Feeding the preterm infant: an overview of the evidence

Feeding from own mother's milk is not always an option for preterm infants, and choosing between alternative means of feeding should be made in light of their effect on infants' health. In this work, we aimed to present evidence regarding feeding pre-term infants with human milk, either own mother's or donor milk (DM), and the potential effects on growth and other health related outcomes. Exclusive breastfeeding (BF) remains the optimal option, whereas feeding with DM as a sole diet or supplemental to maternal milk confers immunological advantages and fewer rates of necrotising enterocolitis against preterm formula feeding, yet the latter results in greater growth velocity. Literature gaps in the use of DM, practical suggestions for choosing suitable feeding means (i.e. continuous support of BF, adequate education regarding feeding preterm infants, including DM), and future perspectives on the potential effects of dietary manipulations of the maternal diet, are also discussed.

Long-Chain Polyunsaturated Fatty Acids and Lipid Peroxidation Products in Donor Human Milk in the United Kingdom: Results From the LIMIT 2-Centre Cross-Sectional Study

BACKGROUND

Donor human milk (DHM) is used as alternative to maternal milk to feed preterm infants; however, it may provide less long-chain (LC) polyunsaturated fatty acids (PUFAs) and more oxidized lipids, which may be detrimental to preterm infant health and development. Levels have not been reported for DHM in the United Kingdom.

METHODS

DHM (n = 19) from 2 neonatal units, preterm milk from a neonatal unit (n = 10), and term milk from the community (n = 11) were analyzed for fatty acids, malondialdehyde, 4-hydroxy-2-nonenal, and hexanal.

STUDY REGISTRATION

NCT03573531.

RESULTS

DHM had significantly lower absolute LCPUFA content than term (P < .001) and significantly lower ω-3 PUFAs than preterm milk (P < .05), although relative LCPUFA composition did not differ. Exclusive DHM feeding leads to significantly lower fat (3.7 vs 6.7 g/d) and LCPUFA (docosahexaenoic acid [DHA]: 10.6 vs 16.8 mg/d; arachidonic acid [ARA]: 17.4 vs 25.2 mg/d) intake than recommended by the European Society for Pediatric Gastroenterology, Hepatology and Nutrition, and provides 17.3% and 43.1% of the in utero accreted ARA and DHA. DHM had the highest proportion of lipid peroxidation.

CONCLUSIONS

This study confirms that DHM in the United Kingdom has insufficient LCPUFAs for preterm infants. It demonstrates for the first time that DHM has the highest level of lipid peroxidation, compared with preterm or term milk. This has important implications for preterm infant nutrition, as exclusive DHM feeding might not be suitable long term and may contribute to the development of major preterm neonatal morbidities.

Policy statement of enteral nutrition for preterm and very low birthweight infants

For preterm and very low birthweight infants, the mother's own milk is the best nutrition. Based on the latest information for mothers who give birth to preterm and very low birthweight infants, medical staff should encourage and assist mothers to pump or express and provide their own milk whenever possible. If the supply of maternal milk is insufficient even though they receive adequate support, or the mother's own milk cannot be given to her infant for any reason, donor human milk should be used. Donors who donate their breast milk need to meet the Guideline of the Japan Human Milk Bank Association. Donor human milk should be provided according to the medical needs of preterm and very low birthweight infants, regardless of their family's financial status. In the future, it will be necessary to create a system to supply an exclusive human milk-based diet (EHMD), consisting of human milk with the addition of a human milk-derived human milk fortifier, to preterm and very low birthweight infants.

Evaluation of the Tempo® System: Improving the Microbiological Quality Monitoring of Human Milk

Background: Bacteriological testing of donor human milk is mostly done both before and after pasteurization to control contamination in the end-product and meet the microbiological standards. Although the plate count method represents a reliable and sensitive technique and is considered the gold standard for bacteriological testing, it is recognized for being time-consuming and requiring qualified personnel. Recently, faster testing technologies, mostly geared toward the food industry, have been developed. Among these, the bioMérieux TEMPO® system uses the most probable number method to assess microbiological content in a semi-automated fashion. Objective: The performances of the TEMPO® system in enumerating bacterial quality indicators in human milk were assessed and compared to the reference plate count method. Methods: Naturally and artificially contaminated human milk samples were used to compare the analytical performances of the TEMPO® system to the plate count technique. More specifically, bacteria belonging to the genera Bacillus, Enterobacteriaceae, Staphylococcus aureus, and total aerobic flora were screened using both methods. Bacteria isolated on agar plates containing selective media were identified by supplemental testing. Bacterial testing results and method parameters were compared using linear regression analyses and Bland-Altman approaches. Results: Naturally contaminated milk samples (n = 55) tested for total aerobic flora showed < 1 log (CFU/ml) discrepancy between the two methods in the output results for 98% of the samples. Comparative linear regression analyses demonstrate good correlations between the two methods (R ² > 0.9). At lower levels of bacterial contamination, the TEMPO® method precision (C.V. < 8%) and accuracy (> 83%) were comparable to plate counts. Conclusions: The analytical performances of the TEMPO® system for human milk bacteriological testing are equivalent to the reference plate count method. Results from the TEMPO® system are available within a 24-h turnaround time from sample inoculation without the need for further supplemental testing, suggesting that this semi-automated method could be implemented within milk bank operations as an in-process monitoring technology to optimize end-product quality and safety.

Human Milk's Hidden Gift: Implications of the Milk Microbiome for Preterm Infants' Health

Breastfeeding is considered the gold standard for infants' nutrition, as mother's own milk (MOM) provides nutritional and bioactive factors functional to optimal development. Early life microbiome is one of the main contributors to short and long-term infant health status, with the gut microbiota (GM) being the most studied ecosystem. Some human milk (HM) bioactive factors, such as HM prebiotic carbohydrates that select for beneficial bacteria, and the specific human milk microbiota (HMM) are emerging as early mediators in the relationship between the development of GM in early life and clinical outcomes. The beneficial role of HM becomes even more crucial for preterm infants, who are exposed to significant risks of severe infection in early life as well as to adverse short and long-term outcomes. When MOM is unavailable or insufficient, donor human milk (DHM) constitutes the optimal nutritional choice. However, little is known about the specific effect of DHM on preterm GM and its potential functional implication on HMM. The purpose of this narrative review is to summarize recent findings on HMM origin and composition and discuss the role of HMM on infant health and development, with a specific focus on preterm infants.

Analytical Study of Donor's Milk Bank Macronutrients by Infrared Spectroscopy. Correlations With Clinic-Metabolic Profile of 100 Donors

For its specific qualitative characteristics human donor milk (DM) is the main alternative to preterm infants nutrition and growing. How several studies suggest child's physical and mental development is influenced by breastfeeding that prevents the necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and sepsis common in preterm newborns. Our research was conducted in NICU's Human Milk Bank (HMB) "Allattiamolavita." Our study was based on macronutrients analysis (MA) of 100 DM samples taken until 10 days since childbirth and analyzed by spectroscopic infrared innovative method (MIRIS). This is a specific method to analyse fat (F), crude proteins (CP), true proteins (TP), carbohydrate (CHO), and total solids (TS). We also analyzed the 100 donors' clinic-metabolic profile by blood tests (PMT). Both data was collected between September 2015 and February 2018. The research was structured in two parts. In the first part we compared PMT with qualitative and quantitative characteristics of MA while in the second one we studied every DM macronutrient finding furthermore possible relations between them. Statistical Package for Social Sciences (SPSS-IBM 24) was used to compare data and reporting coefficient of determination using Spearman's Rho and Kendall's Tau. We also analyzed samples using Kolmogorov-Smirnov test, Student T-test, ANOVA, Whitney U-test, and chi-square test. Statistically significant correlations were noted between maternal serum proteins and CP-TP of DM. The research showed also significant correlations between azotaemia and TP and an inverse correlation between serum creatinine and CP. No statistically significant correlation was observed between donors' glycaemia and CHO. Mineral concentrations of DM emerged independent of blood minerals (P, Ca, Fe, Na). We also calculated a normal range for individual macronutrient of human transitional milk (TM) that was not established in literature yet. Our experience allowed us to underline that human milk is a privileged site compared to donors' clinical and metabolic disorders. Our analysis showed the major role of the HMB to provide DM to improve clinical status, growing, and neurocognitive short and long term outcome of preterm infants.

