Availability of Donor Milk for Very Preterm Infants Decreased the Risk of Necrotizing Enterocolitis without Adversely Impacting Growth or Rates of Breastfeeding

The impact of breastfeeding on the preterm infant's microbiome and metabolome: a pilot study

BACKGROUND

Human milk is unquestionably beneficial for preterm infants. We investigated how the transition from tube to oral/breastfeeding impacts the preterm infants' oral and gut microbiome and metabolome.

METHODS

We analyzed stool, saliva, and milk samples collected from a cohort of preterm infants enrolled in the MAP Study, a prospective observational trial. The microbiome and metabolome of the samples were analyzed from 4 longitudinal sample time points, 2 during tube feeds only and 2 after the initiation of oral/breastfeeding.

RESULTS

We enrolled 11 mother-infant dyads (gestational age = 27.9 (23.4-32.2)) and analyzed a total of 39 stool, 44 saliva, and 43 milk samples over 4 timepoints. In saliva samples, there was a shift towards increased Streptococcus and decreased Staphylococcus after oral feeding/breastfeeding initiation (p < 0.05). Milk sample metabolites were strongly influenced by the route of feeding and milk type (p < 0.05) and represented the pathways of Vitamin E metabolism, Vitamin B12 metabolism, and Tryptophan metabolism.

CONCLUSION

Our analysis demonstrated that the milk and preterm infant's saliva microbiome and metabolome changed over the course of the first four to 5 months of life, coinciding with the initiation of oral/breastfeeds.

IMPACT

The microbiome and metabolome is altered in the infant's saliva but not their stool, and in mother's milk when feeds are transitioned from tube to oral/breastfeeding. We assessed the relationship between the gut and oral microbiome/metabolome with the milk microbiome/metabolome over a longitudinal period of time in preterm babies. Metabolites that changed in the infants saliva after the initiation of oral feeds have the potential to be used as biomarkers for disease risk.

Monitoring the Use of Human Milk, the Ideal Food for Very Low-Birth-Weight Infants-A Narrative Review

Aware of the utmost importance of feeding premature babies-especially those of lower weight-with human milk, as well as the need to monitor this important element of neonatal care, we focused on four aspects in this review. First of all, we reviewed the beneficial effects of feeding premature infants with breast milk in the short and long term. Secondly, we performed a quantitative evaluation of the rates of breastfeeding and feeding with human milk in Very-Low-Birth-Weight infants (VLBWs) during hospitalization in the Neonatal Intensive Care Unit (NICU) and at discharge. Our aim was to take a snapshot of the current status of human milk-feeding care and track its trends over time. Then we analyzed, on the one hand, factors that have been proven to facilitate the use of maternal milk and, on the other hand, the risk factors of not feeding with breast milk. We also considered the spread of human milk banking so as to assess the availability of donated milk for the most vulnerable category of premature babies. Finally, we proposed a protocol designed as a tool for the systematic monitoring of actions that could be planned and implemented in NICUs in order to achieve the goal of feeding even more VLBWs with human milk.

Characterization of exosomal microRNAs in preterm infants fed with breast milk and infant formula

Breastfeeding not only reduces infection-related morbidity, but also increases growth of preterm infants. Advantages of breast milk (BM) for preterm infants are significant. They continue to be studied. However, because not all preterm infants can receive breastfeeding, bovine-based infant formula (IF) is used as an alternative, which may increase the risk of several preterm complications. Exosomes isolated from biofluids are emerging as biomarkers in research of various diseases. Here, we characterized miRNA contents of exosomes in urine and serum samples of preterm infants who were BM and IF fed and performed transcriptomic analysis of small RNA libraries. We identified significantly up-regulated 6 miRNAs and 10 miRNAs, respectively. Gene Ontology (GO) analysis revealed that target genes of these miRNAs might participate in neuronal development, immunity modulation, detoxification of reactive oxygen species, and transmembrane exchange. Our data suggest that exosome-based systemic screening for preterm infants with breastfeeding might be a screening tool for identifying target molecules involved in therapy for preterm infants in neonatal intensive care unit (NICU) and for future application as nutraceutical formulations or pharmaceuticals.

