Infant formula safety

Assessing growth of infants with chylothorax receiving fortified skimmed human breast milk

LEARNING OUTCOME

To learn how skimmed human milk (SHM) can be used in infants with chylothorax to support adequate weight gain and nutrition while receiving human milk.

BACKGROUND

Traditional nutrition management for chylothorax is to limit long-chain triglycerides (LCTs) and provide a diet high in medium-chain triglycerides (MCTs). Transition from human milk to formula has been required to provide the ratio of MCT to LCT required to stop the accumulation of chyle. Although SHM may provide the right fat content for a baby with chylothorax, previous studies have shown slow growth in infants receiving SHM.

OBJECTIVE

To demonstrate that infants receiving SHM fortified with high-MCT infant formula will have age appropriate growth without re-accumulation of chyle.

DESIGN/METHODS

Between 2017 and 2019, term infants with the diagnosis of chylothorax who were previously receiving human milk and transitioned to fortified SHM were monitored for growth and reaccumulation of chyle.

RESULTS

The six infants who were prescribed fortified SHM with high-MCT infant formula using standardized recipes did not show reaccumulation of chyle and showed positive weight gain in five of the six study patients. The infants gained a mean weight of 30.5 g/day (±19.5), and their weight z scores improved by a mean of +0.29 (±0.33).

CONCLUSIONS

Fortified SHM is a safe treatment option that can provide adequate nutrition for the infant with chylothorax to gain weight appropriately for age.

Use of human milk and fortification in the NICU

Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow's milk, however there are concerns regarding a possible association between the use of cow's milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or "blind fortification", adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

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.

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

BACKGROUND

Use of human milk is recommended for low birth weight (VLBW) infants, but must be safety fortified with sterile liquid fortifiers to be nutritionally sufficient. Due to clinical concern for a high incidence of metabolic acidosis among VLBW infants fed human milk fortified with acidified liquid human milk fortifier (ALHMF), we aimed to retrospectively compare the outcomes of infants fed ALHMF to those fortified with non-acidified liquid HMF (NLHMF).

METHODS

Medical records of VLBW neonates admitted to our institution's neonatal intensive care unit from July 1st, 2013 to June 30th, 2014 were reviewed. 129 patients were included in the study, 61 of which received ALHMF and 68 received NLHMF. Metabolic, nutritional and clinical outcomes, including growth, were compared between the two cohorts.

RESULTS

Of the infants who received ALHMF, 70.5% developed metabolic acidosis compared to only 11.8% in the NLHMF group (p < 0.001). In addition, infants who received NLHMF had a 10% greater growth velocity during the period of fortification (p = 0.01). During the full course of hospitalization, no difference in growth velocity was seen between the groups and greater length gains were found in the ALHMF group.

CONCLUSIONS

The use of human milk fortified with ALHMF was associated with an increased incidence of metabolic acidosis and poorer growth during the period of fortification when compared to NLHMF-fortified feedings. These growth effects were not apparent when the duration of hospitalization was considered, suggesting a need for further study to better characterize the advantages and disadvantages of each fortifier.

Routine versus Selective Fortification of Human Milk with Powdered Human Milk Fortifiers in Very Low Birth Weight (VLBW) Preterm Infants: A Retrospective Pre-Post Cohort Study

OBJECTIVES

The objective of this study was to show the effects of routine vs. selective fortification of human milk (HM) on short-term growth and metabolic parameters.

METHODS

Single-centre retrospective pre-post cohort study in India. Preterm infants ≤32 weeks' gestation and weighing ≤1500 g were included. Routine fortification: pre-fixed feed volume (100 ml/kg/day in our unit) at which fortification was done. Selective fortification: feed volume was gradually optimized till 180-200 ml/kg/day. If weight gain was below the expected threshold (<10 g/kg/day), then fortification was considered. Primary outcome measure was rate of growth till discharge.