Lipid Profile, Lipase Bioactivity, and Lipophilic Antioxidant Content in High Pressure Processed Donor Human Milk

Human milk fat plays an essential role as the source of energy and cell function regulator; therefore, the preservation of unique human milk donors’ lipid composition is of fundamental importance. To compare the effects of high pressure processing (HPP) and holder pasteurization on lipidome, human milk was processed at 62.5 °C for 30 min and at five variants of HPP from 450 MPa to 600 MPa, respectively. Lipase activity was estimated with QuantiChrom™ assay. Fatty acid composition was determined with the gas chromatographic technique, and free fatty acids content by titration with 0.1 M KOH. The positional distribution of fatty acid in triacylglycerols was performed. The oxidative induction time was obtained from the pressure differential scanning calorimetry. Carotenoids in human milk were measured by liquid chromatography. Bile salt stimulated lipase was completely eliminated by holder pasteurization, decreased at 600 MPa, and remained intact at 200 + 400 MPa; 450 MPa. The fatty acid composition and structure of human milk fat triacylglycerols were unchanged. The lipids of human milk after holder pasteurization had the lowest content of free fatty acids and the shortest induction time compared with samples after HPP. HPP slightly changed the β-carotene and lycopene levels, whereas the lutein level was decreased by 40.0% up to 60.2%, compared with 15.8% after the holder pasteurization.

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

Human milk contains non-nutritional factors that promote intestinal maturation and protect against infectious and inflammatory conditions. In the Neonatal Intensive Care Unit (NICU) setting, donor milk (DM) is recommended when availability of own mother’s milk (OMM) is not enough. Our aim was to compare the incidence of necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) in very preterm infants (VPI) after the introduction of DM. Growth and breastfeeding rates were examined as secondary outcomes. Single center, observational and retrospective cohort study comparing 227 VPI admitted to our neonatal unit before (Group 1, n = 99) and after (Group 2, n = 128) DM introduction. Enteral nutrition was started earlier after DM availability (2.6 ± 1.1 vs. 2.1 ± 1 days, p = 0.001). Incidence of NEC decreased in group 2 (9.1% vs. 3.4%, p = 0.055), especially in those born between 28 and 32 weeks (5.4 vs. 0.0%, p = 0.044). Surgical NEC was also less frequent. Suffering NEC was 4 times more likely in group 1 (multivariate analysis). Availability of DM did not impact breastfeeding rates or preterm growth. Our findings support the protective role of DM against NEC, particularly in non-extreme VPI, a group less frequently included in clinical guidelines and research studies on the use of DM.

A Modified Holder Pasteurization Method for Donor Human Milk: Preliminary Data

Background: Holder pasteurization (HoP) is the recommended method of pasteurization for donor human milk (DHM). The aim of the present study was to compare nutritional and microbiological impact on DHM of a new technique of pasteurization based on technical changes of HoP. Methods: We analyzed milk samples from 25 donors. Each sample, derived from one breast milk expression, was subdivided into three aliquots according to pasteurization: The first was not pasteurized, the second pasteurized by HoP, and the third was pasteurized by modified HoP (MHoP). Each aliquot was assessed as to its microbiological and nutritional profile. Nutritional profile included calcium and triglycerides concentrations detected by spectrophotometry and amino acid levels assessed by high-performance liquid chromatography (HPLC). Results: Triglycerides were significantly lower in pasteurized, by both methods, than in not pasteurized aliquots, while calcium and amino acids concentration were similar. Microbiological profile did not differ between HoP and MHoP aliquots. Conclusions: HoP and MHoP seem to have similar efficacy in preserving some nutritional characteristics of DHM and to confer similar microbiological safety. MHoP is time-saving and potentially costs-effective when compared to HoP, and it is; therefore, potentially of more interest from a practical point of view. Further studies are needed to confirm these findings.

Effect of Donor Milk Supplementation on Breastfeeding Outcomes in Term Newborns: A Randomized Controlled Trial

BACKGROUND

Pasteurized donor human milk (DHM) use for healthy newborns is increasing; however, no studies have explored its effect on breastfeeding outcomes.

PATIENTS AND METHODS

We enrolled 60 healthy, term breastfeeding newborns with ≥4.5% weight loss in the first 36 hours in a randomized controlled trial. Thirty newborns were randomly assigned to early limited-volume DHM supplementation and 30 newborns to exclusive breastfeeding. Mothers were surveyed at 1 week and 1, 2, and 3 months regarding the mode of infant feeding. Comparing infants randomized to DHM supplementation with those exclusively breastfeeding, there was no significant difference in the proportion using formula at 1 week (21% vs 7%, P = .15), nor in the proportion of any breastfeeding (79% vs 90%, P = .30) or breastfeeding without formula at 3 months (62% vs 77%, P = .27). Conclusion For newborns with ≥4.5% weight loss in the first 36 hours, early limited-volume supplementation with DHM is unlikely to have a significant favorable impact on breastfeeding outcomes.

High Hydrostatic Pressure Processing Better Preserves the Nutrient and Bioactive Compound Composition of Human Donor Milk

BACKGROUND

When mother's milk is insufficient, pasteurized human donor milk (DM) is the recommended supplement for hospitalized very-low-birth-weight infants. The current method of pasteurization (Holder, 62.5°C, 30 min) negatively affects heat-sensitive nutrients and bioactive proteins.

OBJECTIVES

Objectives of this study were to compare changes in DM composition after thermal pasteurization (Holder and flash-heating) and nonthermal methods [UV-C irradiation and high hydrostatic pressure (HHP)]. We hypothesized that nonthermal techniques would result in fewer changes to composition.

METHODS

Holder, flash-heating (brought to boil), UV-C irradiation (250 nm, 25 min), and HHP (500 MPa, 8 min) were studied. Pools of milk from 17 women known to contain bacteria at >5 × 107 colony forming units (CFU)/L were collected from the Rogers Hixon Ontario Human Milk Bank and underwent each pasteurization technique. Macronutrients, heat-sensitive micronutrients (vitamin C, folate), and bioactive components [bile-salt-stimulated lipase (BSSL), lysozyme, lactoferrin] were measured in raw and pools of pasteurized milk. Milk was cultured to determine how well each technique produced a culture negative result (detection limit <1 × 103 CFU/L).

RESULTS

Folate was reduced by 24-27% after Holder, flash-heating, and UV-C (P < 0.05); no reduction was observed after HHP. All pasteurization methods reduced vitamin C (60-75%, P < 0.001). BSSL was abolished after Holder and flash-heating (P < 0.001), reduced after UV-C (48%, P < 0.001), but unaffected by HHP. Lysozyme activity was reduced after flash-heating (44%) and UV-C (74%, P < 0.004) but unaffected by Holder or HHP. Lactoferrin was reduced by all methods (P < 0.02) but most severely by flash-heating (74%) and least severely by HHP (25%). Holder and UV-C reduced lactoferrin by ∼48%. All pasteurization methods reduced the number of culture positive DM samples (P < 0.001).

CONCLUSIONS

HHP better preserves human milk composition than Holder pasteurization. Future research on the feasibility of HHP for pasteurizing human milk is warranted because its implementation may improve the nutritional status and health of DM-fed infants.

