively. Protein content ranged from 0·8 to 3·3 g/100 ml, and four studies suggested a negative association with nutritional status. Fat content ranged from 2·1 to 9·8 g/100 ml, and 68 % of the studies reported positive associations with nutritional status. Carbohydrate content ranged from 5·8 to 7·5 g/100 ml, and 67 % of the included studies did not report an association between intake and status. Literature investigating associations of maternal dietary intake and nutrition status with BM composition of macronutrients and energy content is diversified, both in terms of used methodology and results. Further studies using well-defined and standard parameters are essential to aid the formulation of scientific recommendations.
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15
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Bajwa RU, Raju MNP, Govande VP, Hemingway M, Hammonds K, Vora N. Infant nutrition (donor human milk vs. maternal milk) and long-term neurodevelopmental and growth outcomes in very low birth weight infants. J Matern Fetal Neonatal Med 2022; 35:10025-10029. [PMID: 35703947 DOI: 10.1080/14767058.2022.2086794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Human milk, the ultimate source of nutrition for premature infants, enhances host defense mechanism, gastrointestinal maturation, lowers infection rate, improves neurodevelopmental outcomes, and reduces long-term cardiovascular and metabolic disease. Recently, there has been an increase in donor breast milk (DBM) use for premature infants; however, data are limited on the long-term effects of DBM on the infant's growth and neurodevelopmental outcomes. OBJECTIVE To determine if there is an association between type of infant nutrition (maternal breast milk (MBM) or DBM) and neurodevelopmental and growth outcomes in very low birth weight (VLBW) infants. DESIGN/METHODS Retrospective cohort study of VLBW (<1500 g) infants admitted to the Baylor Scott & White Memorial Hospital Neonatal Intensive Care Unit from January 2014 to December 2016. Infants with major congenital anomalies, born at an outside hospital, who were nil per os (NPO) for >15 days, or who died before NICU discharge were excluded. Infants were stratified into two groups (MBM or DBM) based on predominant nutrition (>50%) received in the first month of life. Primary outcomes of neurodevelopmental delay(s) between 2 and 4 years of age identified via ICD 9/10 codes. Growth data (weight, length, and head circumference) were obtained from well-check visits at 12-, 18-, 24-, 36-, and 48-months. Severity of illness was determined using the Clinical Risk Index in Babies-II (CRIB-II) score. Generalized linear models were used to assess the relationship between nutrition and neurodevelopmental delay and trends in growth over time. RESULTS Two hundred and nine infants were included: 146 MBM; 63 DBM. Median gestational age was 28 weeks (range, 23-35) and median birthweight was 1050 g (range, 410-1470). There were no significant differences in birthweight, gestational age, CRIB-II score, or length of stay between the groups. Infants fed DBM had a significantly larger weight z-score (p=.005), length z-score (p=.01), and head circumference z-score (p=.04), on average from birth to 48 months compared to MBM infants, while controlling for NICU length of stay and number of follow-up months; however, this only equated to DBM infants being 0.5 in taller and 0.9 lbs heavier at 48 months. There were no statistically significant differences among type of infant nutrition and long-term neurodevelopmental outcomes, while controlling for CRIB-II score. CONCLUSIONS Infants fed DBM have a slightly greater propensity for growth over time compared to infants fed MBM. Longer follow-up is needed to further determine the effect, infant nutrition has on neurodevelopmental outcomes.
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Affiliation(s)
- Raza U Bajwa
- Department of Neonatology, Baylor Scott and White Health, Temple, TX, USA
| | - Muppala N P Raju
- Department of Neonatology, Baylor Scott and White Health, Temple, TX, USA
| | - Vinayak P Govande
- Department of Neonatology, Baylor Scott and White Health, Temple, TX, USA
| | - Martha Hemingway
- Department of Neonatology, Baylor Scott and White Health, Temple, TX, USA
| | | | - Niraj Vora
- Department of Neonatology, Baylor Scott and White Health, Temple, TX, USA
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16
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Perrin MT, Friend LL, Sisk PM. Fortified Donor Human Milk Frequently Does Not Meet Sodium Recommendations for the Preterm Infant. J Pediatr 2022; 244:219-223.e1. [PMID: 35093320 DOI: 10.1016/j.jpeds.2022.01.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 12/18/2022]
Abstract
We measured the sodium content of donor human milk (DHM) and calculated the estimated intake at a feeding volume of 160 mL/kg/day. The mean sodium content of unfortified DHM was 102.0 mg/L (4.4 mEq). Because <1% of bovine-fortified samples met the recommended sodium content, infants born preterm who are fed predominantly DHM likely require additional sodium.
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Affiliation(s)
- Maryanne T Perrin
- Department of Nutrition, University of North Carolina Greensboro, Greensboro, NC.
| | - Linda L Friend
- Department of Nutrition, University of North Carolina Greensboro, Greensboro, NC
| | - Paula M Sisk
- Neonatal Intensive Care Unit, Forsyth Medical Center, Winston-Salem, NC
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17
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The importance of nutrition in pregnancy and lactation: lifelong consequences. Am J Obstet Gynecol 2022; 226:607-632. [PMID: 34968458 PMCID: PMC9182711 DOI: 10.1016/j.ajog.2021.12.035] [Citation(s) in RCA: 163] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022]
Abstract
Most women in the United States do not meet the recommendations for healthful nutrition and weight before and during pregnancy. Women and providers often ask what a healthy diet for a pregnant woman should look like. The message should be “eat better, not more.” This can be achieved by basing diet on a variety of nutrient-dense, whole foods, including fruits, vegetables, legumes, whole grains, healthy fats with omega-3 fatty acids that include nuts and seeds, and fish, in place of poorer quality highly processed foods. Such a diet embodies nutritional density and is less likely to be accompanied by excessive energy intake than the standard American diet consisting of increased intakes of processed foods, fatty red meat, and sweetened foods and beverages. Women who report “prudent” or “health-conscious” eating patterns before and/or during pregnancy may have fewer pregnancy complications and adverse child health outcomes. Comprehensive nutritional supplementation (multiple micronutrients plus balanced protein energy) among women with inadequate nutrition has been associated with improved birth outcomes, including decreased rates of low birthweight. A diet that severely restricts any macronutrient class should be avoided, specifically the ketogenic diet that lacks carbohydrates, the Paleo diet because of dairy restriction, and any diet characterized by excess saturated fats. User-friendly tools to facilitate a quick evaluation of dietary patterns with clear guidance on how to address dietary inadequacies and embedded support from trained healthcare providers are urgently needed. Recent evidence has shown that although excessive gestational weight gain predicts adverse perinatal outcomes among women with normal weight, the degree of prepregnancy obesity predicts adverse perinatal outcomes to a greater degree than gestational weight gain among women with obesity. Furthermore, low body mass index and insufficient gestational weight gain are associated with poor perinatal outcomes. Observational data have shown that first-trimester gain is the strongest predictor of adverse outcomes. Interventions beginning in early pregnancy or preconception are needed to prevent downstream complications for mothers and their children. For neonates, human milk provides personalized nutrition and is associated with short- and long-term health benefits for infants and mothers. Eating a healthy diet is a way for lactating mothers to support optimal health for themselves and their infants.