Preterm Birth and Infantile Appendicitis

OBJECTIVE

To investigate the potential association between preterm birth and infantile appendicitis.

METHODS

We conducted a retrospective, multicenter, matched case-control study. This study included consecutive patients <1 year of age with surgery- or autopsy-confirmed appendicitis, admitted between December 2007 and May 2023. For each case, 10 healthy infants were randomly selected and matched by age. Infants were categorized as neonates (0 to 28 days) or older infants (>28 days and <1 year).

RESULTS

The study included 106 infants diagnosed with appendicitis (median age 2.4 months) and 1060 age-matched healthy controls. In the univariate analysis, preterm birth was significantly associated with the development of appendicitis within the first year of life (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.67-6.70). Other factors associated with a higher risk of infantile appendicitis included being male (OR, 1.91; 95%CI, 1.25-2.94), weight-for-age z-score (OR, 0.72; 95%CI, 0.64-0.81), and exclusively fed on formula (OR, 2.95; 95%CI, 1.77-4.91). In multivariable analyses, preterm remained significantly associated with appendicitis (adjusted OR, 3.32; 95%CI, 1.76-6.24). Subgroup analysis revealed that a preterm birth history increased the risk of appendicitis in both neonates (adjusted OR, 4.56; 95%CI, 2.14-9.71) and older infants (adjusted OR, 3.63; 95%CI, 1.72-7.65). However, preterm did not significantly influence the incidence of appendiceal perforation.

CONCLUSIONS

Preterm infants have an increased risk of appendicitis during the first year of life. A preterm birth history may help improve the timely diagnosis of infantile appendicitis.

Effects of Maternal Stress on Breast Milk Production and the Microbiota of Very Premature Infants

Perinatal stress experienced by mothers of very premature newborns may influence the mother's milk and the infant's intestinal microbiota. This prospective study of mothers of very preterm infants fed with mother's own milk (MOM) was carried out in a tertiary hospital over a 2-year period. The assessment of maternal stress in 45 mothers of 52 very preterm newborns using the parental stress scale (PSS:NICU) revealed an inverse relationship between stress and MOM production in the first days of life (p = 0.012). The greatest contributor to stress was the one related to the establishment of a mother-child bond. Maternal stress was lower in mothers in whom the kangaroo method was established early (p = 0.011) and in those with a higher educational level (p = 0.032). Levels of fecal calprotectin (FC) decreased with the passage of days and were directly correlated with birthweight (p = 0.044). FC levels 7 days post-delivery were lower in newborns that received postnatal antibiotics (p = 0.027). High levels of maternal stress resulted in progressive decreases and increases in the proportions of Firmicutes and Proteobacteria species, respectively, over 15 days post-delivery, both in MOM and in fecal samples from premature newborns. These findings underscore the importance of recognizing and appropriately managing maternal stress in neonatal units, given its marked influence on both the microbiota of maternal milk and the intestinal microbiota of premature newborns.

Stability and heterogeneity in the antimicrobiota reactivity of human milk-derived immunoglobulin A

Immunoglobulin A (IgA) is secreted into breast milk and is critical for both protecting against enteric pathogens and shaping the infant intestinal microbiota. The efficacy of breast milk-derived maternal IgA (BrmIgA) is dependent upon its specificity; however, heterogeneity in BrmIgA binding ability to the infant microbiota is not known. Using a flow cytometric array, we analyzed the reactivity of BrmIgA against bacteria common to the infant microbiota and discovered substantial heterogeneity between all donors, independent of preterm or term delivery. Surprisingly, we also observed intradonor variability in the BrmIgA response to closely related bacterial isolates. Conversely, longitudinal analysis showed that the antibacterial BrmIgA reactivity was relatively stable through time, even between sequential infants, indicating that mammary gland IgA responses are durable. Together, our study demonstrates that the antibacterial BrmIgA reactivity displays interindividual heterogeneity but intraindividual stability. These findings have important implications for how breast milk shapes the development of the preterm infant microbiota and protects against necrotizing enterocolitis.