Processing of Donor Human Milk: Update and Recommendations From the European Milk Bank Association (EMBA)

Background: A mother's own milk (MOM) is the gold standard for the feeding and nutrition of preterm and full term infants. When MOM is not available or there is not enough, donor human milk (DHM) should be used. Milk delivered to Human Milk Banks (HMBs) should be pasteurized to inactivate viral and bacterial agents. Currently, a pasteurization process at 62.5°C for 30 min (Holder pasteurization, HoP) is recommended in all international HMBs guidelines. State of the art: It is known that HoP affects some of the nutritional and biological components of human milk. Studies have demonstrated that temperature cycle in HoP is not always controlled or calibrated. A better check of these parameters in the pasteurizers on the market today may contribute to an improvement of the quality of HM, still maintaining some of the negative effects of the heat treatment of human milk. So, food industry, and dairy industry in particular, are evaluating innovative methodologies alternative to HoP to better preserve the nutritional and biological properties of fresh human milk, while assuring at least the same microbiological safety of HoP. The most studied processing techniques include High-Temperature-Short-Time (HTST) pasteurization, High Pressure Processing (HPP), and Ultraviolet-C (UV-C) irradiation. HTST is a thermal process in which milk is forced between plates or pipes that are heated on the outside by hot water at a temperature of 72°C for 5-15 s. HPP is a non-thermal processing method that can be applied to solid and liquid foods. This technology inactivates pathogenic microorganisms by applying a high hydrostatic pressure (usually 300-800 MPa) during short-term treatments (<5-10 min). UV irradiation utilizes short-wavelength ultraviolet radiation in the UV-C region (200-280 nm), which is harmful to microorganisms. It is effective in destroying the nucleic acids in these organisms, so that their DNA is disrupted by UV radiation. Aim: The aim of this paper is to present the EMBA recommendations on processing of HM, based on the most recent results obtained with these new technologies. Conclusions: Although research on the most promising technologies that will represent an alternative to HoP (HTST, HPP, UV-C) in the future is progressing, it is now important to recognize that the consistency and quality assurance of the pasteurizers on the market today represent a fundamental component that was previously lacking in the Holder approach.

Temporal Progression of Fatty Acids in Preterm and Term Human Milk of Mothers from Switzerland

We longitudinally compared fatty acids (FA) from human milk (HM) of mothers delivering term and preterm infants. HM was collected for 4 months postpartum at 12 time points for preterm and for 2 months postpartum at 8 time points for term group. Samples were collected from the first feed of the morning, and single breast was fully expressed. FA were analyzed by gas chromatography coupled with flame ionization detector. Oleic, palmitic and linoleic acids were the most abundant FA across lactation and in both groups. Preterm colostrum contained significantly (p < 0.05) higher 8:0, 10:0, 12:0, sum medium chain fatty acids (MCFA), 18:3 n-3 FA compared to term counterparts. Preterm mature milk contained significantly higher 12:0, 14:0, 18:2 n-6, sum saturated fatty acids (SFA), and sum MCFA. We did not observe any significant differences between the preterm and term groups for docosahexaenoic acid, arachidonic acid and eicosapentaenoic acid at any stage of lactation. Overall, preterm milk was higher for SFA with a major contribution from MCFA and higher in 18:2 n-6. These observational differences needs to be studied further for their implications on preterm developmental outcomes and on fortification strategies of either mothers’ own milk or donor human milk.

Understanding Barriers and Facilitators for Human Milk Banking Among Service Providers, Mothers, and Influencers of Preterm and Sick Neonates Admitted at Two Health Facilities in a Metropolitan City in India

BACKGROUND

Scaling-up human milk banks (HMBs) is a promising solution for saving vulnerable newborns. Exploring perceptions and practices on donor human milk (DHM) and HMBs is essential to strengthen and scale-up an integrated HMB system resting on a model called the "Mother Baby Friendly Initiative Plus" (MBFI+), which includes promoting breastfeeding, encouraging kangaroo mother care, and providing safe DHM to vulnerable babies without access to mother's own milk.

MATERIALS AND METHODS

A qualitative research was conducted among 56 service recipients including mothers and key influencers and 9 service providers to understand their perceptions and practices on DHM and HMBs.

RESULTS

Service providers opined that DHM is safe and lifesaving for vulnerable babies. Challenges shared were limited supply of DHM because of low awareness on milk donation, shortage of trained staff, and risk of milk contamination. They stated that although most mothers were comfortable in donating milk, few were reluctant to donate milk as they feared shortage of milk for their own babies, or milk expression may cause weakness. Recipient mothers accepted use of DHM as per facility norms but had concerns about donor mothers' health and hygiene and measures for ensuring milk safety. Most grandmothers were resistant toward donating or receiving DHM for their grandchildren. Many fathers were comfortable with donating once they knew it is lifesaving and did not compromise supply for their babies. Service providers shared opportunities for scale-up, like improving awareness and infrastructure, lactation counseling by skilled personnel, supportive hospital environment, and establishing HMBs in every city and district.

CONCLUSIONS

Human milk banking should be strengthened as part of the MBFI+ model. For this, behavior change communication targeted at mothers and influencers about breastfeeding and HMB from the antenatal period, capacity-building among service providers, and government ownership is necessary.

A Decision Tree for Donor Human Milk: An Example Tool to Protect, Promote, and Support Breastfeeding

Despite decades of breastfeeding promotion, exclusive breastfeeding rates for the first 6 months of life remain low: around 40% globally. Infants that are admitted to a neonatal ward are even less likely to be exclusively breastfed. Lactogenesis is frequently delayed in mothers that deliver early, with the added burden of separation of the unstable newborn and mother. For such vulnerable infants, donor human milk is recommended by the World Health Organization, UNICEF, and professional organizations as the next best alternative when mother's own milk is unavailable and can serve as a bridge to full feeding with mother's own milk. Hospital support of optimal breastfeeding practices is essential with thoughtful integration of donor human milk policies for those infants that need it most. We propose a decision tree for neonatal wards that are considering the use of donor human milk to ensure donor human milk is used to replace formula, not to replace mothers' own milk. By first evaluating barriers to full feeding with mother's own milk, healthcare workers are encouraged to systematically consider the appropriateness of donor human milk. This tool also seeks to prevent overuse of donor human milk, which has the potential to undermine successful lactation development. In settings where donor human milk supplies are limited, prioritization of infants by medical status is also needed. Readily available and easy-to-use tools are needed to support healthcare staff and mothers in order to improve lactation development and neonatal nutrition.

Donor Human Milk: Effects of Storage and Heat Treatment on Oxidative Stress Markers

Mother's own milk is the first choice for the feeding and nutrition of preterm and term newborns. When mother's own milk is unavailable or in short supply donor human milk (DM) could represent a solution. Heat treatment and cold storage are common practices in Human Milk Banks (HMBs). Currently, Holder pasteurization process is the recommended heat treatment in all international guidelines. This method is thought to lead to a good compromise between the microbiological safety and nutritional/biological quality of DM. Moreover, storage of refrigerated milk is a common practice in HMBs and in NICUs. Depending on the length and on the type of storage, human milk may lose some important nutritional and functional properties. The available data on oxidative stress markers confirm that pasteurization and refrigeration affected this important elements to variable degrees, even though it is rather difficult to quantify the level of deterioration. Nonetheless, clinical practice demonstrates that many beneficial properties of human milk are preserved, even after cold storage and heat treatment. Future studies should be focused on the evaluation of new pasteurization techniques, in order to achieve a better compromise between biological quality and safety of DM.

Human Milk Fortification with Bovine Colostrum Is Superior to Formula-Based Fortifiers to Prevent Gut Dysfunction, Necrotizing Enterocolitis, and Systemic Infection in Preterm Pigs

BACKGROUND

Fortification of donor human milk (DHM) is required for optimal growth of very preterm infants, but there are concerns of more gut dysfunction and necrotizing enterocolitis (NEC) when using formula-based fortifiers (FFs), especially soon after birth. Intact bovine colostrum (BC) is rich in nutrients and bioactive factors, and protects against NEC in preterm pigs. We hypothesized that fortification of DHM with BC is superior to FFs to prevent gut dysfunction and infections when provided shortly after preterm birth.