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18
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Sinkiewicz-Darol E, Martysiak-Żurowska D, Puta M, Adamczyk I, Barbarska O, Wesołowska A, Bernatowicz-Łojko U. Nutrients and Bioactive Components of Human Milk After One Year of Lactation: Implication for Human Milk Banks. J Pediatr Gastroenterol Nutr 2022; 74:284-291. [PMID: 34520401 DOI: 10.1097/mpg.0000000000003298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Specifying the nutrient content and bioactive compounds in milk from long-term lactation for the purpose of finding additional sources of donors' milk for human milk banks. METHOD Human milk samples were collected from 43 mothers of term infants (term infant human milk, TIHM) (3-6 weeks of lactation) and 50 mothers who have breastfed for over a year (long-nursing human milk, LNHM). The milk collection time was 24 hours. The analyses of fat, protein, carbohydrate and energy content were performed with human milk analyzer MIRIS (Miris HMA™ ); lactoferrin and vitamin C content using high performance liquid chromatography in reversed phase (RP-HPLC); total antioxidant activity (TAC) and lysozyme by enzyme-linked immunosorbent assay (ELISA); and the activity of glutathione peroxidase (GPx) and catalase (CAT) via spectrophotometric methods. Sociodemographic characteristics of both groups of mothers have been compiled. RESULTS Higher fat content and energy value was found in LNHM than in TIHM. Protein content in LNHM and TIHM did not differ. Carbohydrate content was lower in LNHM than in TIHM. TAC, CAT and GPx activity were higher in LNHM compared to TIHM. No significant differences in the content of lysozyme, lactoferrin and vitamin C between the studied groups were found. CONCLUSIONS The findings suggest that after 12 months of lactation, human milk still has significant nutritional value, does not lose bioactive components and can be considered for use in human milk banks.
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Affiliation(s)
- Elena Sinkiewicz-Darol
- Human Milk Bank, Ludwik Rydygier' Provincial Polyclinic Hospital in Torun, Torun
- Department of Physiology and Toxicology, Faculty of Biological Sciences, Kazimierz Wielki University, Bydgoszcz
| | - Dorota Martysiak-Żurowska
- Department of Chemistry, Technology and Biotechnology of Food, Chemical Faculty, Gdansk University of Technology, Gdansk
| | - Małgorzata Puta
- Department of Chemistry, Technology and Biotechnology of Food, Chemical Faculty, Gdansk University of Technology, Gdansk
| | - Iwona Adamczyk
- Human Milk Bank, Ludwik Rydygier' Provincial Polyclinic Hospital in Torun, Torun
- Department of Physiology and Toxicology, Faculty of Biological Sciences, Kazimierz Wielki University, Bydgoszcz
| | - Olga Barbarska
- Laboratory of Human Milk and Lactation Research at Regional Human Milk Bank in Holy Family Hospital; Medical University of Warsaw, The Faculty of Health Sciences, Department of Medical Biology, Warsaw
| | - Aleksandra Wesołowska
- Laboratory of Human Milk and Lactation Research at Regional Human Milk Bank in Holy Family Hospital; Medical University of Warsaw, The Faculty of Health Sciences, Department of Medical Biology, Warsaw
| | - Urszula Bernatowicz-Łojko
- Human Milk Bank, Ludwik Rydygier' Provincial Polyclinic Hospital in Torun, Torun
- Department of Midwifery, Centre of Postgraduate Medical Education, St. Sophia's Hospital, Warsaw, Poland
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19
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Tyebally Fang M, Chatzixiros E, Grummer-Strawn L, Engmann C, Israel-Ballard K, Mansen K, O'Connor DL, Unger S, Herson M, Weaver G, Biller-Andorno N. Developing global guidance on human milk banking. Bull World Health Organ 2021; 99:892-900. [PMID: 34866685 PMCID: PMC8640695 DOI: 10.2471/blt.21.286943] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 11/27/2022] Open
Abstract
Donor human milk is recommended by the World Health Organization both for its advantageous nutritional and biological properties when mother’s own milk is not available and for its recognized support for lactation and breastfeeding when used appropriately. An increasing number of human milk banks are being established around the world, especially in low- and middle-income countries, to facilitate the collection, processing and distribution of donor human milk. In contrast to other medical products of human origin, however, there are no minimum quality, safety and ethical standards for donor human milk and no coordinating global body to inform national policies. We present the key issues impeding progress in human milk banking, including the lack of clear definitions or registries of products; issues around regulation, quality and safety; and ethical concerns about commercialization and potential exploitation of women. Recognizing that progress in human milk banking is limited by a lack of comparable evidence, we recommend further research in this field to fill the knowledge gaps and provide evidence-based guidance. We also highlight the need for optimal support for mothers to provide their own breastmilk and establish breastfeeding as soon as and wherever possible after birth.
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Affiliation(s)
- Mirriam Tyebally Fang
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
| | - Efstratios Chatzixiros
- Department of Health Product Policy and Standards, World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada
| | | | - Marisa Herson
- School of Medicine, Deakin University, Geelong, Australia
| | | | - Nikola Biller-Andorno
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurerstrasse 30, 8006 Zurich, Switzerland
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20
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Parker MG, Stellwagen LM, Noble L, Kim JH, Poindexter BB, Puopolo KM. Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant. Pediatrics 2021; 148:peds.2021-054272. [PMID: 34635582 DOI: 10.1542/peds.2021-054272] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.
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Affiliation(s)
- Margaret G Parker
- Department of Pediatrics, Boston Medical Center, School of Medicine, Boston University, Boston, Massachusetts
| | - Lisa M Stellwagen
- University of California Health Milk Bank, San Diego, California.,Department of Pediatrics, University of California, San Diego, Health, San Diego, California
| | - Lawrence Noble
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.,New York City Health + Hospitals/Elmhurst
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center and College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brenda B Poindexter
- Children's Healthcare of Atlanta and School of Medicine, Emory University, Atlanta, Georgia
| | - Karen M Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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21
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Protein Enrichment of Donor Breast Milk and Impact on Growth in Very Low Birth Weight Infants. Nutrients 2021; 13:nu13082869. [PMID: 34445027 PMCID: PMC8401419 DOI: 10.3390/nu13082869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/27/2022] Open
Abstract
Protein content is often inadequate in donor breast milk (DBM), resulting in poor growth. The use of protein-enriched target-pooled DBM (DBM+) has not been examined. We compared three cohorts of very low birth weight (VLBW) infants, born ≤ 1500 g: DBM cohort receiving > 1-week target-pooled DBM (20 kcal/oz), MBM cohort receiving ≤ 1-week DBM, and DBM+ cohort receiving > 1-week DBM+. Infants followed a standardized feeding regimen with additional fortification per clinical discretion. Growth velocities and z-scores were calculated for the first 4 weeks (n = 69 for DBM, 71 for MBM, 70 for DBM+) and at 36 weeks post-menstrual age (n = 58, 64, 59, respectively). In total, 60.8% MBM infants received fortification >24 kcal/oz in the first 30 days vs. 78.3% DBM and 77.1% DBM+. Adjusting for SGA, length velocity was greater with DBM+ than DBM in week 1. Average weight velocity and z-score change were improved with MBM compared to DBM and DBM+, but length z-score decreased similarly across all groups. Incidences of NEC and feeding intolerance were unchanged between eras. Thus, baseline protein enrichment appears safe in stable VLBW infants. Weight gain is greatest with MBM. Linear growth comparable to MBM is achievable with DBM+, though the overall length trajectory remains suboptimal.