RESULTS

The median rate of weight gain (g/kg/day) in the routine fortification group [10.8 (3.3, 17.1)] was comparable with that in the selective fortification group [8.4 (0, 14.2), p = 0.6]. Serum phosphorus showed a significantly higher value (5.9 vs. 4.8, p = 0.03), while rest of the metabolic parameters showed a trend towards a favourable outcome in the selective fortification group. Adverse outcomes showed a trend towards decreased feed intolerance, necrotizing enterocolitis, and sepsis in the selective fortification group.

CONCLUSIONS

Selective fortification had a comparable growth rate and showed a trend towards better metabolic parameters and lesser adverse outcomes compared with routine fortification of HM.

Fortification of human milk for preterm infants

Human milk is the preferred feeding for all infants, including those of very low birth weight (<1500 g). It has both nutritional and anti-infective properties which are especially important for infants at risk for sepsis and necrotizing enterocolitis. When maternal milk is not available or the amount produced is not sufficient to meet daily needs, donor human milk may (should) be used in its place. However, donor human milk is generally term in quality and likely has insufficient protein to promote appropriate growth. Whether donor or mother's own milk, fortification of human milk is required to meet nutrient requirements for growth and development for these preterm infants who are at high risk for growth faltering during the hospital stay. There are multiple strategies and products that may be employed to support desired growth rates. The advent of human milk analyzers may be helpful in a more customized approach to fortification.

Relative cost-effectiveness of using a liquid human milk fortifier in preterm infants in the US

Objective

To human milk fortifier (LHMF) compared to a powdered human milk fortifier (PHMF) in preterm infants in the US from the perspective of third-party payers and parents.

Methods

This was a decision modelling study using patient data obtained from a randomized controlled trial comparing a LHMF with a PHMF in preterm infants, supplemented with additional data obtained by performing a chart review among 79% of the trial patients. The model estimated the cost-effectiveness of LHMF versus PHMF in US$ at 2014/2015 prices.

Results

More infants in the LHMF group were discharged home (92% versus 89%) and more infants in the PHMF group were transferred to another unit (9% versus 5%). Gestational age was an independent predictor for being discharged home (odds ratio of 2.18; p=0.006 for each week of gestational age). Mean length of neonatal intensive care unit (NICU) stay was 1 day less in the LHMF than the PHMF group (62.3 versus 63.4 days), but mean length of NICU stay among infants who developed NEC or sepsis was 79.3 days and 61.2 days in the PHMF and LHMF groups, respectively. Total management cost up to discharge was $10,497 per infant less in the LHMF group than the PHMF group ($240,928 versus $251,425).

Conclusion

Using LHMF instead of PHMF in preterm infants enabled resources to be freed-up for alternative use within the system. There is no health economic reason why LHMF should not be used in preference to PHMF in the NICU.

Clinical and nutritional outcomes of two liquid human milk fortifiers for premature infants

BACKGROUND

In preterm infants fortification of human milk with human milk fortifiers (HMF) to optimize nutrition and growth is standard practice. We compared clinical, nutrition and growth outcomes in infants receiving two types of liquid HMF (LHMF).

METHODS

Clinical, nutrition and growth outcomes were compared between infants admitted to a level IV NICU, and born with birth weight less than or equal to 1800 grams, between 10/1/2014-12/31/2014 and received human milk with acidified LHMF (ALHMF) and between 1/1/2015-4/31/2015 and received human milk with heat treated LHMF (HTLHMF).

RESULTS

Of the 85 qualifying infants, 67 received human milk and LHMF. ALHMF group had significantly higher incidence of metabolic acidosis and lower bicarbonate and base excess levels relative to infants receiving HTLHMF (P < 0.001). There were no significant differences by LHMF status in other clinical outcomes and nutrition and growth outcomes. In multivariate analyses, ALHMF use was associated with metabolic acidosis, and lower base excess and bicarbonate levels.

CONCLUSION

In our study, the clinical, nutrition and growth outcomes between the two LHMF groups were similar. However, use of ALHMF in preterm infants was associated with increased incidence of metabolic acidosis in our cohort. Further randomized control trials are warranted to evaluate these findings.