METHODS

Two FF products, Enfamil (ENF; intact protein, vegetable oil) and PreNAN+Nutrilon (NAN; extensively hydrolyzed protein, maltodextrin), were compared with BC as fortifier to DHM fed to preterm pigs for 5 days.

RESULTS

Relative to the DHM+BC group, DHM+FF groups had higher diarrhea score and lower hexose uptake and lactase activity, and specifically the DHM+NAN group showed higher gut permeability, NEC score, more mucosa-adherent bacteria with altered gut microbiota structure (ie, lower diversity, increased Enterococcus, decreased Staphylococcus abundance). Both DHM+FF groups showed higher expression of intestinal cytokine and inflammation-related genes, more gut-derived bacteria in the bone marrow, lower density of mucin-containing goblet cells, and slightly higher colon lactate, stomach pH and acetate, and blood neutrophil-to-lymphocyte levels than the DHM+BC group.

CONCLUSIONS

Used as a fortifier to DHM, BC is superior to FFs to support gut function, nutrient absorption, and bacterial defense mechanisms in preterm pigs. It is important to optimize the composition of nutrient fortifiers for preterm infants fed human milk.

Preterm Gut Microbiome Depending on Feeding Type: Significance of Donor Human Milk

Preterm microbial colonization is affected by gestational age, antibiotic treatment, type of birth, but also by type of feeding. Breast milk has been acknowledged as the gold standard for human nutrition. In preterm infants breast milk has been associated with improved growth and cognitive development and a reduced risk of necrotizing enterocolitis and late onset sepsis. In the absence of their mother's own milk (MOM), pasteurized donor human milk (DHM) could be the best available alternative due to its similarity to the former. However, little is known about the effect of DHM upon preterm microbiota and potential biological implications. Our objective was to determine the impact of DHM upon preterm gut microbiota admitted in a referral neonatal intensive care unit (NICU). A prospective observational cohort study in NICU of 69 neonates <32 weeks of gestation and with a birth weight ≤1,500 g was conducted. Neonates were classified in three groups according to feeding practices consisting in their MOM, DHM, or formula. Fecal samples were collected when full enteral feeding (defined as ≥150 cc/kg/day) was achieved. Gut microbiota composition was analyzed by 16S rRNA gene sequencing. Despite the higher variability, no differences in microbial diversity and richness were found, although feeding type significantly influenced the preterm microbiota composition and predictive functional profiles. Preterm infants fed MOM showed a significant greater presence of Bifidobacteriaceae and lower of Staphylococcaceae, Clostridiaceae, and Pasteurellaceae compared to preterm fed DHM. Formula fed microbial profile was different to those observed in preterm fed MOM. Remarkably, preterm infants fed DHM showed closer microbial profiles to preterm fed their MOM. Inferred metagenomic analyses showed higher presence of Bifidobacterium genus in mother's milk group was related to enrichment in the Glycan biosynthesis and metabolism pathway that was not identified in the DHM or in the formula fed groups. In conclusion, DHM favors an intestinal microbiome more similar to MOM than formula despite the differences between MOM and DHM. This may have potential beneficial long-term effects on intestinal functionality, immune system, and metabolic activities.

A Systematic Review and Meta-Analysis of Human Milk Feeding and Morbidity in Very Low Birth Weight Infants

This systematic review and meta-analysis synthesised the post-1990 literature examining the effect of human milk on morbidity, specifically necrotising enterocolitis (NEC), late onset sepsis (LOS), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD) and neurodevelopment in infants born ≤28 weeks' gestation and/or publications with reported infant mean birth weight of ≤1500 g. Online databases including Medline, PubMed, CINAHL, Scopus, and the Cochrane Central Register of Controlled Trials were searched, and comparisons were grouped as follows: exclusive human milk (EHM) versus exclusive preterm formula (EPTF), any human milk (HM) versus EPTF, higher versus lower dose HM, and unpasteurised versus pasteurised HM. Experimental and observational studies were pooled separately in meta-analyses. Risk of bias was assessed for each individual study and the GRADE system used to judge the certainty of the findings. Forty-nine studies (with 56 reports) were included, of which 44 could be included in meta-analyses. HM provided a clear protective effect against NEC, with an approximate 4% reduction in incidence. HM also provided a possible reduction in LOS, severe ROP and severe NEC. Particularly for NEC, any volume of HM is better than EPTF, and the higher the dose the greater the protection. Evidence regarding pasteurisation is inconclusive, but it appears to have no effect on some outcomes. Improving the intake of mother's own milk (MOM) and/or donor HM results in small improvements in morbidity in this population.

Does fortification of pasteurized donor human milk increase the incidence of necrotizing enterocolitis among preterm neonates? A randomized controlled trial

Objective: To compare the effect of fortified pasteurized donor human milk (PDHM) versus unfortified PDHM on the incidence of necrotizing enterocolitis (NEC) and immediate outcome among preterm neonates. Methods: This randomized controlled trial (RCT) conducted in a tertiary care teaching hospital, south India included 80 healthy preterm neonates randomized to two groups (Group A and B). Neonates in Group A and B were fed with fortified PDHM and unfortified PDHM, respectively. Neonates in both groups were managed uniformly as per standard NICU protocol. The primary outcome was the incidence of NEC and the secondary outcomes included severity of NEC, incidence of sepsis, mortality, duration of hospital stay, number of days to reach full enteral feeds and weight gain. Neonates were followed up for 28 days or discharge whichever was earlier. Results: The baseline maternal and neonatal characteristics in both groups were comparable. There was no increase in incidence of NEC in fortified PDHM group compared to unfortified PDHM group (2.5 versus 7.5%, p = .31). Severity of NEC, incidence of sepsis, mortality, duration of hospital stay, number of days to reach full enteral feeds and weight gain were also similar in both groups. Conclusions: Standard fortification of PDHM does not increase the incidence of NEC among preterm neonates.

Human Donor Milk or Formula: A Qualitative Study of Maternal Perspectives on Supplementation

BACKGROUND

Breastfeeding is fundamental to maternal and child health and is the most cost-effective intervention to reduce child mortality. Pasteurized human donor milk (HDM) is increasingly provided for term newborns requiring temporary supplementation. Few studies examine maternal perspectives on supplementation of term newborns.

MATERIALS AND METHODS

We conducted semistructured in-person interviews with mothers of term newborns (n = 24) during postpartum hospitalization. Mothers were asked whether they had chosen or would choose to supplement with HDM versus infant formula, if medically indicated, and why. Data were gathered to saturation and analyzed inductively by consensus. Emerging semantic themes were compared between mothers who chose or would choose HDM and those who chose or would choose infant formula.

RESULTS

Most mothers had concerns about HDM, including uncertainty regarding screening and substances passed through HDM. Experiences with prior children influenced decision-making. Mothers who chose or would choose HDM (56%, n = 14) praised it as "natural," and some felt suspicious of infant formula as "synthetic." Mothers who chose or would choose infant formula (44%, n = 10) did not know enough about HDM to choose it, and many viewed infant formula as a short-term solution to supply concerns. Mothers unanimously mistrusted online milk purchasing sources, although the majority felt positively about using a friend or family member's milk.

CONCLUSIONS

Counseling regarding term newborn supplementation should focus on HDM education, specifically on areas of greatest concern and uncertainty such as donor selection, screening, transmission of substances, and mother's milk supply. Research is needed to assess the long-term impact of attitudes and choices on breastfeeding.