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22
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Bzikowska-Jura A, Machaj N, Sobieraj P, Barbarska O, Olędzka G, Wesolowska A. Do Maternal Factors and Milk Expression Patterns Affect the Composition of Donor Human Milk? Nutrients 2021; 13:2425. [PMID: 34371935 PMCID: PMC8308884 DOI: 10.3390/nu13072425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
A primary role of Human Milk Banks (HMBs) is to provide human milk (HM) for preterm infants and to support the mothers of these infants as they establish their own milk supply. A better understanding of the variation in the energy and macronutrients contents of donor human milk (DHM) potentiates targeted nutrition for preterm babies. Therefore, the aim of this study was to assess the variability of energy and macronutrients content in DHM and to investigate the impact of maternal factors and feeding practices on the nutritional value of DHM. The study involved 49 donors registered in the HMB in the Holy Family Hospital in Warsaw, Poland. Samples from each donor were pooled within a maximum of two weeks. The composition of DHM, including energy content, protein, fat, and carbohydrate concentrations, was analyzed using the Miris Human Milk Analyzer. The analyses were performed before the pasteurization process. The mean time of milk donation to HMB was 13.2 ± 6.0 weeks. There were no significant differences in energy and macronutrients contents of DHM in the beginning and at the end of milk donation to HMB, however, HM fat concentration was positively correlated with afternoon feedings (r = 0.289, p = 0.044). The method of feeding (breastfeeding vs. feeding only expressed milk) also did not impact the nutritional value of DHM. Future research for the DHM should include a further cross-sectional observational study with the collection of detailed donor information and characteristics of milk expression and feeding practices to further evaluate the pooling processes and the effect on DHM composition.
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Affiliation(s)
- Agnieszka Bzikowska-Jura
- Department of Clinical Dietetics, Faculty of Health Sciences, Medical University of Warsaw, E Ciolka Str. 27, 01445 Warsaw, Poland;
| | - Natalia Machaj
- Department of Medical Biology, Faculty of Health Sciences, Medical University of Warsaw, Litewska Str. 14/16, 00575 Warsaw, Poland; (N.M.); (O.B.); (G.O.)
| | - Piotr Sobieraj
- Department of Internal Medicine, Hypertension and Vascular Diseases, Faculty of Medicine, Medical University of Warsaw, Banacha Str. 1a, 02097 Warsaw, Poland;
| | - Olga Barbarska
- Department of Medical Biology, Faculty of Health Sciences, Medical University of Warsaw, Litewska Str. 14/16, 00575 Warsaw, Poland; (N.M.); (O.B.); (G.O.)
| | - Gabriela Olędzka
- Department of Medical Biology, Faculty of Health Sciences, Medical University of Warsaw, Litewska Str. 14/16, 00575 Warsaw, Poland; (N.M.); (O.B.); (G.O.)
| | - Aleksandra Wesolowska
- Laboratory of Human Milk and Lactation Research, Regional Human Milk Bank in Holy Family Hospital, Department of Medical Biology, Faculty of Health Science, Medical University of Warsaw, Litewska Str. 14/16, 00575 Warsaw, Poland
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23
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Wong RK, Pitino MA, Mahmood R, Zhu IY, Stone D, O'Connor DL, Unger S, Chan TCY. Predicting Protein and Fat Content in Human Donor Milk Using Machine Learning. J Nutr 2021; 151:2075-2083. [PMID: 33847342 DOI: 10.1093/jn/nxab069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/20/2021] [Accepted: 02/23/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Donor milk is the standard of care for hospitalized very low birth weight (VLBW) infants when mother's milk is unavailable; however, growth of donor milk-fed infants is frequently suboptimal. Variability in nutrient composition of donated milk complicates the production of a uniform pooled product and, subsequently, the provision of adequate nutrition to promote optimal growth and development of VLBW infants. We reasoned a machine learning approach to construct batches using characteristics of the milk donation might be an effective strategy in reducing the variability in donor milk product composition. OBJECTIVE The objective of this study was to identify whether machine learning models can accurately predict donor milk macronutrient content. We focused on predicting fat and protein, given their well-established importance in VLBW infant growth outcomes. METHODS Samples of donor milk, consisting of 272 individual donations and 61 pool samples, were collected from the Rogers Hixon Ontario Human Milk Bank and analyzed for macronutrient content. Four different machine learning models were constructed using independent variable groups associated with donations, donors, and donor-pumping practices. A baseline model was established using lactation stage and infant gestational status. Predictions were made for individual donations and resultant pools. RESULTS Machine learning models predicted protein of individual donations and pools with a mean absolute error (MAE) of 0.16 g/dL and 0.10 g/dL, respectively. Individual donation and pooled fat predictions had an MAE of 0.91 g/dL and 0.42 g/dL, respectively. At both the individual donation and pool levels, protein predictions were significantly more accurate than baseline, whereas fat predictions were competitive with baseline. CONCLUSIONS Machine learning models can provide accurate predictions of macronutrient content in donor milk. The macronutrient content of pooled milk had a lower prediction error, reinforcing the value of pooling practices. Future research should examine how macronutrient content predictions can be used to facilitate milk bank pooling strategies.
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Affiliation(s)
- Rachel K Wong
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Michael A Pitino
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rafid Mahmood
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Ian Yihang Zhu
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Debbie Stone
- Rogers Hixon Ontario Human Milk Bank, Sinai Health, Toronto, Ontario, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,Rogers Hixon Ontario Human Milk Bank, Sinai Health, Toronto, Ontario, Canada.,Department of Pediatrics, Sinai Health, Toronto, Ontario, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,Rogers Hixon Ontario Human Milk Bank, Sinai Health, Toronto, Ontario, Canada.,Department of Pediatrics, Sinai Health, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Timothy C Y Chan
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
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24
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Suganuma M, Rumbold AR, Miller J, Chong YF, Collins CT. A Systematic Review and Meta-Analysis of Human Milk Feeding and Short-Term Growth in Preterm and Very Low Birth Weight Infants. Nutrients 2021; 13:2089. [PMID: 34207261 PMCID: PMC8234723 DOI: 10.3390/nu13062089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/16/2022] Open
Abstract
Human milk (HM) is the gold standard for feeding infants but has been associated with slower growth in preterm infants compared with preterm formula. This systematic review and meta-analysis summarises the post-1990 literature to examine the effect of HM feeding on growth during the neonatal admission of preterm infants with birth weight ≤1500 g and/or born ≤28 weeks' gestation. Medline, PubMed, CINAHL, and Scopus were searched, and comparisons were grouped as exclusive human milk (EHM) vs. exclusive preterm formula (EPTF), any HM vs. EPTF, and higher vs. lower doses of HM. We selected studies that used fortified HM and compared that with a PTF; studies comparing unfortified HM and term formula were excluded. Experimental and observational studies were pooled separately. The GRADE system was used to evaluate risk of bias and certainty of evidence. Forty-four studies were included with 37 (n = 9963 infants) included in the meta-analyses. In general, due to poor quality studies, evidence of the effect of any HM feeds or higher versus lower doses of HM was inconclusive. There was a possible effect that lower doses of HM compared with higher doses of HM improved weight gain during the hospital admission, and separately, a possible effect of increased head circumference growth in infants fed EPTF vs. any HM. The clinical significance of this is unclear. There was insufficient evidence to determine the effects of an exclusive HM diet on any outcomes.
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Affiliation(s)
- Machiko Suganuma
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia; (M.S.); (A.R.R.); (J.M.)
| | - Alice R. Rumbold
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia; (M.S.); (A.R.R.); (J.M.)
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5006, Australia
| | - Jacqueline Miller
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia; (M.S.); (A.R.R.); (J.M.)
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5001, Australia;
| | - Yan Fong Chong
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5001, Australia;
| | - Carmel T. Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, SA 5006, Australia; (M.S.); (A.R.R.); (J.M.)