Stability and heterogeneity in the anti-microbiota reactivity of human milk-derived Immunoglobulin A

Immunoglobulin A (IgA) is secreted into breast milk and is critical to both protecting against enteric pathogens and shaping the infant intestinal microbiota. The efficacy of breast milk-derived maternal IgA (BrmIgA) is dependent upon its specificity, however heterogeneity in BrmIgA binding ability to the infant microbiota is not known. Using a flow cytometric array, we analyzed the reactivity of BrmIgA against bacteria common to the infant microbiota and discovered substantial heterogeneity between all donors, independent of preterm or term delivery. We also observed intra-donor variability in the BrmIgA response to closely related bacterial isolates. Conversely, longitudinal analysis showed that the anti-bacterial BrmIgA reactivity was relatively stable through time, even between sequential infants, indicating that mammary gland IgA responses are durable. Together, our study demonstrates that the anti-bacterial BrmIgA reactivity displays inter-individual heterogeneity but intra-individual stability. These findings have important implications for how breast milk shapes the development of the infant microbiota and protects against Necrotizing Enterocolitis.

SUMMARY

We analyze the ability of breast milk-derived Immunoglobulin A (IgA) antibodies to bind the infant intestinal microbiota. We discover that each mother secretes into their breast milk a distinct set of IgA antibodies that are stably maintained over time.

State of the Science on the Benefits of Human Milk for Hospitalized, Vulnerable Neonates

Research on human milk has increased dramatically in recent years. The purpose of this review is to describe the literature on the health benefits of human milk for hospitalized, vulnerable neonates. PubMed, CINAHL, and Embase were searched for research articles reporting the health outcomes of hospitalized neonates who were exposed to human milk. Human milk, particularly a mother's own milk, has the potential to reduce the risk of death and the risk and severity of necrotizing enterocolitis, infection, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, kidney disease, and liver disease. Dose and timing of human milk is important, with more human milk and earlier introduction having a greater impact on health. When a mother's own milk is not available, donor human milk provides benefits over infant formula.

Availability of donor milk improves enteral feeding but has limited effect on body growth of infants with very-low birthweight: Data from a historic cohort study

Compare with preterm formula, donor human milk (DM) is associated with a lower risk of mortality and morbidity in preterm infants. It is thus deemed superior to preterm formula as the sole diet or supplement to own mother's milk (OMM) for preterm infants, especially for those with very low birthweight (VLBW). This historic cohort study investigated the relationship between DM availability, and enteral feeding, body growth of VLBW infants by comparing two cohorts before and after the establishment of a human milk bank. A sub‐analysis was also conducted between small‐for‐gestational‐age (SGA) and non‐SGA infants in our cohorts. Our results showed that DM availability was associated with earlier initiation and faster advancement of enteral feeding, earlier attainment of full enteral feeding, and a higher proportion of OMM in enteral feeding. DM availability was also associated with earlier regain of birthweight, but not with better body growth. SGA and non‐SGA infants responded differently to DM availability with only the non‐SGA group showing improved enteral feeding associated with DM availability. The poor growth of VLBW infants with fortified DM warrants further investigations on better fortification strategies to further improve body growth. Studies are also needed on long‐term effects of DM feeding on the development of VLBW infants.

Compared with the infants before the introduction of donor human milk (DM), very low birthweight infants after that had improved enteral feeding process, shown as earlier enteral feeding introduction, faster advancement, and earlier attainment of full enteral feeding.