Donor Human Milk Protects against Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis

Bronchopulmonary dysplasia (BPD) is the most common complication after preterm birth. Pasteurized donor human milk (DHM) has increasingly become the standard of care for very preterm infants over the use of preterm formula (PF) if the mother's own milk (MOM) is unavailable. Studies have reported beneficial effects of DHM on BPD. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies on the effects of DHM on BPD and other respiratory outcomes. Eighteen studies met the inclusion criteria. Meta-analysis of RCTs could not demonstrate that supplementation of MOM with DHM reduced BPD when compared to PF (three studies, risk ratio (RR) 0.89, 95% confidence interval (CI) 0.60-1.32). However, meta-analysis of observational studies showed that DHM supplementation reduced BPD (8 studies, RR 0.78, 95% CI 0.67-0.90). An exclusive human milk diet reduced the risk of BPD, compared to a diet with PF and/or bovine milk-based fortifier (three studies, RR 0.80, 95% CI 0.68-0.95). Feeding raw MOM, compared to feeding pasteurized MOM, protected against BPD (two studies, RR 0.77, 95% CI 0.62-0.96). In conclusion, our data suggest that DHM protects against BPD in very preterm infants.

Improving Growth for Infants ≤1250 Grams Receiving an Exclusive Human Milk Diet

BACKGROUND

An exclusive human milk diet (EHM) fortified with human milk-based fortifier decreases necrotizing enterocolitis (NEC) compared to maternal milk supplemented with preterm formula and bovine fortifier (PTF). Growth has been less with EHM and also maternal milk supplemented with donor human milk and bovine fortifier (HMBF). The objective was to evaluate the effect of a standardized feeding protocol on the growth of infants ≤1250 g birth weight supported with EHM and HMBF. The effect on the incidence of NEC was also evaluated.

DESIGN/METHODS

A retrospective study of growth before and after implementation of a feeding protocol for infants who received either EHM or HMBF. Primary outcomes were weight, length, and head circumference gain velocities from birth to discharge. The incidence of NEC was also recorded.

RESULTS

Analysis of covariance for 379 total infants showed that earlier day of life for fortification to 24 Kcal/oz was associated with increased weight gain (p = 0.0166) and length gain (p = 0.0064). Implementation of the feeding protocol was associated with increased head circumference gain (p = 0.006). EHM was associated with decreased incidence of NEC (p = 0.0302).

CONCLUSIONS

Implementation of a standardized feeding protocol including earlier fortification of maternal milk was associated with improved growth for infants receiving human milk feedings. EHM significantly decreased NEC. Earlier fortification had no effect on NEC.

[Role of donor human milk feeding in preventing nosocomial infection in very low birth weight infants]

OBJECTIVE

To investigate the role of donor human milk in the prevention of nosocomial infection in very low birth weight infants. MeETHODS: A total of 105 hospitalized preterm infants with a very low birth weight were enrolled. They were classified into mother's own milk feeding group, donor human milk feeding group, and preterm formula feeding group, with 35 infants in each group. The three groups were compared in terms of incidence rates of nosocomial infection, necrotizing enterocolitis, and feeding intolerance, time to full enteral feeding, and early growth indices.

RESULTS

Compared with the preterm formula feeding group, the donor human milk feeding group and the mother's own milk feeding group had significantly lower incidence rates of nosocomial infection and necrotizing enterocolitis and shorter time to full enteral feeding (P<0.05). There were no significant differences in head circumference, body length, and weight growth velocity among the three groups.

CONCLUSIONS

Donor human milk can be used in case of a lack of mother's own milk and may help to reduce nosocomial infection.

Best Practices to Limit Contamination of Donor Milk in a Milk Bank

Human milk donated to a milk bank can become contaminated in a number of ways, but processes exist to eradicate pathogenic bacterial growth. Donor human milk may be cultured before or after pasteurization or both. The purpose of this article is to describe standard operations of the Mothers' Milk Bank of the Children's Hospital of Philadelphia, best practices to limit the bacterial contamination of donor human milk, and implications for future research.

Better Control of Holder Pasteurization Results in Higher Retention of Human Milk Lactoferrin, IgA, and Lysozyme

Background: Holder pasteurization is commonly used in milk banks. We previously reported that the pattern of temperature and time may be different according to the pasteurizer used. Aim: The aim of our study was to assess the variances in pasteurization using two different devices: a standard pasteurizer (Past STD) and an optimized pasteurizer (Past OPTI). Methods: Immunoglobulin A (IgA), lactoferrin (LF), and lysozyme (LZ) content were assessed before and after pasteurization of 24 donor human milk samples. The impact of the pasteurization device was evaluated by testing 50- to 200-mL samples. Results: Mean temperature and duration of the plateau were 1.5°C lower and 11 min shorter, respectively, with Past OPTI vs. Past STD. The loss of IgA, LF, and LZ was 17.6, 5.6, and 9.8% lower, respectively, with Past OPTI than with Past STD. Conclusions: Accurate control of temperature enabled better preservation of IgA, LF, and LZ in donor milk. Holder pasteurization should be optimized, and new techniques proposed to treat donor milk should be compared with Holder pasteurization performed with a well-controlled device under realistic conditions.

Pasteurization Preserves IL-8 in Human Milk

Background: Pasteurized donor human milk is an alternative feeding when mothers' own milk is not available for premature infants. The effects of pasteurization on the host defense properties of human milk are unclear. We investigated the effects of Holder pasteurization on concentrations of anti-inflammatory and pro-inflammatory cytokines in human milk. Objective: To compare concentrations of anti-inflammatory and pro-inflammatory cytokines before and after pasteurization of donor human milk. Study Design: A single milk sample was obtained from each of 24 mothers of premature infants in the neonatal intensive care unit by electric breast pump and was stored at -80°C. At the time of pasteurization, milk samples were thawed and divided into two aliquots. The first aliquot was re-stored at -80°C and the second aliquot was heat-treated at 62.5°C for 30 min and then re-stored at -80°C. At the time of batch cytokine analyses samples were thawed rapidly. Results: Most cytokine concentrations declined following pasteurization. The most prevalent cytokine, IL-8, was preserved (89%) following pasteurization. There were no relationships between gestational age, postnatal age of milk collection, duration of milk storage, and the concentrations cytokines. Conclusion: In contrast to most cytokines after pasteurization, IL-8 is preserved or liberated from another compartment. The maintenance of IL-8 in human milk after pasteurization and the loss of anti-inflammatory cytokines following pasteurization, suggests that the effects of inflammatory activity in pasteurized human milk should be evaluated. These data may account, in part, for the lesser protective effect on the host of pasteurized donor human milk compared with mother's own milk.

The Effect of Human Milk on Modulating the Quality of Growth in Preterm Infants

Introduction: Human milk is the optimal nutrition for preterm infants. When the mother's own milk is unavailable, donor human milk is recommended as an alternative for preterm infants. The association among early nutrition, body composition and the future risk of disease has recently attracted much interest. The aim of this study was to investigate the effect of human milk on the body composition of preterm infants. Materials and Methods: Very low birth weight infants (VLBW: birth weight <1,500 g) with a gestational age (GA) between 26 and 34 weeks were included. Clinical data, anthropometric measurements and nutritional intake in terms of the volume of human milk were extracted from computerized medical charts. The human milk intake was expressed as a percentage of target fortified donor human milk and/or target fortified fresh mother's milk, compared with the total volume of milk intake during the hospital stay. All included infants underwent anthropometric measurements and body composition analysis (expressed as fat-free mass percentage) at term corrected age (CA) by air-displacement plethysmography. A comparison between infants fed human milk at <50% (group 1) and infants fed human milk at ≥50% of the total volume of milk intake (group 2) was conducted. Multiple linear regression analyses were conducted to explore the modulating effect of fortified human milk on fat-free mass at term CA. Results: Seventy-three VLBW infants were included in the study. The mean weight and GA at birth were 1,248 ± 198 g and 30.2 ± 2.0 weeks, respectively. No differences were found regarding anthropometric measurements at birth, at discharge and at term CA between the two groups. The mean fortified human milk intake was 34.9 ± 12.5 and 80.9 ± 15.5% in groups 1 and 2, respectively (p < 0.001). A multiple regression analysis corrected for sex and birth weight demonstrated that intake of ≥50% fortified human milk was associated with a higher fat-free mass percentage at term CA than intake of <50% fortified human milk. Conclusion: The use of target fortified human milk modulated growth and improved growth quality in vulnerable preterm infants. Thus, the use of donor human milk should be encouraged when fresh mother's milk is insufficient or not available.