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5006, Australia
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25
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Meng F, Uniacke-Lowe T, Ryan AC, Kelly AL. The composition and physico-chemical properties of human milk: A review. Trends Food Sci Technol 2021. [DOI: 10.1016/j.tifs.2021.03.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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26
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Sillner N, Walker A, Lucio M, Maier TV, Bazanella M, Rychlik M, Haller D, Schmitt-Kopplin P. Longitudinal Profiles of Dietary and Microbial Metabolites in Formula- and Breastfed Infants. Front Mol Biosci 2021; 8:660456. [PMID: 34124150 PMCID: PMC8195334 DOI: 10.3389/fmolb.2021.660456] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/13/2021] [Indexed: 01/02/2023] Open
Abstract
The early-life metabolome of the intestinal tract is dynamically influenced by colonization of gut microbiota which in turn is affected by nutrition, i.e. breast milk or formula. A detailed examination of fecal metabolites was performed to investigate the effect of probiotics in formula compared to control formula and breast milk within the first months of life in healthy neonates. A broad metabolomics approach was conceptualized to describe fecal polar and semi-polar metabolites affected by feeding type within the first year of life. Fecal metabolomes were clearly distinct between formula- and breastfed infants, mainly originating from diet and microbial metabolism. Unsaturated fatty acids and human milk oligosaccharides were increased in breastfed, whereas Maillard products were found in feces of formula-fed children. Altered microbial metabolism was represented by bile acids and aromatic amino acid metabolites. Elevated levels of sulfated bile acids were detected in stool samples of breastfed infants, whereas secondary bile acids were increased in formula-fed infants. Microbial co-metabolism was supported by significant correlation between chenodeoxycholic or lithocholic acid and members of Clostridia. Fecal metabolites showed strong inter- and intra-individual behavior with features uniquely present in certain infants and at specific time points. Nevertheless, metabolite profiles converged at the end of the first year, coinciding with solid food introduction.
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Affiliation(s)
- Nina Sillner
- Research Unit Analytical BioGeoChemistry, Helmholtz Zentrum München, Neuherberg, Germany.,ZIEL Institute for Food and Health, Technical University of Munich, Freising, Germany
| | - Alesia Walker
- Research Unit Analytical BioGeoChemistry, Helmholtz Zentrum München, Neuherberg, Germany
| | - Marianna Lucio
- Research Unit Analytical BioGeoChemistry, Helmholtz Zentrum München, Neuherberg, Germany
| | - Tanja V Maier
- Research Unit Analytical BioGeoChemistry, Helmholtz Zentrum München, Neuherberg, Germany
| | - Monika Bazanella
- Chair of Nutrition and Immunology, Technical University of Munich, Freising, Germany
| | - Michael Rychlik
- Chair of Analytical Food Chemistry, Technical University of Munich, Freising, Germany
| | - Dirk Haller
- ZIEL Institute for Food and Health, Technical University of Munich, Freising, Germany.,Chair of Nutrition and Immunology, Technical University of Munich, Freising, Germany
| | - Philippe Schmitt-Kopplin
- Research Unit Analytical BioGeoChemistry, Helmholtz Zentrum München, Neuherberg, Germany.,ZIEL Institute for Food and Health, Technical University of Munich, Freising, Germany.,Chair of Analytical Food Chemistry, Technical University of Munich, Freising, Germany
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27
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Abstract
Human milk is the preferred enteral diet for preterm infants. It provides macronutrients, micronutrients, and bioactive factors that support physical growth and neurodevelopment. Challenges of the human milk diet include the variability in its composition and a need for fortification to mirror placental nutrient delivery and prevent extrauterine growth restriction. Various strategies exist to attain target nutrient provision and optimize growth, including leveraging new technology for point-of-care human milk analysis. When maternal milk is unavailable or in short supply, pasteurized donor human milk is the preferred alternative. Infants fed donor milk may have slower weight gain than those fed exclusively maternal milk or formula, whereas infants fed fortified maternal milk have similar weight gain to preterm formula-fed infants. Future directions include more rigorous characterization of the variation in human milk, further investigation of the clinical benefits of non-nutrient bioactive factors in milk, and novel approaches to optimize fortification.
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Affiliation(s)
- Margaret L Ong
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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28
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Colaizy TT. Effects of milk banking procedures on nutritional and bioactive components of donor human milk. Semin Perinatol 2021; 45:151382. [PMID: 33632557 DOI: 10.1016/j.semperi.2020.151382] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pasteurized donor human milk is in wide use for preterm infants in neonatal intensive care units when maternal milk is unavailable. Pasteurization of donor milk is required to prevent bacterial contamination, and multiple methods are used in the non-profit and commercial milk banking industries. Pasteurization results in changes in the nutrient and bioactive components in donor milk compared to unpasteurized human milk, and these changes vary by the type of pasteurization process. Other milk bank practices including freezing of milk, pooling of milk from multiple donors and use of pre-processing macronutrient analysis also affect the nutritional composition of donor milk. This review compiles evidence regarding three common pasteurization techniques for donor milk: Holder pasteurization, vat pasteurization, and retort pasteurization and their effects on the nutritional content and bioactive factors in human milk. It also includes review of literature investigating the impact of freezing and storage, and best practices for multi-donor milk pooling.
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Affiliation(s)
- Tarah T Colaizy
- Professor of Pediatrics, University of Iowa, 8809 JPP, UIHC, 200 Hawkins Drive, Iowa City, IA 52242, United States.
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29
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Schinkel ER, Nelson ER, Young BE, Bernstein RM, Taylor SN, Hay WW, Brown LD, Brown KJ, Prenni J. Concentrating human milk: an innovative point-of-care device designed to increase human milk feeding options for preterm infants. J Perinatol 2021; 41:582-589. [PMID: 33060780 PMCID: PMC9848740 DOI: 10.1038/s41372-020-00820-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 08/17/2020] [Accepted: 09/14/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether a point-of-care osmotic device concentrates important human milk (HM) nutrients to support feeding neonates requiring high-nutrient, low-volume feedings. STUDY DESIGN Raw and pasteurized HM samples were concentrated to determine the effects of time and temperature on concentration. Concentrated samples were compared with matched baseline samples to measure changes in selected nutrient concentrations. Furthermore, changes in concentration of certain bioactive components of raw milk samples were measured. RESULT The device significantly increased the concentrations of the majority of the measured nutrient and bioactive levels (p < 0.05). Increasing temperature of HM from 4 to 37 °C increased the concentration rate >30%. In all cases, the concentration rate of pasteurized HM was greater than that of raw HM. CONCLUSIONS The osmotic concentration of HM is a promising option for neonatal nutrition. Further studies are needed to establish an evidence base for the practical applications of this point-of-care device.
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Affiliation(s)
| | | | - Bridget E. Young
- Division of Pediatric Allergy and Immunology, University of Rochester School of Medicine and Dentistry
| | - Robin M. Bernstein
- Department of Anthropology and Institute of Behavioral Science, University of Colorado, Boulder
| | | | | | | | - Kitty J. Brown
- Center for Proteomics and Metabolomics at Colorado State University
| | - Jessica Prenni
- Center for Proteomics and Metabolomics at Colorado State University
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30
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Lamb RL, Haszard JJ, Little HMJ, Franks AF, Meeks MG. Macronutrient Composition of Donated Human Milk in a New Zealand Population. J Hum Lact 2021; 37:114-121. [PMID: 33030996 DOI: 10.1177/0890334420963666] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A primary role of human donor milk banks is to provide pasteurized human milk for the sick and preterm infant populations and to support the mothers of these infants as they establish their own milk supply. The results of human milk pasteurization continue to be studied to provide information that enables optimal nutrition in this sick and preterm population. RESEARCH AIMS The aims of our study were to determine macronutrient characteristics (fat, protein, carbohydrate) and energy content of human milk donated to the Christchurch Women's Hospital Human Milk Bank in New Zealand, and the influence of Holder pasteurization on this macronutrient composition. METHODS This was a retrospective, pre/post pasteurization observational design to describe the macronutrient content within two groups of donors, mature preterm PDM (n = 13; 21%) and mature term PDM (n = 50; 79%). Sixty three samples of human milk donated to the human milk bank by 27 registered participants (mothers of preterm and term infants) were analyzed. This analysis took place July-September 2018 using a human milk analyzer before and after Holder pasteurization (62.5 °C for 30 min). RESULTS Preterm milk contained on average 76 kcal/100 ml energy, 4.0 g/100 ml fat, 1.1 g/100 ml protein and 8.2 g/100 ml total carbohydrate; and mature term milk contained 68 kcal/100 ml energy, 3.5 g/100 ml fat, 0.8 g/100 ml protein and 7.9 g/100 ml total carbohydrate. Wide variation between single, donor-pooled samples was demonstrated and there was no major result of pasteurization. CONCLUSION This research adds to the evidence regarding the macronutrient content of preterm and term milk and that these values are unaffected by Holder pasteurization. The variance in individual pooled donor human milk indicates the importance of determining the nutrient composition of donated milk to inform fortification procedures.