Considerations in meeting protein needs of the human milk-fed preterm infant

Preterm infants provided with sufficient nutrition to achieve intrauterine growth rates have the greatest potential for optimal neurodevelopment. Although human milk is the preferred feeding for preterm infants, unfortified human milk provides insufficient nutrition for the very low-birth-weight infant. Even after fortification with human milk fortifier, human milk often fails to meet the high protein needs of the smallest preterm infants, and additional protein supplementation must be provided. Although substantial evidence exists to support quantitative protein goals for human milk-fed preterm infants, the optimal type of protein for use in human milk fortification remains uncertain. This question was addressed through a PubMed literature search of prospective clinical trials conducted since 1990 in preterm or low-birth-weight infant populations. The following 3 different aspects of protein quality were evaluated: whey-to-casein ratio, hydrolyzed versus intact protein, and bovine milk protein versus human milk protein. Because of a scarcity of current studies conducted with fortified human milk, studies examining protein quality using preterm infant formulas were included to address certain components of the clinical question. Twenty-six studies were included in the review study. No definite advantage was found for any specific whey-to-casein ratio. Protein hydrolyzate products with appropriate formulations can support adequate growth and biochemical indicators of nutrition status and may reduce gastrointestinal transit time, gastroesophageal reflux events, and later incidence of atopic dermatitis in some infants. Plasma amino acid levels similar to those of infants fed exclusive human milk-based diets can be achieved with products composed of a mixture of bovine proteins, peptides, and amino acids formulated to replicate the amino acid composition of human milk. Growth and biochemical indicators of nutrition status are similar for infants fed human milk fortified with human milk protein and bovine milk protein.

Fortification of human milk in very low birth weight infants (VLBW <1500 g birth weight)

The American Academy of Pediatrics supports the feeding of human milk for all infants. Very-low-birth-weight and extremely low-birth-weight infants especially can benefit from the immune and neurodevelopmental effects of human milk. However, human milk alone is nutritionally inadequate for the rapid growth of the very-low-birth-weight infant during a critical window for brain development and requires fortification to meet current recommendations. There are a variety of products, devices, and strategies that can be used to fine tune nutritional support of these very vulnerable infants.

Human milk and the premature infant

Human milk is the preferred feeding for both term and preterm infants. While being considered optimal for term infants, human milk, even from mothers delivering preterm infants, is lacking in protein, energy, sodium, calcium, and phosphorus, resulting in poorer growth and nutrient deficiencies when compared to formulas designed for these high-risk infants. Further, the lack of growth is associated with long-term adverse consequences. Since human milk has unique properties in promoting gastrointestinal maturation and immunological benefits, it is prudent to implement strategies to fortify it appropriately to realize its benefits which include reduced rates of necrotizing enterocolitis, fewer episodes of sepsis and urinary tract infections, and improved visual and neurocognitive development. Donor human milk is being widely used when mothers' own milk is not available or is in short supply. While it retains some of the biological properties and clinical benefits of mothers' own milk, it requires additional care in fortification, especially if the donor milk is from a pool of term human milk. As nutritional strategies improve, the ultimate goal is to minimize extrauterine growth restriction and promote appropriate growth after regaining birth weight.

The effects of acidification on human milk's cellular and nutritional content

OBJECTIVE

Fortification of human milk for preterm infants is necessary and a common newborn intensive care practice. Currently, acidified human milk as part of a human milk fortifier is being fed to preterm infants. However, there are little data on the acidification effects on mother's milk. The aim of this study is to determine the effects of acidification on human milk's cellular and nutritional composition.

STUDY DESIGN

One hundred milk samples were collected from eight mothers who had infants in the neonatal intensive care unit. All milk samples were frozen at 4 °C. The frozen samples were thawed and divided into two equal aliquots, control and acidified. The control milk sample had its pH determined while the other sample was acidified to pH 4.5. Each milk sample was examined for pH, white cells, total protein, creamatocrit, lipase activity and free fatty acids.