Cost and Cost-Effectiveness of Donor Human Milk to Prevent Necrotizing Enterocolitis: Systematic Review

BACKGROUND

Necrotizing enterocolitis (NEC) is a costly gastrointestinal disorder that mainly affects preterm and low-birth-weight infants and can lead to considerable morbidity and mortality. Mother's own milk is protective against NEC but is not always available. In such cases, donor human milk has also been shown to be protective (although to a lesser extent) compared with formula milk, but it is more expensive. This systematic review aimed at evaluating the cost of donor milk, the cost of treating NEC, and the cost-effectiveness of exclusive donor milk versus formula milk feeding to reduce the short-term health and treatment costs of NEC.

MATERIALS AND METHODS

We systematically searched five relevant databases to find studies with verifiable costs or charges of donor milk and/or treatment of NEC and any economic evaluations comparing exclusive donor milk with exclusive formula milk feeding. All search results were double screened.

RESULTS

Seven studies with verifiable donor milk costs and 17 with verifiable NEC treatment costs were included. The types of cost or charge included varied considerably across studies, so quantitative synthesis was not attempted. Estimates of the incremental length of stay associated with NEC were ∼18 days for medical NEC and 50 days for surgical NEC. Two studies claimed to report economic evaluations but did not do so in practice.

CONCLUSIONS

It is likely that donor milk provides short-term cost savings by reducing the incidence of NEC. Future studies should provide more details on cost components included and a full economic evaluation, including long-term outcomes, should be undertaken.

Donor Milk Utilization for Healthy Infants: Experience at a Single Academic Center

BACKGROUND

Banked donor milk (BDM) has historically been used as an alternative to formula for preterm infants. Recently, BDM has been endorsed by two national organizations for use in healthy infants. We sought to quantify utilization trends and characteristics of mothers and their healthy newborns who received BDM during their postpartum stay between 2013 and 2016 at a single academic medical center.

MATERIALS AND METHODS

In this observational study, we used a clinical log to identify all infants who received BDM in the well-baby nursery between July 2013 and June 2016. From this log, we abstracted data on the numbers of babies who received BDM, the quantity of BDM provided, and indications for usage. We also collected clinical data from the medical records of a subset of corresponding mothers and infants.

RESULTS

BDM utilization increased over time in healthy infants, with 0.04% of infants before July 2014 receiving BDM compared with 4.7% in July 2015 to June 2016. During the same periods, the number of bottles provided per infant also increased, from 0.6 bottles per infant to 4.6 bottles per infant. The most common indications for providing BDM were parent/caregiver request (19%) and excessive weight loss/dehydration (17%).

CONCLUSION

At our center, the use of BDM for healthy infants increased substantially over the study period. More research is urgently needed to understand the repercussions of this practice on resource utilization as well as short- and long-term breastfeeding and health outcomes.

Systematic Review of the Effect of Enteral Feeding on Gut Microbiota in Preterm Infants

OBJECTIVE

To examine the effect of feeding type on microbial patterns among preterm infants and to identify feeding factors that promote the colonization of beneficial bacteria.

DATA SOURCES

PubMed, Cochrane Database of Systematic Reviews, Scopus, and the Cummulative Index of Nursing and Allied Health Literature were thoroughly searched for articles published between January 2000 and January 2017, using the keywords gut microbiome, gut microbiota, enteral microbiome, enteral microbiota, premature infant, preterm infant, extremely low birth weight infant, ELBW infant, very low birth weight infant, feeding, breast milk, breastfeeding, formula, prebiotic, probiotic, and long chain polyunsaturated fatty acid.

STUDY SELECTION

Primary studies written in English and focused on the association between enteral feeding and gut microbiome patterns of preterm infants were included in the review.

DATA EXTRACTION

We independently reviewed the selected articles and extracted information using predefined data extraction criteria including study design, study participants, type of feeding, type and frequency of biospecimen (e.g., feces, gastric aspirate) collection, microbiological analysis method, and major results.

DATA SYNTHESIS

In 4 of the 18 studies included in the review, researchers described the effects of milk products (mothers' own milk, donor human milk, and formula). In 5 studies, the effects of prebiotics were assessed, and in 9 studies, the effects of probiotics on the gut microbiome were described. Mothers' own breast milk feeding influenced the compositional structure of preterm infants' gut microbial community and increased diversity of gut microbiota compared with donor human milk and formula feeding. The results of the use of prebiotics and probiotics varied among studies; however, the majority of the researchers reported positive bifidogenic effects on the development of beneficial bacteria.

CONCLUSION

Mothers' own milk is considered the best form of nutrition for preterm infants and the gut microbial community. Variation in fatty acid composition across infant feeding types can affect microbial composition. The evidence for supplementation of prebiotics and probiotics to promote the gut microbial community structure is compelling; however, additional research is needed in this area.

A retrospective study on the effects of exclusive donor human milk feeding in a short period after birth on morbidity and growth of preterm infants during hospitalization

The risks and benefits of feeding preterm formula (PF) versus donor human milk (DHM) in preterm infants are uncertain, and studies evaluating the efficacy of DHM to the morbidities and growth of preterm infants in the neonatal intensive care unit are confused by the need for milk fortification. We aimed to determine and compare the outcome of short-term morbidities in neonatal intensive care unit and growth between premature infants fed exclusively DHM only until a volume of 130 mL/kg/d of enteral feeding was achieved and infants fed with a PF mix after birth. The data of 132 infants with low birth weight of <1500 g and gestational age of less than 32 weeks were considered. Ninety infants were analyzed, of which 86 were discharged alive. The DHM group (n = 36) was made up of infants who were fed exclusively with DHM, whereas the PF group (n = 54) consisted of infants who were fed with a combination of PF and either DHM or human milk, until a volume of 130 mL/kg/d of enteral feeding was achieved. Once feeding in the DHM group progressed to volumes greater than 130 mL/kg/d, infants were fed fortified DHM and PF alternately. One infant (2.8%) in the DHM group had late-onset sepsis or necrotizing enterocolitis compared with 21 (38.9%) in the PF group (adjusted odds ratio 0.05, 95% confidence interval 0.01-0.41); 13 (36.1%) infants in the DHM group had bronchopulmonary dysplasia compared with 38 (70.4%) in the PF group (odds ratio 0.18, 95% confidence interval 0.05-0.41). Although the DHM group demonstrated a comparatively lower rate of weight gain, head circumference increment, and height increment from birth to the age at which an enteral feeding volume of 130 mL/kg/d was achieved, there were no significant differences in these values at 36 weeks' postmenstrual age between both groups.

Bacteria and Bioactivity in Holder Pasteurized and Shelf-Stable Human Milk Products

Background: Historically, Holder pasteurization has been used to pasteurize donor human milk available in a hospital setting. There is extensive research that provides an overview of the impact of Holder pasteurization on bioactive components of human milk. A shelf-stable (SS) human milk product, created using retort processing, recently became available; however, to our knowledge, little has been published about the effect of retort processing on human milk. Objective: We aimed to assess the ability of retort processing to eliminate bacteria and to quantify the difference in lysozyme and secretory immunoglobulin A (sIgA) activity between Holder pasteurized (HP) and SS human milk. Methods: Milk samples from 60 mothers were pooled. From this pool, 36 samples were taken: 12 samples were kept raw, 12 samples were HP, and 12 samples were retort processed to create an SS product. All samples were analyzed for total aerobic bacteria, coliform bacteria, Bacillus cereus, sIgA activity, and lysozyme activity. Raw samples served as the control. Results: One raw sample and 3 HP samples contained B. cereus at the time of culture. There were no detectable bacteria in SS samples at the time of culture. Raw samples had significantly greater lysozyme and sIgA activity than HP and SS samples (P < 0.0001). HP samples retained significantly more lysozyme and sIgA activity (54% and 87%, respectively) than SS samples (0% and 11%, respectively). Conclusions: Human milk processed using Holder pasteurization should continue to be screened for the presence of B. cereus. Clinicians should be aware of the differences in the retention of lysozyme and sIgA activity in HP and SS products when making feeding decisions for medically fragile or immunocompromised infants to ensure that patients are receiving the maximum immune protection.