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Affiliation(s)
| | - Jillian J Haszard
- 2495 Department of Human Nutrition, University of Otago, Dunedin, New Zealand
| | - Helen M J Little
- 299516 Nutrition and Dietetics, Christchurch Hospital, Christchurch, New Zealand
| | - Anthea F Franks
- 299516 Human Milk Bank, Neonatal Intensive Care Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Maggie G Meeks
- 299516 Neonatal Intensive Care Unit, Christchurch Women's Hospital, Christchurch, New Zealand
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31
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Cardoso M, Virella D, Macedo I, Silva D, Pereira-da-Silva L. Customized Human Milk Fortification Based on Measured Human Milk Composition to Improve the Quality of Growth in Very Preterm Infants: A Mixed-Cohort Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020823. [PMID: 33477964 PMCID: PMC7835734 DOI: 10.3390/ijerph18020823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
Adequate nutrition of very preterm infants comprises fortification of human milk (HM), which helps to improve their nutrition and health. Standard HM fortification involves a fixed dose of a multi-nutrient HM fortifier, regardless of the composition of HM. This fortification method requires regular measurements of HM composition and has been suggested to be a more accurate fortification method. This observational study protocol is designed to assess whether the target HM fortification method (contemporary cohort) improves the energy and macronutrient intakes and the quality of growth of very preterm infants, compared with the previously used standard HM fortification (historical cohorts). In the contemporary cohort, a HM multi-nutrient fortifier and modular supplements of protein and fat are used for HM fortification, and the enteral nutrition recommendations of the European Society for Paediatric Gastroenterology Hepatology and Nutrition for preterm infants will be considered. For both cohorts, the composition of HM is assessed using the Miris Human Milk analyzer (Uppsala, Sweden). The quality of growth will be assessed by in-hospital weight, length, and head circumference growth velocities and a single measurement of adiposity (fat mass percentage and fat mass index) performed just after discharge, using the air displacement plethysmography method (Pea Pod, Cosmed, Italy). ClinicalTrials.gov registration number: NCT04400396.
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Affiliation(s)
- Manuela Cardoso
- Nutrition Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, 2890-495 Lisbon, Portugal;
| | - Daniel Virella
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal;
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
| | - Israel Macedo
- Neonatal Intensive Care Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, 2890-495 Lisbon, Portugal;
| | - Diana Silva
- Faculdade de Ciências de Nutrição e da Alimentação, Universidade do Porto, 4150-180 Porto, Portugal;
| | - Luís Pereira-da-Silva
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
- Nutrition Lab., Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), Medicine of Woman, Childhood and Adolescence, NOVA Medical School, Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal
- Correspondence: ; Tel.: +351-917-235-528
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32
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Torres Martínez E, García Robles AA, Gormaz Moreno M, Gimeno Navarro A, Izquierdo Macián I, Poveda Andrés JL, Vento M. Efecto de la adición de fortificantes y de módulo de proteínas en la osmolalidad de la leche materna donada. An Pediatr (Barc) 2020; 93:297-304. [DOI: 10.1016/j.anpedi.2020.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022] Open
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33
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Effect of adding fortifiers and protein supplements on the osmolality of donated maternal milk. An Pediatr (Barc) 2020. [DOI: 10.1016/j.anpede.2020.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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34
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Young BE, Murphy K, Borman LL, Heinrich R, Krebs NF. Milk Bank Pooling Practices Impact Concentrations and Variability of Bioactive Components of Donor Human Milk. Front Nutr 2020; 7:579115. [PMID: 33123548 PMCID: PMC7573550 DOI: 10.3389/fnut.2020.579115] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/26/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Donor human milk (DHM) bank practices, such as pasteurization and pooling according to postpartum age of milk donations and number of donors included in a pool may impact the resulting concentration of bioactive components of DHM. Aims: We determined the impact of Holder pasteurization, postpartum milk age, and pool donor number (number of donors included in a pool) on resulting concentrations of total immunoglobulin A (IgA; which provides immune protection to the recipient infant) and insulin (an important hormone for gut maturation).We also documented inter-relationships between these bioactive components and macronutrients in DHM pools. Methods: Pre and post-pasteurization aliquots of 128 DHM samples were obtained from the Rocky Mountain Children's Foundation Mother's Milk Bank (a member of the Human Milk Banking Association of North America, HMBANA). Macronutrients were measured via mid-infrared spectroscopy. Total IgA was measured via customized immunoassay in skim milk and insulin was measured via chemiluminescent immunoassay. Results: Mean post-pasteurization total IgA concentration was 0.23 ± 0.10 (range: 0.04-0.65) mg/mL a 17.9% decrease due to pasteurization (n = 126). Mean post-pasteurization DHM insulin concentration was 7.0 ± 4.6 (range: 3-40) μU/mL, a decrease of 13.6% due to pasteurization (n = 128). The average DHM pool postpartum milk age was not associated with total IgA or insulin concentrations, but pool donor number was associated with bioactive components. Pools with only one donor had lower total IgA and lower insulin concentrations than pools with at least 2 donors (p < 0.05). Increasing the number of donors in a pool decreased the variability in total IgA and insulin concentrations (p < 0.04). Conclusion: Increasing the number of donors included in DHM pools may help optimize bioactive components in DHM received by premature infants. These results help inform milk banking practices to decrease compositional variability in produced DHM pools.
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Affiliation(s)
- Bridget E Young
- Department of Pediatrics Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Katherine Murphy
- Department of Pediatrics Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Laraine L Borman
- Mothers' Milk Bank, Rocky Mountain Children's Health Foundation, Arvada, CO, United States
| | - Rebecca Heinrich
- Mothers' Milk Bank, Rocky Mountain Children's Health Foundation, Arvada, CO, United States
| | - Nancy F Krebs
- Department of Pediatrics - Section of Nutrition, University of Colorado School of Medicine, Aurora, CO, United States
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Belfort M, Cherkerzian S, Bell K, Soldateli B, Cordova Ramos E, Palmer C, Steele T, Pepin H, Ellard D, Drouin K, Inder T. Macronutrient Intake from Human Milk, Infant Growth, and Body Composition at Term Equivalent Age: A Longitudinal Study of Hospitalized Very Preterm Infants. Nutrients 2020; 12:nu12082249. [PMID: 32731348 PMCID: PMC7468722 DOI: 10.3390/nu12082249] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/01/2020] [Accepted: 07/24/2020] [Indexed: 12/04/2022] Open
Abstract
The variable macronutrient content of human milk may contribute to growth deficits among preterm infants in the neonatal intensive care unit (NICU). In a longitudinal study of 37 infants < 32 weeks gestation, we aimed to (1) determine the between-infant variation in macronutrient intake from human milk and (2) examine associations of macronutrient intake with growth outcomes. We analyzed 1626 human milk samples (median, 43 samples/infant) with mid infrared spectroscopy. Outcomes at term equivalent age were weight, length, head circumference, fat mass, and fat-free mass. Median (range) intakes from human milk were: protein 1.37 (0.88, 2.43) g/kg/day; fat 4.20 (3.19, 5.82) g/kg/day; carbohydrate 8.94 (7.72, 9.85) g/kg/day; and energy 82.5 (68.7, 99.3) kcal/kg/day. In median regression models adjusted for birth size and gestational age, and other covariates, greater intakes of fat and energy were associated with higher weight (0.61 z-scores per g/kg/day fat, 95% CI 0.21, 1.01; 0.69 z-scores per 10 kcal/kg/day, 95% CI 0.28, 1.10), whereas greater protein intake was associated with greater body length (0.84 z-scores per g/kg/day protein, 95% CI 0.09, 1.58). Higher fat intake was also associated with higher fat mass and fat-free mass. Macronutrient intakes from human milk were highly variable and associated with growth outcomes despite routine fortification.