DM availability affects body growth to a limited extent, which calls for a better fortification strategy for DM‐fed infants.

The setup of a human donor milk bank increased the use of own mother's milk for enteral feeding.

Initiation of lactation and the provision of human milk to preterm infants in German neonatal intensive care units from the mothers' perspective

Background

If infants with a very low birth weight (VLBW) are to be fed exclusively with human milk, it is essential to focus on lactation initiation. The aim of the study is to learn more about the current state of lactation initiation and human milk provision in neonatal intensive care units in Germany from the mothers' perspective.

Methods

Written surveys were conducted with mothers of VLBW infants to learn more about the timing of initiation of lactation, pumping frequency during the first three days postpartum and feeding of the preterm infant during hospitalisation.

Results

The data of 437 mothers (response rate: 44.7%) were included in the analyses. Of these, only 7.8% stated that they had initiated lactation immediately after delivery and 38.2% within 6 h. In terms of pumping frequency, 50.1% pumped 7–9 times a day within the first 3 days postpartum; 60.9% reported that their infant received formula feedings during the hospital stay.

Conclusion

Overall, deficits were still evident with regard to the initiation of lactation in mothers of VLBW infants in Germany, resulting in a large proportion of VLBW infants receiving formula in the hospital.

Trial registration

German Clinical Trial Register: DRKS00017755.

Milk Formula Diet Alters Bacterial and Host Protein Profile in Comparison to Human Milk Diet in Neonatal Piglet Model

The metaproteome profiling of cecal contents collected from neonatal piglets fed pasteurized human milk (HM) or a dairy-based infant formula (MF) from postnatal day (PND) 2 to 21 were assessed. At PND 21, a subset of piglets from each group (n = 11/group) were euthanized, and cecal contents were collected for further metaproteome analysis. Cecal microbiota composition showed predominantly more Firmicutes phyla and Lachnospiraceae family in the lumen of cecum of HM-fed piglets in comparison to the MF-fed group. Ruminococcus gnavus was the most abundant species from the Firmicutes phyla in the cecal contents of the HM-fed piglets at 21 days of age. A greater number of expressed proteins were identified in the cecal contents of the HM-fed piglets relative to the MF-fed piglets. Greater abundances of proteins potentially expressed by Bacteroides spp. such as glycoside enzymes were noted in the cecal lumen of HM-fed piglets relative to the MF. Additionally, lyases associated with Lachnospiraceae family were abundant in the cecum of the HM group relative to the MF group. Overall, our findings indicate that neonatal diet impacts the gut bacterial taxa and microbial proteins prior to weaning. The metaproteomics data were deposited into PRIDE, PXD025432 and 10.6019/PXD025432.

Multifunctional Benefits of Prevalent HMOs: Implications for Infant Health

Breastfeeding is the best source of nutrition during infancy and is associated with a broad range of health benefits. However, there remains a significant and persistent need for innovations in infant formula that will allow infants to access a wider spectrum of benefits available to breastfed infants. The addition of human milk oligosaccharides (HMOs) to infant formulas represents the most significant innovation in infant nutrition in recent years. Although not a direct source of calories in milk, HMOs serve as potent prebiotics, versatile anti-infective agents, and key support for neurocognitive development. Continuing improvements in food science will facilitate production of a wide range of HMO structures in the years to come. In this review, we evaluate the relationship between HMO structure and functional benefits. We propose that infant formula fortification strategies should aim to recapitulate a broad range of benefits to support digestive health, immunity, and cognitive development associated with HMOs in breastmilk. We conclude that acetylated, fucosylated, and sialylated HMOs likely confer important health benefits through multiple complementary mechanisms of action.

