Association between type of feeding at discharge from the hospital and nutritional status of very low birth weight preterm infants

Infants admitted to Danish neonatal units demonstrate satisfactory growth independent of feeding type at discharge

AIM

The aim was to investigate feeding type at discharge; exclusively breastfeeding (EBF), mixed breastfeeding (MBF), and formula milk feeding (FMF), factors associated with feeding type, and changes in weight-for-age z-score (ΔWAZ) in infants admitted to Danish neonatal units.

METHODS

Using data from the Danish National Quality Database for Births and the Danish Newborn Quality Database, we included 8639 mother-infant dyads admitted ≥5 days between February 2019 and December 2021. We used logistic regression to investigate associations between maternal and infant factors and feeding type, and descriptive statistics to describe ΔWAZ and feeding type at discharge.

RESULTS

Of all infants 59.1% were EBF, 16.9% MBF and 24.0% FMF at discharge. Gestational age <37 weeks, caesarean section, multiple births, small for gestational age, weeks at hospital, ≥6 h before skin-to-skin contact, and few weeks at hospital were associated with failure to EBF at discharge. Median (min-max) ΔWAZ in EBF, MBF and FMF infants was -0.44 (-4.78 to 4.88), -0.43 (-3.47 to 4.42) and -0.39 (-3.54 to 4.03), respectively. ΔWAZ was higher in EBF compared to FMF infants, p-value 0.01, but no significant difference in ΔWAZ between MBF and FMF infants, p-value 0.06.

CONCLUSION

Danish newborn infants demonstrated satisfactory growth during admission to the neonatal unit, independent of feeding type at discharge. Rates of exclusively breastfeeding need improvement.

Association between type of feeding at hospital discharge and nutritional status of Brazilian very preterm infants: a multicenter study

OBJECTIVES

To examine trends over time in diet and size of very preterm infants, and associations of diet with size at hospital discharge/transfer.

METHODS

The authors studied 4062 surviving very preterm infants born < 32 weeks' gestational age and < 1500 g between January 2012 and December 2020 from 12 Brazilian Neonatal Intensive Care Units. Diet type at discharge/transfer was classified as exclusive human milk, exclusive formula, or mixed. Outcomes were weight and head circumference at hospital discharge and the change in each from birth to discharge. The authors used linear regression to estimate adjusted associations of diet type with infant size, overall, and stratified by fetal growth category (small vs. appropriate for gestational age). The authors also examined trends in diet and infant size at discharge over the years.

RESULTS

Infants' mean gestational age at birth was 29.3 weeks, and the mean birth weight was 1136 g. Diet at discharge/transfer was exclusive human milk for 22 %, mixed for 62 %, and exclusive formula for 16 %. Infant size in weight and head circumference were substantially below the growth chart reference for all diets. Infants fed human milk and mixed diets were lighter and had smaller heads at discharge/transfer than infants fed formula only (weight z: -2.0, -1.8, and -1.5; head z: -1.3, -1.2 and -1.1 for exclusive human milk, mixed and exclusive formula respectively).

CONCLUSION

Results suggest high human milk use but gaps in nutrient delivery among hospitalized Brazilian very preterm infants, with little evidence of improvement over time.

The Association of Different Proportions of Human Milk of the Total Enteral Intake on Health Outcomes in Preterm Infants: A Systematic Review