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Affiliation(s)
- Mandy Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-617-525-4135
| | - Sara Cherkerzian
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Katherine Bell
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Betina Soldateli
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
| | - Erika Cordova Ramos
- Division of Newborn Medicine, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Caroline Palmer
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
| | - Tina Steele
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Department of Nursing, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Hunter Pepin
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Department of Nutrition, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Deirdre Ellard
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Department of Nutrition, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Kaitlin Drouin
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA; (S.C.); (K.B.); (B.S.); (C.P.); (T.S.); (H.P.); (D.E.); (K.D.); (T.I.)
- Harvard Medical School, Boston, MA 02115, USA
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Basu S, Upadhyay J, Singh P, Kumar M. Early versus late fortification of breast milk in preterm infants: a systematic review and meta-analysis. Eur J Pediatr 2020; 179:1057-1068. [PMID: 32458060 DOI: 10.1007/s00431-020-03677-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/20/2020] [Accepted: 05/06/2020] [Indexed: 11/29/2022]
Abstract
This systematic review and meta-analysis assessed the effects of early fortification (EF) versus late fortification (LF) of breast milk (BM) on growth of preterm infants. Randomized and quasi-randomized controlled trials (RCTs) dealing with the effects of EF versus LF on growth parameters, incidence of adverse events, and duration of hospital stay in preterm infants were included. Data were pooled using the RevMan 5.3 software. Quality of evidence for predefined outcomes was analyzed by GRADE. Available evidence (3 RCTs, 309 preterm infants) showed no statistically significant difference between EF and LF of BM for any of the growth parameters-weight (standardized mean difference (SMD) 0.13; 95% confidence interval (CI) - 0.09, 0.36); length (SMD 0.02; 95% CI - 0.20, 0.25); and head circumference (SMD - 0.10; 95% CI - 0.33, 0.12). Total parenteral nutrition days were similar. Duration of hospital stay was significantly higher with EF (MD 4.29; 95% CI 0.84, 7.75) with a trend of non-significant increase in feed intolerance and necrotizing enterocolitis (NEC).Conclusion: Very low quality evidence did not find any significant difference in growth parameters of preterm infants in association with EF or LF of BM. A significant increase in hospital stay and non-significant increase in feed intolerance and NEC were associated with EF.PROSPERO registration number: CRD42019139235What is Known:• Fortification of breast milk with essential macro- and micronutrients is necessary for optimization of nutrition in preterm infants.• There is no consensus regarding the breast milk feeding volume at which fortification should be initiated.What is New:• Very low quality evidence showed no significant difference between early and late fortification of breast milk on growth parameters of preterm infants.• Early fortification was associated with non-significant increase in feed intolerance and necrotizing enterocolitis and a significant increase in hospital stay.
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Affiliation(s)
- Sriparna Basu
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
| | - Jaya Upadhyay
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Poonam Singh
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Manish Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Gorakhpur, India
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Perrin MT, Belfort MB, Hagadorn JI, McGrath JM, Taylor SN, Tosi LM, Brownell EA. The Nutritional Composition and Energy Content of Donor Human Milk: A Systematic Review. Adv Nutr 2020; 11:960-970. [PMID: 32119744 PMCID: PMC7360450 DOI: 10.1093/advances/nmaa014] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/17/2019] [Accepted: 02/04/2020] [Indexed: 11/14/2022] Open
Abstract
The American Academy of Pediatrics recommends donor human milk (DHM) as the preferred feeding strategy for preterm infants when the milk of the mother is unavailable, based on conclusive evidence of lower rates of necrotizing enterocolitis with DHM feedings compared with preterm infant formula. The nutritional composition of DHM may differ from maternal milk for many reasons including differences in maternal characteristics, milk collection methods, and the impact of donor milk banking practices. The purpose of this systematic review is to examine the literature regarding research on the fat, protein, carbohydrate, vitamin, and mineral composition of DHM obtained through nonprofit milk banks or commercial entities. PubMed, CINAHL, and Scopus databases were searched for articles published between 1985 and 30 April, 2019. In total, 164 abstracts were screened independently by 2 investigators, and 14 studies met all inclusion criteria. Studies were predominantly small (<50 samples) and measured macronutrients. Few studies assessed vitamins and minerals. Information bias was prevalent due to the use of a variety of analytical methods which influence accuracy and cross-study comparisons. Other sources of information bias included missing information regarding methods for protein and calorie assessment. Despite these limitations, existing research suggests the potential for 2-fold and greater differences in the fat, protein, and energy composition of DHM, with mean values for energy and fat often below clinical reference values expected for human milk. Further research is warranted regarding the nutritional composition of DHM, with a prioritization on measuring macronutrients and micronutrients using established reference methods.
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Affiliation(s)
- Maryanne T Perrin
- Department of Nutrition, The University of North Carolina Greensboro, Greensboro, NC, USA
| | - Mandy B Belfort
- Department of Pediatric Newborn Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - James I Hagadorn
- Connecticut Human Milk Research Center, Connecticut Children's Medical Center, Division of Neonatology, Connecticut Children's, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jacqueline M McGrath
- School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Sarah N Taylor
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Lauren M Tosi
- Connecticut Human Milk Research Center, Connecticut Children's Medical Center, Division of Neonatology, Connecticut Children's, Hartford, CT, USA
| | - Elizabeth A Brownell
- Connecticut Human Milk Research Center, Connecticut Children's Medical Center, Division of Neonatology, Connecticut Children's, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
- School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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38
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Friend LL, Perrin MT. Fat and Protein Variability in Donor Human Milk and Associations with Milk Banking Processes. Breastfeed Med 2020; 15:370-376. [PMID: 32311292 DOI: 10.1089/bfm.2020.0046] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: The impact of milk banking processes on macronutrient variability in donor human milk (DHM) is largely unknown. Objective: To gain a better understanding of fat and protein composition in DHM and assess potential relationships with modifiable milk bank processes. Methods: Samples of raw, pooled DHM were collected from 20 milk banks (n = 300) along with the following processing attributes: if macronutrient analysis was used to select donors for pooling (target pooling; yes/no), number of donors per pool, pooling container material (glass/plastic/other), and method for mixing during bottling (manual/mechanical). Fat and protein were assessed. Homoscedasticity was assessed and magnitude of the spread was quantified. Results: Fat ranged from 1.9 to 6.1 g/dL (n = 298) and protein ranged from 0.7 to 1.4 g/dL (n = 300). Variability in fat was significantly lower in samples that had been target pooled (p = 0.04), contained more donors per pool (p < 0.001), and had been mixed mechanically (p < 0.001). Variability in protein was significantly lower in samples that contained more donors per pool (p = 0.001). In a stratified analysis, increasing the number of donors per pool only reduced nutrient variability in samples that were not target pooled. Conclusion: For milk banks that do not target pool, using a greater number of donors in a pool may reduce fat and protein variability.