Improving donor human milk collection in a hospital without a human milk bank: a quality improvement initiative at an urban tertiary-care teaching hospital

Feed intolerance and necrotising enterocolitis (NEC) are challenges while treating sick neonates. These can be reduced by giving human milk, but adequate availability of mother’s own milk or pasteurised donor human milk (PDHM) is a challenge in neonatal setups, like ours, without an attached human milk bank. Hence, this quality improvement initiative was taken to improve donor human milk collection in our urban tertiary-care teaching hospital, to at least 500 mL per week in 4 weeks. After analysing the problem, our quality improvement team identified a shortage of human milk donation that was due to low awareness among the stakeholders and lack of a system to collect and store human milk and transport it to a milk bank. The team first established a system of supplies needed for milk collection, storage and transportation. It then tested change idea of information, education and counselling to increase milk donation. The team carried out a few plan-do-study-act cycles (individual and group counsellings, and usage of videos and information leaflets) to test the change ideas and adapted a few and abandoned some. During this journey, the milk collection increased to above the target amount. Various challenges were addressed, and there was a need for constant motivation of the stakeholders, especially the mothers, and now there is sustained milk donation in the setup. This is incorporated in the standard operating procedure and as a quality indicator of the unit for sustaining the changes in the unit. Our initiative can be replicated in other setups for increasing collection of donor human milk. Greater PDHM availability for sick neonates will, in effect, reduce NEC and feeding intolerance rates, leading to reduced hospital stay, morbidity, mortality and economic burden.

Gestation-Based Viability-Difficult Decisions with Far-Reaching Consequences

Most clinicians rely on outcome data based on completed weeks of gestational of fetal maturity for antenatal and postnatal counseling, especially for preterm infants born at the margins of viability. Contemporary estimation of gestational maturity, based on ultrasounds, relies on the use of first-trimester scans, which offer an accuracy of ±3-7 days, and depend on the timing of the scans and the measurements used in the calculations. Most published literature on the outcomes of babies born prematurely have reported on short- and long-term outcomes based on completed gestational weeks of fetal maturity at birth. These outcome data change significantly from one week to the next, especially around the margin of gestational viability. With a change in approach solely from decisions based on survival, to disability-free survival and long-term functional outcomes, the complexity of the parental and care provider's decision-making in the perinatal and postnatal period for babies born at less than 25 weeks gestation remains challenging. While sustaining life following birth at the margins of viability remains our priority-identifying and mitigating risks associated with extremely preterm birth begins in the perinatal period. The challenge of supporting the normal maturation of these babies postnatally has far-reaching consequences and depends on our ability to sustain life while optimizing growth, nutrition, and the repair of organs compromised by the consequences of preterm birth. This article aims to explore the ethical and medical complexities of contemporary decision-making in the perinatal and postnatal periods. We identify gaps in our current knowledge of this topic and suggest areas for future research, while offering a perspective for future collaborative decision-making and care for babies born at the margins of viability.

A Systematic Review and Meta-Analysis of Human Milk Feeding and Short-Term Growth in Preterm and Very Low Birth Weight Infants

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.

The Interaction of Donor Human Milk Availability and Race/Ethnicity on Provision of Mother's Own Milk for Very Low Birth Weight Infants

Objective: To compare (1) differences in mother's own milk (MOM) provision and enteral feeding outcomes, (2) differences in preterm formula and donor human milk (DHM) uses as bridges to exclusive MOM feedings at discharge, and (3) MOM and enteral feeding outcomes for racial/ethnic subgroups before and after the implementation of a hospital DHM feeding program. Methods: Retrospective data from 313 very low birth weight (VLBW; birth weight <1,500 g) infants born between January 2011 to December 2012 (pre-DHM, n = 157) and April 2013 to March 2015 (DHM, n = 156) were analyzed. Results: For this predominantly low-income and minority VLBW infant cohort, the percent of enteral fed hospitalization days was higher in the DHM group (pre-DHM 94% [88, 97] versus DHM 98% [95, 99], p < 0.001). Although MOM remained the predominant first enteral feeding type, significantly fewer DHM infants received MOM (pre-DHM 89% versus DHM 75%, p = 0.001). During days of life 1-14, a lower percentage of DHM infants received 100% MOM (pre-DHM 68% versus DHM 55%, p = 0.02). For the entire cohort, the risk for MOM discontinuation was significantly associated with maternal young age, multiparity, non-Hispanic Black race/ethnicity, and low income. Implementation of a DHM program did not predict duration of MOM feedings. However, non-Hispanic White infants had a longer duration of MOM feedings with DHM availability. Conclusions: Our findings highlight the importance of using precise dose and exposure period methodology to determine the impact of DHM on MOM provision. In addition, DHM availability may be associated with varying effects on MOM provision among racial/ethnic groups.