RESULT

Mean pH of the human milk control was 6.8 ± 0.1 (M ± s.d.) with the acidified milk at 4.5 ± 0.1. Acidification caused a 76% decrease in white cells, a 56% decrease in lipase activity and a 14% decrease in the total protein but a 36% increase in the creamatocrit.

CONCLUSION

Acidification of human milk causes significant changes of the milk's cellular and nutritional components that may not be beneficial to preterm infants.

A new liquid human milk fortifier and linear growth in preterm infants

OBJECTIVES

To evaluate the growth, tolerance, and safety of a new ultraconcentrated liquid human milk fortifier (LHMF) designed to provide optimal nutrients for preterm infants receiving human breast milk in a safe, nonpowder formulation.

METHODS

Preterm infants with a body weight ≤ 1250 g fed expressed and/or donor breast milk were randomized to receive a control powder human milk fortifier (HMF) or a new LHMF for 28 days. When added to breast milk, the LHMF provided ∼20% more protein than the control HMF. Weight, length, head circumference, and serum prealbumin, albumin, blood urea nitrogen, electrolytes, and blood gases were measured. The occurrence of sepsis, necrotizing enterocolitis, and serious adverse events were monitored.

RESULTS

This multicenter, third party-blinded, randomized controlled, prospective study enrolled 150 infants. Achieved weight and linear growth rate were significantly higher in the LHMF versus control groups (P = .04 and 0.03, respectively). Among infants who adhered closely to the protocol, the LHMF had a significantly higher achieved weight, length, head circumference, and linear growth rate than the control HMF (P = .004, P = .003, P = .04, and P = .01, respectively). There were no differences in measures of feeding tolerance or days to achieve full feeding volumes. Prealbumin, albumin, and blood urea nitrogen were higher in the LHMF group versus the control group (all P < .05). There was no difference in the incidence of confirmed sepsis or necrotizing enterocolitis.

CONCLUSIONS

Use of a new LHMF in preterm infants instead of powder HMF is safe. Benefits of LHMF include improvements in growth and avoidance of the use of powder products in the NICU.

Tap or bottled water: drinking preferences among urban minority children and adolescents

The last decade has seen an increasing trend in consumer preference of bottled water over tap water. Little is known what type of water children and adolescents prefer for drinking and what their parents think of their community tap water. The study objective was to assess drinking water preferences, perceptions of the qualities of tap water and bottled water, and fluoride knowledge in an urban pediatric population. We conducted an anonymous survey of a convenience sample of caretakers of children and adolescents at an urban clinic regarding their preferences for tap or bottled water, their perceptions of the quality of tap and bottled water and their knowledge of fluoride. Of the 208 participants (79% African American, 9% Latino), 59% drank tap water, 80% bottled water. Only 17% drank tap water exclusively, 38% drank bottled water exclusively, 42% drank both. We found no significant differences in water preferences across age groups, from infancy to adulthood, or among ethnic groups. Ratings for taste, clarity, purity and safety were significantly higher for bottled water than tap water (P < 0.001). Only 24% were aware of fluoride in drinking water. We conclude bottled water was preferred over tap water in an urban minority pediatric population. Perceptions of the qualities of water seemed to drive drinking preferences. Public health strategies are needed to increase public awareness of the impact of bottled water consumption on oral health, household budgets and the environment.

GPs' decision-making when prescribing medicines for breastfeeding women: Content analysis of a survey

BACKGROUND

Many breastfeeding women seek medical care from general practitioners (GPs) for various health problems and GPs may consider prescribing medicines in these consultations. Prescribing medicines to a breastfeeding mother may lead to untimely cessation of breastfeeding or a breastfeeding mother may be denied medicines due to the possible risk to her infant, both of which may lead to unwanted consequences. Information on factors governing GPs' decision-making and their views in such situations is limited.