Pasteurization Procedures for Donor Human Milk Affect Body Growth, Intestinal Structure, and Resistance against Bacterial Infections in Preterm Pigs

Background: Holder pasteurization (HP) destroys multiple bioactive factors in donor human milk (DM), and UV-C irradiation (UVC) is potentially a gentler method for pasteurizing DM for preterm infants.Objective: We investigated whether UVC-treated DM improves gut maturation and resistance toward bacterial infections relative to HP-treated DM.Methods: Bacteria, selected bioactive components, and markers of antioxidant capacity were measured in unpasteurized donor milk (UP), HP-treated milk, and UVC-treated milk (all from the same DM pool). Fifty-seven cesarean-delivered preterm pigs (91% gestation; ratio of males to females, 30:27) received decreasing volumes of parental nutrition (average 69 mL · kg^-1 · d^-1) and increasing volumes of the 3 DM diets (n = 19 each, average 89 mL · kg^-1 · d^-1) for 8-9 d. Body growth, gut structure and function, and systemic bacterial infection were evaluated.Results: A high bacterial load in the UP (6×10⁵ colony forming units/mL) was eliminated similarly by HP and UVC treatments. Relative to HP-treated milk, both UVC-treated milk and UP showed greater activities of lipase and alkaline phosphatase and concentrations of lactoferrin, secretory immunoglobulin A, xanthine dehydrogenase, and some antioxidant markers (all P < 0.05). The pigs fed UVC-treated milk and pigs fed UP showed higher relative weight gain than pigs fed HP-treated milk (5.4% and 3.5%), and fewer pigs fed UVC-treated milk had positive bacterial cultures in the bone marrow (28%) than pigs fed HP-treated milk (68%) (P < 0.05). Intestinal health was also improved in pigs fed UVC-treated milk compared with those fed HP-treated milk as indicated by a higher plasma citrulline concentration (36%) and villus height (38%) (P < 0.05) and a tendency for higher aminopeptidase N (48%) and claudin-4 (26%) concentrations in the distal intestine (P < 0.08). The gut microbiota composition was similar among groups except for greater proportions of Enterococcus in pigs fed UVC-treated milk than in pigs fed UP and those fed HP-treated milk in both cecum contents (20% and 10%) and distal intestinal mucosa (24% and 20%) (all P < 0.05).Conclusions: UVC is better than HP treatment in preserving bioactive factors in DM. UVC-treated milk may induce better weight gain, intestinal health, and resistance against bacterial infections as shown in preterm pigs as a model for DM-fed preterm infants.

The Effect of Holder Pasteurization on Activin A Levels in Human Milk

INTRODUCTION

There is evidence that mother's own milk is the best nutrient in terms of multiorgan protection and infection prevention. However, when maternal milk is scarce, the solution can be represented by donor milk (DM), which requires specific storage procedures such as Holder Pasteurization (HoP). HoP is not free from side effects since it is widely known that it causes qualitative/quantitative changes in milk composition, particularly in the protein content. Therefore, the aim of this study is to investigate the effects of HoP on Activin A, a neurobiomarker known to play an important role in the development and protection of the central nervous system.

METHODS

In 24 mothers who delivered preterm (n = 12) and term (n = 12) healthy newborns, we conducted a pretest/test study where the milk donors acted as their own controls. Each sample was divided into two parts: the first was frozen at -80°C (Group 1); the second was Holder-pasteurized before freezing at -80°C (Group 2). Activin A was quantified using an ELISA test.

RESULTS

Activin A was detected in all samples. There were no significant differences (p > 0.05) between the two groups, also when the analysis was stratified for gestational age at delivery and milk maturation degree (p > 0.05, for both).

CONCLUSION

The present findings on the absence of any side effects of HoP on the milk concentration of Activin A offer additional support to the efficacy of HoP in DM storage. Our data open up to further investigations on neurobiomarkers' assessment in human milk and their preanalytical stability according to storage procedures.

Bovine colostrum improves neonatal growth, digestive function, and gut immunity relative to donor human milk and infant formula in preterm pigs

Mother's own milk is the optimal first diet for preterm infants, but donor human milk (DM) or infant formula (IF) is used when supply is limited. We hypothesized that a gradual introduction of bovine colostrum (BC) or DM improves gut maturation, relative to IF during the first 11 days after preterm birth. Preterm pigs were fed gradually advancing doses of BC, DM, or IF (3-15 ml·kg(-1)·3 h(-1), n = 14-18) before measurements of gut structure, function, microbiology, and immunology. The BC pigs showed higher body growth, intestinal hexose uptake, and transit time and reduced diarrhea and gut permeability, relative to DM and IF pigs (P < 0.05). Relative to IF pigs, BC pigs also had lower density of mucosa-associated bacteria and of some putative pathogens in colon, together with higher intestinal villi, mucosal mass, brush-border enzyme activities, colonic short chain fatty acid levels, and bacterial diversity and an altered expression of immune-related genes (higher TNFα, IL17; lower IL8, TLR2, TFF, MUC1, MUC2) (all P < 0.05). Values in DM pigs were intermediate. Severe necrotizing enterocolitis (NEC) was observed in >50% of IF pigs, while only subclinical intestinal lesions were evident from DM and BC pigs. BC, and to some degree DM, are superior to preterm IF in stimulating gut maturation and body growth, using a gradual advancement of enteral feeding volume over the first 11 days after preterm birth in piglets. Whether the same is true in preterm infants remains to be tested.

Use of Donor Human Milk and Maternal Breastfeeding Rates: A Systematic Review

The number of human milk banks is growing worldwide. The introduction of donor human milk (DHM) to neonatal units has been advocated as a strategy to promote maternal breastfeeding. However, concern has been raised that the introduction of DHM may actually lead to a decrease in maternal breastfeeding. To address this question, we conducted a systematic literature review of studies that assessed maternal breastfeeding rates before and after the introduction of DHM. We searched 7 electronic databases, carried out citation tracking, and contacted experts in the field. Where data for breastfeeding rates before and after the introduction of DHM were directly comparable, a relative risk was calculated. Our search identified 286 studies, of which 10 met the inclusion criteria. Definitions of patient populations and study outcomes varied, limiting meaningful comparison. Where possible, relative risks (RR) were calculated on aggregated data. The introduction of DHM had a significant positive impact on any breastfeeding on discharge (RR, 1.19; 95% confidence interval [CI], 1.06-1.35;P= .005) but none on exclusive maternal breastfeeding on discharge (RR, 1.12; 95% CI, 0.91-1.40;P= .27) or on exclusive administration of own mother's milk (OMM) days 1 to 28 of life (RR, 1.08; 95% CI, 0.78-1.49; P= .65). A single-center study demonstrated a significant decrease in the percentage of feeds that were OMM after the introduction of DHM. In conclusion, the available data demonstrate some evidence of positive and negative effects on measures of maternal breastfeeding when DHM is introduced to a neonatal unit.

Necessity of human milk banking in Japan: Questionnaire survey of neonatologists

BACKGROUND

If their own mother's milk (OMM) is not available, another mother's milk may be used for extremely low-birthweight (ELBW) infants. Human milk is a bodily fluid, however, therefore we have assumed that other mother's milk is currently seldom given to infants despite its superiority to formula. Although the World Health Organization and the American Academy of Pediatrics have recommended using donor human milk (DHM) from a human milk bank (HMB) in the case that OMM is not available, there is no HMB in Japan. To assess whether other mother's milk is used for ELBW infants and whether an HMB is necessary in Japan, we surveyed neonatal intensive care units (NICU) via questionnaire.