Human milk bank and personalized nutrition in the NICU: a narrative review

The number of infants born preterm including extremely premature babies is rising worldwide, particularly in low- and middle-income countries, which challenge neonatologists and milk banks for the provision of the most adequate nutrition for successful infant's growth and development. The benefits of mother's own milk (MOM) have been extensively recognized, but the use of donor milk (DM) is a commonly routine practice in preterm neonates admitted to the NICU. Pasteurized mature milk from milk banks is not the same composition than the mother's colostrum and premature milk, the characteristics of which protect the infant from the risk for necrotizing enterocolitis, late-onset sepsis, and other comorbidities associated with prematurity. The development of a personalized nutrition unit (PNU) allows to obtain DM from mothers who have their infants admitted to the NICU and produce an excess of milk, a practice that matches MOM by gestational age and the stage of lactation, ensuring an adequate composition of DM to target the nutritional requirements of premature infants.Conclusion: This narrative review presents salient data of our current knowledge and concerns regarding milk feeding of preterm infants in the NICU, with special emphasis on personalized DM as a result of establishing a PNU. What is Known: • Donor milk bank is mature or pooled milk from lactating mothers at different stages of lactation. • Milk composition varies by gestational age and stage of lactation. What is New: • Donor milk from mothers delivered prematurely have the most adequate composition for preterm infant feeding. • Personalized nutrition for premature infants with preterm donor milk is feasible.

Fortification With Bovine Colostrum Enhances Antibacterial Activity of Human Milk

Objectives

Human milk (HM) is the optimal diet for neonates, but it does not provide enough nutrients for preterm infants. HM fortifiers based on highly processed mature bovine milk (BMFs) are routinely used for preterm infants despite risks of causing gut dysfunction and systemic infection. Gently‐processed bovine colostrum as a fortifier (BCF) may better protect against infection and inflammation. We hypothesized that BCF‐fortified HM has enhanced antimicrobial activity against pathogens that commonly cause neonatal sepsis, relative to BMF‐fortified HM.

Methods

Holder‐pasteurized HM samples (10 mothers) were aliquoted into 3 fractions: unfortified HM and HM fortified with either BMF or BCF. The samples were analyzed for pH, lactoferrin concentrations, and antimicrobial activities against Staphylococcus epidermidis, Escherichia coli, and Enterococcus faecalis.

Results

HM+BCF had a lower pH and higher lactoferrin levels than HM+BMF, with HM being intermediate. Relative to infant formula, HM decreased the growth of S epidermidis, E coli, and E faecalis, with no difference between preterm and term HM. Addition of BMF abolished the antimicrobial effect of HM against S epidermidis and E faecalis but not E coli. By contrast, addition of BCF into HM enhanced antimicrobial activity against S epidermidis and E coli, relative to unfortified HM. HM+BCF was superior to HM+BMF in inhibiting growth of all tested bacteria.

Conclusion

BMF fortification decreased whereas BCF fortification enhanced in vitro antimicrobial activity of HM. This effect may partly be derived from the high levels of antimicrobial factors found in BCF, including lactoferrin. BCF may be a better fortifier than BMF for preterm infants.