Background: Human milk (HM) is a proven optimal food for preterm infants. However, there is uncertainty regarding the effects of different proportions of HM of the total enteral intake on health outcomes in preterm infants. Therefore, we conducted a systematic review of studies examining the effects of different proportions of HM of the total enteral intake on health outcomes in preterm infants. Methods: We conducted a literature search in the Web of Science, PubMed, and Scopus databases. The methodological quality of the included articles and the certainty of evidence were assessed according to the Newcastle-Ottawa Scale and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool, respectively. Results: Twelve studies were included in the review. Among the clinical findings, the effect of different proportions of HM of the total enteral feeding on health outcomes in preterm infants was divided into six primary outcomes: physical growth, length of stay, morbidity of any disease, all-cause mortality, feeding-related outcomes, and other health outcomes. The studies presented a high risk of bias for most of the domains. The certainty of the evidence was considered low or very low. Conclusions: The findings reiterated that greater proportions of HM positively affect the health outcomes of preterm infants. Overall, when the HM accounts for at least 20% of the total enteral intake, it has an effect on health outcomes in preterm infants. If the proportion of HM reaches 50%, the incidence and severity of necrotizing enterocolitis, as well as the time to reach enteral feeds, will be reduced. Increasing the proportion of HM in enteral feeding should be considered a priority in the feeding strategy for preterm infants in clinical practice.

Effects of Formula Milk Feeding in Premature Infants: A Systematic Review

The preterm baby is born at a critical period for the growth and development of the gastrointestinal and neuromotor systems. Breast milk is the food of choice for infants during the first months of life, as it provides multiple short- and long-term benefits to preterm and sick newborns. Despite this, breastfeeding is often nutritionally insufficient, requiring the addition of fortifiers. In other cases, it is important to ensure the necessary nutrients and calories, which can be provided by formula milk or pasteurized and fortified donated human milk. However, the specific guidelines for the use of formula milk have not yet been determined. Therefore, a systematic search was considered necessary in order to identify the effects of feeding with formula milk in preterm infants. A systematic search in Scopus, Medline, Pubmed, Cinahl, ClinicalTrials and Web of Science with the terms Infant Formula and Infant Premature was conducted. A total of 18 articles were selected, of which, eight were experimental and ten were observational studies. Among the objectives of the analyzed investigations, we distinguished nine that compared the effects of feeding with formula milk, breast milk and donated human milk, five that evaluated the effects of different compositions of formula milk and/or fortifiers and four investigations that compared the effects of formula milk and donated human milk. In conclusion, when breast milk is insufficient or unavailable, formula milk is a good nutritional option, due to its higher caloric density and protein content. Nevertheless, the preterm infant's diet should incorporate breast milk to reduce the incidence of morbidities such as necrotizing enterocolitis and sepsis (related to hospital handling of fortifiers and formula milk).

Factors Associated With Breastfeeding Very Low Birth Weight Infants at Neonatal Intensive Care Unit Discharge: A Single-Center Brazilian Experience

BACKGROUND

The mothers of very low birth weight infants face many challenges to achieve breastfeeding at hospital discharge, especially during long stays.

RESEARCH AIM

The aim of this study was to describe the incidence and factors associated with breastfeeding rates (exclusive or with formula) at discharge, for very low birth weight infants, in a private Neonatal Intensive Care Unit in southern Brazil.

METHODS

We conducted a prospective longitudinal cohort study of infants (N = 335) with very low birth weight and/or less than 30 weeks gestational age, who survived to discharge and had no contraindication to mother's own milk. Participants were initially divided into three groups (exclusive breastfeeding, some breastfeeding, and no breastfeeding) based on their feedings at discharge; however, later, two groups were analyzed (any breastfeeding, no breastfeeding).

RESULTS

Most (93.4%; n = 313) were breastfeeding directly at least once daily at discharge, of which 16.1% (n = 54) were receiving exclusive mother's milk and 77.3% (n = 259) mixed feeding (mother's milk and formula). Breastfeeding at discharge was associated with gestational age ≥ 28 weeks, higher birth weight, not developing neonatal sepsis or bronchopulmonary dysplasia during the hospital stay, shorter lengths of stay, and lower weight at discharge. After Poisson regression, breastfeeding at discharge was associated only with a shorter length of stay (RR 0.98; CI 95% [0.95, 0.99], p < .05).

CONCLUSIONS

In our single unit experience in Brazil, most infants were breastfeeding at discharge. NICU staff might address mothers of infants who have prolonged hospitalization with specific strategies. Mothers and infants at risk can be identified early and personalized interventions can be developed for improving breastfeeding rates at discharge.