METHODS

GPs providing shared maternity care at the Royal Women's Hospital, Melbourne were surveyed using an anonymous postal survey to determine their knowledge, attitudes and practices on medicines and breastfeeding, in 2007/2008 (n = 640). Content analysis of their response to a question concerning decision-making about the use of medicine for a breastfeeding woman was conducted. A thematic network was constructed with basic, organising and global themes.

RESULTS

335 (52%) GPs responded to the survey, and 253 (76%) provided information on the last time they had to decide about the use of medicine for a breastfeeding woman. Conditions reported were mastitis (24%), other infections (24%) and depressive disorders (21%). The global theme that emerged was "complexity of managing risk in prescribing for breastfeeding women". The organising themes were: certainty around decision-making; uncertainty around decision-making; need for drug information to be available, consistent and reliable; joint decision-making; the vulnerable "third party" and infant feeding decision. Decision-making is a spectrum from a straight forward decision, such as treatment of mastitis, to a complicated one requiring multiple inputs and consideration. GPs use more information seeking and collaboration in decision-making when they perceive the problem to be more complex, for example, in postnatal depression.

CONCLUSION

GPs feel that prescribing medicines for breastfeeding women is a contentious issue. They manage the risk of prescribing by gathering information and assessing the possible effects on the breastfed infant. Without evidence-based information, they sometimes recommend cessation of breastfeeding unnecessarily.

Enterobacter sakazakii: a coliform of increased concern to infant health

The first cases of neonatal meningitis believed to have been caused by Enterobacter sakazakii were reported in 1961. Prompted by several subsequent outbreaks of E. sakazakii infections in neonates and an increasing number of neonates in intensive care units being fed rehydrated powdered infant formula, considered to be a source of the pathogen, public health authorities and researchers are exploring ways to eliminate the bacterium or control its growth in dry infant formula, processing environments and formula preparation areas in hospitals. Reviewed here are advances in taxonomy and classification of E. sakazakii, methods of detecting, isolating and typing the bacterium, antibiotic resistance, clinical etiology and pathogenicity. Outbreaks of E. sakazakii infections in neonates and adults are summarized. Reports on the presence of E. sakazakii in clinical settings, the environment and foods and food processing facilities are reviewed. Tolerance of the pathogen to environmental stresses, its behavior in powdered and rehydrated infant formulae and hazard analysis and risk management are discussed. Research needs are presented.

Characterization of Clostridium botulinum strains associated with an infant botulism case in the United Kingdom

The sixth case of infant botulism in the United Kingdom was reported in 2001. The case was caused by a type B strain of Clostridium botulinum. Strains of C. botulinum were isolated from the baby's feces and from foodstuffs in the household in an attempt to document transmission. The aims of this study were to characterize the strains of C. botulinum associated with the botulism case. This was performed using a variety of techniques, including C. botulinum culture phenotypic properties, neurotoxin characterization, and pulsed-field gel electrophoresis (PFGE) banding patterns. Cultures associated with this case as well as isolates from stored and historical samples were analyzed and compared. C. botulinum type B PFGE patterns from the infant and from an opened container of infant formula were indistinguishable, while the PFGE profile of a strain presumably isolated from an unopened archival container was unique. The results suggest that the unopened brand of formula was not the source for transmission of spores to the infant and that the strain was distinct from previous botulism cases in the United Kingdom. Since environmental testing was not performed, it is not possible to deduce other sources of transmission.

Breast-feeding, bottle-feeding and Dr. Spock: the shifting context of choice

In today's environment, breast-feeding represents both a medical gold standard for infant feeding and a moral gold standard for mothering. The morally charged character of this discourse makes the notion of choice in infant feeding particularly problematic and fraught with difficulty. From an historical content analysis of selected editions from 1946 to 1998 of Dr. Spock's famous child-care manual, this paper explicates the process through which the breast versus bottle discourse has shifted over the last half-century, and how these shifts have shaped the context of choice within which mothers must make their infant-feeding decisions.