Reply: "It is Time for a Universal Nutrition Policy in Very Preterm Neonates during the Neonatal Period? Comment on: Applying Methods for Postnatal Growth Assessment in the Clinical Setting: Evaluation in a Longitudinal Cohort of Very Preterm Infants Nutrients 2019, 11, 2772"

We would like to thank Gounaris et al [...].

The Role of Glycosaminoglycans in Protection from Neonatal Necrotizing Enterocolitis: A Narrative Review

Necrotizing enterocolitis, a potentially fatal intestinal inflammatory disorder affecting primarily premature infants, is a significant cause of morbidity and mortality in neonates. While the etiology of the disease is, as yet, unknown, a number of risk factors for the development of necrotizing enterocolitis have been identified. One such risk factor, formula feeding, has been shown to contribute to both increased incidence and severity of the disease. The protective influences afforded by breastfeeding are likely attributable to the unique composition of human milk, an extremely potent, biologically active fluid. This review brings together knowledge on the pathogenesis of necrotizing enterocolitis and current thinking on the instrumental role of one of the more prominent classes of bioactive components in human breast milk, glycosaminoglycans.

Breastfeeding and the Risk of Infant Illness in Asia: A Review

Infancy remains the most vulnerable period of human life for death, illness, and establishing a lifetime trajectory of growth and health. It is estimated that there are 5.3 million deaths under five years of age worldwide and approximately 800,000 lives could be saved by improving breastfeeding rates and duration. In Asia, an estimated 300,000-350,000 child deaths could be prevented with optimal breastfeeding and the majority would be under 12 months of age. We present a systematic review of studies of infection and breastfeeding in infants in Asia and further review interactions of selected infectious diseases and breastfeeding. Initially, 2459 records of possible interest were identified, 153 full text papers were reviewed in detail, and 13 papers describing diarrhoeal disease and/or acute respiratory tract infection were selected for inclusion in the review. Additional papers were selected to discuss specific diseases and their relationship to breastfeeding. The review found that a variety of methods were used with differing definitions of breastfeeding and diseases. Overall, breastfeeding when compared to the use of infant formula, is associated with significantly lower rates of diarrhoeal disease and lower respiratory tract infection, with a reduction of 50% or more to be expected, especially in infants under six months of age. The relationship between breastfeeding and specific diseases including measles and HTLV1 were reviewed. Breastfeeding reduces some disease rates, but there remain a few conditions where breastfeeding may be contra-indicated.

Modifications of Own Mothers' Milk Fortification Protocol Affect Early Plasma IGF-I and Ghrelin Levels in Preterm Infants. A Randomized Clinical Trial

The aim was to investigate the effect of two own mother’s milk (OMM) fortification protocols on (a) IGF-I and ghrelin plasma levels at 35 post-conceptional weeks (PCW, T2) and whether this effect is maintained after elimination of the differences in OMM fortification, and (b) growth until 12 months corrected age. Forty-eight OMM-fed preterm infants (GA 24–32 weeks) were randomly allocated to the fixed-fortification (FF) group (n = 23) and the protein-targeting fortification (PTF) group (n = 25) targeting the recommended daily protein intake (PI). Plasma IGF-I and ghrelin were assessed at 35 (T2) and 40 (T3) PCW while growth was longitudinally assessed until 12 months corrected age. PTF group had lower IGF-I and higher ghrelin than FF group at T2, while receiving lower daily protein and energy amounts. PI correlated positively to T2-IGF-I and inversely to T3-ghrelin while energy intake (EI) correlated inversely to T2- and T3-ghrelin. Group and PI were independent predictors of adjusted T2-IGF-I, while group and EI were predictors of adjusted and T2-ghrelin. Growth parameter z-scores were comparable between groups up to 12 months corrected age. Modifications of OMM fortification have a transient effect on early plasma IGF-I and ghrelin levels in preterm infants in a way consistent with the previously recognized protein-energy/endocrine balance, indicating a potential programming effect.