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Affiliation(s)
- Linda L Friend
- Department of Nutrition, University of North Carolina Greensboro, Greensboro, North Carolina, USA
| | - Maryanne T Perrin
- Department of Nutrition, University of North Carolina Greensboro, Greensboro, North Carolina, USA
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Macronutrient analysis of donor human milk labelled as 24 kcal/oz. J Perinatol 2020; 40:666-671. [PMID: 32071366 DOI: 10.1038/s41372-020-0624-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/20/2020] [Accepted: 02/06/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To measure the macronutrient content (MNC) of donor human milk labelled as 24 kcal/oz ("high-calorie DHM," hcDHM), compare to bank-labelled MNC, and examine variability of hcDHM MNC among milk banks. STUDY DESIGN MNC was measured with near-infrared spectroscopy for 75 convenience samples from five milk banks collected during September 2016-July 2017. Concordance of measured MNC with labelled values was evaluated using three different thresholds: within ±20%, similar to FDA labelling standards for class II nutrients in foods; ±10%; and ±5%. RESULTS Protein and caloric content differed significantly between measured and labelled values and varied significantly among milk banks. Measured caloric content ranged from 16.50 to 30.27 kcal/oz, with 89.3% of hcDHM samples within ±20%, 58.7% within ±10%, and 18.7% within ±5% of labelled content. CONCLUSIONS MNC of hcDHM used in clinical practice shows variation that may result in differences from desired diet. The clinical implications of such differences are unexplored.
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40
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Young BE, Borman LL, Heinrich R, Long J, Pinney S, Westcott J, Krebs NF. Effect of Pooling Practices and Time Postpartum of Milk Donations on the Energy, Macronutrient, and Zinc Concentrations of Resultant Donor Human Milk Pools. J Pediatr 2019; 214:54-59. [PMID: 31558278 PMCID: PMC6886691 DOI: 10.1016/j.jpeds.2019.07.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 06/21/2019] [Accepted: 07/15/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To characterize the macronutrient, energy, and zinc composition of pasteurized donor human milk pools and evaluate how composition varies based on pooling practices and "time postpartum" (ie, elapsed time from parturition to expression date) of individual milk donations. STUDY DESIGN The Mothers' Milk Bank (Arvada, Colorado) donated 128 donor human milk pools. Caloric density was assessed via mid-infrared spectroscopy, and zinc concentration was measured by atomic absorption spectroscopy. Pool time postpartum was calculated as the unweighted average of the time postpartum of all milk donations included in any given pool. RESULTS Time postpartum of donor human milk pools ranged from 3 days to 9.8 months. The majority (91%) of donor human milk pools included milk from either 1 donor or 2 donors. Pool energy density ranged from 14.7 to 23.1 kcal/oz, and protein ranged from 0.52 to 1.43 g/dL. Milk zinc concentrations were higher in preterm pools and were negatively correlated with pool time postpartum. We present an equation that estimates donor human milk pool zinc content based on time postpartum and explains 49% of the variability in zinc concentrations (P < .0001). Including more donors in donor human milk pools decreased the variability in protein, but not zinc, concentrations. CONCLUSIONS Donor human milk pools were lower in calories than is normally assumed in standard human milk fortification practices. Zinc concentrations were related to donor human milk time postpartum and were on average insufficient to meet preterm and term infants' needs without fortification or supplementation.
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Affiliation(s)
- Bridget E Young
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO; Department of Pediatrics Allergy and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Laraine L Borman
- Mothers' Milk Bank, Rocky Mountain Children's Health Foundation, Arvada, CO
| | - Rebecca Heinrich
- Mothers' Milk Bank, Rocky Mountain Children's Health Foundation, Arvada, CO
| | - Julie Long
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Sarah Pinney
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Jamie Westcott
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO
| | - Nancy F Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, Aurora, CO
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Casavale KO, Ahuja JKC, Wu X, Li Y, Quam J, Olson R, Pehrsson P, Allen L, Balentine D, Hanspal M, Hayward D, Hines EP, McClung JP, Perrine CG, Belfort MB, Dallas D, German B, Kim J, McGuire M, McGuire M, Morrow AL, Neville M, Nommsen-Rivers L, Rasmussen KM, Zempleni J, Lynch CJ. NIH workshop on human milk composition: summary and visions. Am J Clin Nutr 2019; 110:769-779. [PMID: 31274142 PMCID: PMC6895543 DOI: 10.1093/ajcn/nqz123] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/27/2019] [Indexed: 12/19/2022] Open
Abstract
Nationally representative data from mother-child dyads that capture human milk composition (HMC) and associated health outcomes are important for advancing the evidence to inform federal nutrition and related health programs, policies, and consumer information across the governments in the United States and Canada as well as in nongovernment sectors. In response to identified gaps in knowledge, the National Institute of Diabetes and Digestive and Kidney Diseases of the NIH sponsored the "Workshop on Human Milk Composition-Biological, Environmental, Nutritional, and Methodological Considerations" held 16-17 November 2017 in Bethesda, Maryland. Through presentations and discussions, the workshop aimed to 1) share knowledge on the scientific need for data on HMC; 2) explore the current understanding of factors affecting HMC; 3) identify methodological challenges in human milk (HM) collection, storage, and analysis; and 4) develop a vision for a research program to develop an HMC data repository and database. The 4 workshop sessions included 1) perspectives from both federal agencies and nonfederal academic experts, articulating scientific needs for data on HMC that could lead to new research findings and programmatic advances to support public health; 2) information about the factors that influence lactation and/or HMC; 3) considerations for data quality, including addressing sampling strategies and the complexities in standardizing collection, storage, and analyses of HM; and 4) insights on how existing research programs and databases can inform potential visions for HMC initiatives. The general consensus from the workshop is that the limited scope of HM research initiatives has led to a lack of robust estimates of the composition and volume of HM consumed and, consequently, missed opportunities to improve maternal and infant health.