METHODS

The questionnaire was sent by email to members of the Japanese Neonatologist Association who are responsible for NICU.

RESULTS

In total, 126 completed questionnaires (70.7%) were returned and analyzed. One-fourth of NICU give other mother's milk to ELBW infants. The first choice of nutrition is OMM, but other mother's milk or formula is given to infants at 19% of NICU if OMM is unavailable. Approximately three-fourths of NICU would like an HMB.

CONCLUSION

Although human milk contains contagious agents and authorities do not recommend giving other mother's milk as a substitute for OMM, other mother's milk is still a choice in NICU in Japan. Many neonatologists, however, would prefer a safer alternative, that is, DHM obtained from an accredited HMB. A well-regulated HMB should be established and safe DHM should be available for all preterm infants if necessary.

Human milk banking and milk kinship: Perspectives of mothers in a Muslim country

AIM

The present study aims to determine the knowledge, attitudes and views of mothers regarding infant feeding, breast milk, wet-nursing, milk kinship and human milk banks.

METHODS

This descriptive cross-sectional study was composed of 1042 mothers who delivered at two different hospitals in Turkey.

RESULTS

Almost half of the participating mothers, 49.9%, agreed with the establishment of alternative HMBs in Turkey. Only 7.7% of the mothers in this study expressed views in favour of the establishment of Western-style HMBs. Approximately half of the mothers (42.4%) indicated that they were against the establishment of any kind of HMBs in Turkey. Only 9.2% of the mothers in this study stated that they would volunteer to donate their breast milk to the Western-style HMBs, and only 6.9% of the mothers approved obtaining milk from this type of HMB. Finally, 44.2% of the mothers stated that they would donate their breast milk to the alternative HMBs, and 31.9% of the mothers approved obtaining milk from this type of HMB.

CONCLUSION

This is the first study conducted among mothers in a Muslim community about issues such as infant feeding, breast milk, wet-nursing, milk kinship and HMBs. The majority of the mothers in this study are against the establishment of Western-style HMBs, whereas they have a more positive response to an alternative HMB when their religious concerns are relieved.

Survey of Italian human milk banks

BACKGROUND

At present, the Italian Association of Donor Human Milk Banks (Associazione Italiana Banche del Latte Umano Donato, AIBLUD) consists of 31 milk banks, whose management is based on Italian Guidelines. In 2013, AIBLUD performed a systematic survey to collect data on the activities of banks operating in Italy in the years previous to this date.

OBJECTIVE

The purpose of this survey was to evaluate the operational procedures of Italian Human Milk Banks in order to identify both areas of strength and room for improvement.

METHODS

A questionnaire was utilized to obtain national data from the 28 banks active in the year 2012 in order to evaluate the number of donors, volume of human milk collected, and other information relating to the period 2007 to 2012.

RESULTS

In all, 89% of the banks (25/28) responded to the survey. Data received primarily concerned the number of donors, volume of milk collected, and average amount of milk from each donor in the period 2007 to 2012. It was evident that in 2012 human milk banks collected a higher volume of milk than in 2007. Further, the average amount of milk from each donor was higher. Most of the milk banks were following the Italian Guidelines for traceability, control of donors, bacteriological checks, method of pasteurization, storage, thawing, type of containers, and utilization of the Hazard Analysis and Critical Control Points system.

CONCLUSION

This survey identified both areas of strength and room for improvement in the Italian human milk banks.

Donor human milk for very low birth weights: patterns of usage, outcomes, and unanswered questions

PURPOSE OF REVIEW

Donor milk usage in the United States has increased substantially over the past 10 years. Between 2007 and 2011, donor milk use in level 3 and 4 neonatal ICUs increased from 25 to 45%.

RECENT FINDINGS

Most centers have written protocols based on birth weight or gestational age, and give donor milk in an effort to prevent necrotizing enterocolitis. The evidence for protection against necrotizing enterocolitis using bovine-fortified donor milk vs. formula is limited, although the exclusive human milk diet seems to offer protection compared to diets containing formula. Adequate growth can be achieved with donor milk fortified with either bovine or human milk-derived fortifiers, but use of additional fortification and protein supplementation may be required. Several randomized trials of donor milk vs. formula are ongoing in the very low birth weight population in North America that can answer important questions.

SUMMARY

Further research is needed before donor milk and the exclusive human milk diet are considered the standard of care.

Neonatal Intensive Care Unit Medical Directors

BACKGROUND

Use of donor human milk (DHM) is increasing, but criteria for its use are not well defined.

MATERIALS AND METHODS

We conducted a 34-question Internet-based survey of medical directors of U.S. level 3 and level 4 neonatal intensive care units (NICUs), with the goal of describing specifics of policies developed to guide DHM use in U.S. NICUs. Respondents reported NICU characteristics and details of policies concerning DHM use. Policy-specified criteria for DHM use, if any, were described. Bivariate and multivariate analyses were used to identify NICU characteristics associated with DHM use.

RESULTS

Respondents returned 153 (33%) surveys, with use of DHM reported by 91 (59%). Donor human milk use was more likely with more than 100 annual admissions <1500 g at birth (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.1-4.7) and with Vermont-Oxford Network participants (OR, 4.6; 95% CI, 1.8-11.6). Among 72 NICUs reporting a written policy, criteria for providing DHM required birth weights varying from <1000 to <1800 g and/or gestational ages from <28 to <34 completed weeks, but criteria were reportedly waived in many circumstances. Policies regarding duration of DHM therapy were similarly varied.

CONCLUSIONS

Criteria for initiating and continuing DHM vary widely among U.S. level 3 and level 4 NICUs. Donor human milk use is more frequent in NICUs with many very low-birth-weight admissions and among Vermont-Oxford Network participants. Further research is needed to define short- and long-term outcomes and cost benefits of DHM use in subgroups of NICU patients, particularly for uses other than necrotizing enterocolitis prevention.

Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals

OBJECTIVE

To determine acceptance of donor human milk (DM) for feeding preterm infants and whether offering DM, alters mothers' milk (MM) feeding.

STUDY DESIGN

Infant feeding data were collected from medical records of 650 very preterm infants enrolled between 2006-2011 in two hospital level III neonatal intensive care units (NICUs) in Cincinnati, Ohio. The study was conducted during the implementation of a program offering 14 days of DM.

RESULT

From 2006-2011, any DM use increased from 8 to 77% of infants, largely replacing formula for the first 2 weeks of life; provision of MM did not change. DM was more likely to be given in the first 2 weeks of life, if infants never received MM or were >1000 g birth weight, but DM use did not differ by sociodemographic factors.

CONCLUSION

Offering DM dramatically increased human milk feeding and decreased formula use, but did not alter MM feeding in hospital.

Long-chain polyunsaturated fatty acid levels in US donor human milk: meeting the needs of premature infants?

OBJECTIVE

To determine fatty acid levels in the US donor milk supply.

STUDY DESIGN

Donor human milk samples from Iowa (n=62), Texas (n=5), North Carolina (n=5) and California (n=5) were analyzed by gas chromatography. Levels in the Iowa donor milk were compared before and after pasteurization using Student's t-test. Docosahexaenoic acid (DHA) and arachidonic acid (ARA) levels were compared among all milk banks using analysis of variance.

RESULT

ARA (0.4 pre, 0.4 post, P=0.18) and DHA (0.073 pre, 0.073 post, P=0.84) were not affected by pasteurization. DHA varied between banks (P<0.0001), whereas ARA did not (P=0.3). DHA levels from all banks were lower than published values for maternal milk and infant formula (P<0.0001).

CONCLUSION

Pasteurization of breastmilk does not affect DHA or ARA levels. However, DHA content in US donor milk varies with bank location and may not meet the recommended provision for preterm infants.