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Affiliation(s)
- Kellie O Casavale
- Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Rockville, MD, USA,Address correspondence to KOC (e-mail: ). Present address for KOC: US Food and Drug Administration, Center for Food Safety and Applied Nutrition, College Park, MD, USA
| | - Jaspreet K C Ahuja
- Nutrient Data Laboratory, Beltsville Human Nutrition Research Center, Agricultural Research Service, US Department of Agriculture, Beltsville, MD, USA
| | - Xianli Wu
- Nutrient Data Laboratory, Beltsville Human Nutrition Research Center, Agricultural Research Service, US Department of Agriculture, Beltsville, MD, USA
| | - Ying Li
- Nutrient Data Laboratory, Beltsville Human Nutrition Research Center, Agricultural Research Service, US Department of Agriculture, Beltsville, MD, USA
| | - Julia Quam
- Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Rockville, MD, USA
| | - Richard Olson
- Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Rockville, MD, USA
| | - Pamela Pehrsson
- Nutrient Data Laboratory, Beltsville Human Nutrition Research Center, Agricultural Research Service, US Department of Agriculture, Beltsville, MD, USA
| | - Lindsay Allen
- Western Human Nutrition Research Center, Agricultural Research Service, US Department of Agriculture, Davis, CA, USA
| | - Douglas Balentine
- Center for Food Safety and Applied Nutrition, US Food and Drug Administration, US Department of Health and Human Services, College Park, MD, USA
| | - Manjit Hanspal
- Environmental influences on Child Health Outcomes (ECHO) program, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, USA
| | - Deborah Hayward
- Bureau of Nutritional Sciences, Health Products and Food Branch, Health Canada, Ottawa, Ontario, Canada
| | - Erin Pias Hines
- National Center for Environmental Assessment, US Environmental Protection Agency, Research Triangle Park, NC, USA
| | - James P McClung
- US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Cria G Perrine
- Centers for Disease Control and Prevention; US Department of Health and Human Services, Atlanta, GA, USA
| | | | - David Dallas
- School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Bruce German
- Department of Food Science and Technology, University of California, Davis, Davis, CA, USA
| | - Jae Kim
- Divisions of Neonatology and Pediatric Gastroenterology, University of California, San Diego, San Diego, CA, USA
| | - Mark McGuire
- College of Agricultural and Life Sciences, University of Idaho, Moscow, ID, USA
| | - Michelle McGuire
- School of Biological Sciences, Washington State University, Pullman, WA, USA,Present address for Michelle McGuire: University of Idaho, Moscow, ID, USA
| | - Ardythe L Morrow
- Center for Interdisciplinary Research in Human Milk and Lactation, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Margaret Neville
- Department of Physiology and Biophysics, University of Colorado, Denver, Denver, CO, USA
| | | | | | - Janos Zempleni
- Nebraska Center for the Prevention of Obesity Diseases, University of Nebraska–Lincoln, Lincoln, NE, USA
| | - Christopher J Lynch
- Office of Nutrition Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD, USA
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Fu TT, Schroder PE, Poindexter BB. Macronutrient Analysis of Target-Pooled Donor Breast Milk and Corresponding Growth in Very Low Birth Weight Infants. Nutrients 2019; 11:nu11081884. [PMID: 31412627 PMCID: PMC6722642 DOI: 10.3390/nu11081884] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/03/2019] [Accepted: 08/09/2019] [Indexed: 11/16/2022] Open
Abstract
The macronutrient composition of target-pooled donor breast milk (DBM) (milk combined strategically to provide 20 kcal/oz) and growth patterns of preterm infants receiving it have not been characterized. Caloric target-pooled DBM samples were analyzed by near-infrared spectroscopy. Weekly growth velocities and anthropometric z-scores were calculated for the first 30 days and at 36 weeks corrected gestational age (CGA) for 69 very low birthweight (VLBW) infants receiving minimum one week of DBM. Samples contained mean 18.70 kcal/oz, 0.91 g/dL protein, 3.11 g/dL fat, 7.71 g/dL carbohydrate (n = 96), less than labeled values by 2.43 kcal/oz and 0.11 g/dL protein (p < 0.001). By week 3, growth reached 16.58 g/kg/day, 0.95 cm/week (length), and 1.01 cm/week (head circumference). Infants receiving <50% vs. >50% DBM had similar growth, but infants receiving >50% DBM were more likely to receive fortification >24 kcal/oz (83% vs. 51.9% in the <50% DBM group; p = 0.005). From birth to 36 weeks CGA (n = 60), there was a negative z-score change across all parameters with the greatest in length (−1.01). Thus, target-pooling does not meet recommended protein intake for VLBW infants. Infants fed target-pooled DBM still demonstrate a disproportionate negative change in length z-score over time.
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Affiliation(s)
- Ting Ting Fu
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA.
| | - Paige E Schroder
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Brenda B Poindexter
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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Palmquist AEL, Perrin MT, Cassar-Uhl D, Gribble KD, Bond AB, Cassidy T. Current Trends in Research on Human Milk Exchange for Infant Feeding. J Hum Lact 2019; 35:453-477. [PMID: 31206310 DOI: 10.1177/0890334419850820] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Breastfeeding is critical for the healthy growth and development of infants. A diverse range of infant-feeding methods are used around the world today. Many methods involve feeding infants with expressed human milk obtained through human milk exchange. Human milk exchange includes human milk banking, human milk sharing, and markets in which human milk may be purchased or sold by individuals or commercial entities. In this review, we examine peer-reviewed scholarly literature pertaining to human milk exchange in the social sciences and basic human milk sciences. We also examine current position and policy statements for human milk sharing. Our review highlights areas in need of future research. This review is a valuable resource for healthcare professionals and others who provide evidence-based care to families about infant feeding.
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Affiliation(s)
- Aunchalee E L Palmquist
- 1 Department of Maternal and Child Health, Carolina Global Breastfeeding Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maryanne T Perrin
- 2 Department of Nutrition, University of North Carolina Greensboro, Greensboro, NC, USA
| | - Diana Cassar-Uhl
- 3 Maternal and Child Health Program, School of Public Health, University of Maryland, Cornwall, NY, USA
| | - Karleen D Gribble
- 4 School of Nursing and Midwifery, Western Sydney University, Penrith, NSW, AUS
| | - Angela B Bond
- 5 Center for Evolution and Medicine, Arizona State University, Phoenix, AZ, USA
| | - Tanya Cassidy
- 6 Dublin City University, School of Nursing and Human Sciences, Glasnevin Campus, Dublin 9, Ireland
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44
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Demers-Mathieu V, Huston RK, Markell AM, McCulley EA, Martin RL, Spooner M, Dallas DC. Differences in Maternal Immunoglobulins within Mother's Own Breast Milk and Donor Breast Milk and across Digestion in Preterm Infants. Nutrients 2019; 11:nu11040920. [PMID: 31022910 PMCID: PMC6521323 DOI: 10.3390/nu11040920] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/08/2019] [Accepted: 04/22/2019] [Indexed: 02/06/2023] Open
Abstract
Maternal antibody transfer to the newborn provides essential support for the infant’s naïve immune system. Preterm infants normally receive maternal antibodies through mother’s own breast milk (MBM) or, when mothers are unable to provide all the milk required, donor breast milk (DBM). DBM is pasteurized and exposed to several freeze–thaw cycles, which could reduce intact antibody concentration and the antibody’s resistance to digestion within the infant. Whether concentrations of antibodies in MBM and DBM differ and whether their survival across digestion in preterm infants differs remains unknown. Feed (MBM or DBM), gastric contents (MBM or DBM at 1-h post-ingestion) and stool samples (collected after a mix of MBM and DBM feeding) were collected from 20 preterm (26–36 weeks gestational age) mother–infant pairs at 8–9 and 21–22 days of postnatal age. Samples were analyzed via ELISA for the concentration of secretory IgA (SIgA), total IgA (SIgA/IgA), total IgM (SIgM/IgM) and IgG. Total IgA, SIgA, total IgM and IgG concentrations were 55.0%, 71.6%, 98.4% and 41.1% higher in MBM than in DBM, and were 49.8%, 32.7%, 73.9% and 39.7% higher in gastric contents when infants were fed with MBM than when infants were fed DBM, respectively. All maternal antibody isotypes present in breast milk were detected in the infant stools, of which IgA (not sIgA) was the most abundant.
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Affiliation(s)
- Veronique Demers-Mathieu
- Nutrition Program, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA.
| | - Robert K Huston
- Department of Pediatrics, Randall Children's Hospital at Legacy Emanuel, Portland, OR 97227, USA.
| | - Andi M Markell
- Department of Pediatrics, Randall Children's Hospital at Legacy Emanuel, Portland, OR 97227, USA.
| | - Elizabeth A McCulley
- Department of Pediatrics, Randall Children's Hospital at Legacy Emanuel, Portland, OR 97227, USA.
| | - Rachel L Martin
- Department of Pediatrics, Randall Children's Hospital at Legacy Emanuel, Portland, OR 97227, USA.
| | - Melinda Spooner
- Nutrition Program, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA.
| | - David C Dallas
- Nutrition Program, School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR 97331, USA.
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