Multinutrient fortification of human breast milk for preterm infants following hospital discharge

The Revolution of Breast Milk: The Multiple Role of Human Milk Banking between Evidence and Experience-A Narrative Review

The review recalls the importance of breast milk and deepens the theme of human milk banking, a virtuous reality that is expanding all over the world but is still little known. In the last 15 years, modern biological technologies have crystallized the concept of uniqueness and irreproducibility of human milk, by establishing three new principles: first: human milk: a "life-saving" drug; second: human milk: the best food for preterm infants; and third: human milk: the main component of premature infant care. Our experience teaches us that human milk banking plays many roles that need to be known and shared.

[The value of human milk for preterm infants-overview and practical aspects]

Over the last decades the immense benefit of human milk on the nutrition of preterm infants has become increasingly evident. Research has confirmed that human milk has significant advantages for the preterm infant in terms of host defense, gastrointestinal development and maturation, neurological development, reduction of necrotizing enterocolitis, retinopathy of prematurity and chronic lung disease as well as mental and physical benefits for the mother. Computing these factors into a health-cost-benefit equation, positive economic consequences for a national public health system were demonstrated.Therefore, international feeding guidelines recommend human milk to be the first choice for preterm infants, the primary source being the infant's mother. The first alternative is milk from an established donor milk bank. To meet the unique nutritional demands of preterm infants and to avoid postnatal growth restriction, human milk must be fortified with additional micro- and macronutrients. Concerns about microbial colonization and contamination and hygienic aspects concerning milk handling need to be addressed when feeding human milk to preterm infants.Early initiation and maintenance of lactation is challenging for mothers of preterm infants and their caregivers. Providing lactation support from educated staff, optimal nursing environments, and the positive attitude of an experienced NICU (neonatal intensive care unit) team will contribute to successful lactation and breastfeeding even beyond discharge of the infant.

Nutrient-enriched formula versus standard formula for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding nutrient-enriched formula rather than standard formula to infants after hospital discharge might facilitate 'catch-up' growth and might improve development.

OBJECTIVES

To compare the effects of nutrient-enriched formula versus standard formula on growth and development of preterm infants after hospital discharge.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (2016, Issue 8) in the Cochrane Library, MEDLINE, Embase and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; to 8 September 2016), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared the effects of feeding nutrient-enriched formula (postdischarge formula or preterm formula) versus standard term formula to preterm infants after hospital discharge .

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios and risk differences for dichotomous data, and mean differences (MDs) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity by performing sensitivity analyses. We assessed quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included 16 eligible trials with a total of 1251 infant participants. Trials were of variable methodological quality, with lack of allocation concealment and incomplete follow-up identified as major potential sources of bias. Trials (N = 11) that compared feeding infants with 'postdischarge formula' (energy density about 74 kcal/100 mL) versus standard term formula (about 67 kcal/100 mL) did not find consistent evidence of effects on growth parameters up to 12 to 18 months post term. GRADE assessments indicated that evidence was of moderate quality, and that inconsistency within pooled estimates was the main quality issue.Trials (N = 5) that compared feeding with 'preterm formula' (about 80 kcal/100 mL) versus term formula found evidence of higher rates of growth throughout infancy (weighted mean differences at 12 to 18 months post term: about 500 g in weight, 5 to 10 mm in length, 5 mm in head circumference). GRADE assessments indicated that evidence was of moderate quality, and that imprecision of estimates was the main quality issue.Few trials assessed neurodevelopmental outcomes, and these trials did not detect differences in developmental indices at 18 months post term. Data on growth or development through later childhood have not been provided.

AUTHORS' CONCLUSIONS

Recommendations to prescribe 'postdischarge formula' for preterm infants after hospital discharge are not supported by available evidence. Limited evidence suggests that feeding 'preterm formula' (which is generally available only for in-hospital use) to preterm infants after hospital discharge may increase growth rates up to 18 months post term.

Positive effect of human milk feeding during NICU hospitalization on 24 month neurodevelopment of very low birth weight infants: an Italian cohort study

The aim of this study was to determine the effect of human milk feeding during NICU hospitalization on neurodevelopment at 24 months of corrected age in very low birth weight infants. A cohort of 316 very low birth weight newborns (weight ≤ 1500 g) was prospectively enrolled in a follow-up program on admission to the Neonatal Intensive Care Unit of S. Orsola Hospital, Bologna, Italy, from January 2005 to June 2011. Neurodevelopment was evaluated at 24 months corrected age using the Griffiths Mental Development Scale. The effect of human milk nutrition on neurodevelopment was first investigated using a multiple linear regression model, to adjust for the effects of gestational age, small for gestational age, complications at birth and during hospitalization, growth restriction at discharge and socio-economic status. Path analysis was then used to refine the multiple regression model, taking into account the relationships among predictors and their temporal sequence. Human milk feeding during NICU hospitalization and higher socio-economic status were associated with better neurodevelopment at 24 months in both models. In the path analysis model intraventricular hemorrhage—periventricular leukomalacia and growth restriction at discharge proved to be directly and independently associated with poorer neurodevelopment. Gestational age and growth restriction at birth had indirect significant effects on neurodevelopment, which were mediated by complications that occurred at birth and during hospitalization, growth restriction at discharge and type of feeding. In conclusion, our findings suggest that mother’s human milk feeding during hospitalization can be encouraged because it may improve neurodevelopment at 24 months corrected age.

Benefits of donor milk in the feeding of preterm infants

Mother's own milk is widely recognized as the optimal feeding for term infants, but also provides health benefits that are of vital importance for sick and preterm infants in neonatal intensive care units (NICUs), even though the growth and neurodevelopmental needs of very premature infants are best met by appropriate fortification of human milk (HM). When mother's milk is unavailable or in short supply, donor milk (DM) represents the second best alternative and, although some nutritional elements are inactivated by the pasteurization process, it still has documented advantages compared to formula. Occasionally, the concern that the use of DM might decrease breastfeeding is being raised, but reports exist in literature showing that the use of donor HM in the NICU increases breastfeeding rates at discharge for VLBW infants. The demonstrated benefits of HM highlight the importance of educating health care professionals in breastfeeding support.

Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations

In the World Health Organization/United Nations Children's Fund document Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, neonatal care is mentioned as 1 area that would benefit from expansion of the original Ten Steps to Successful Breastfeeding. The different situations faced by preterm and sick infants and their mothers, compared to healthy infants and their mothers, necessitate a specific breastfeeding policy for neonatal intensive care and require that health care professionals have knowledge and skills in lactation and breastfeeding support, including provision of antenatal information, that are specific to neonatal care. Facilitation of early, continuous, and prolonged skin-to-skin contact (kangaroo mother care), early initiation of breastfeeding, and mothers' access to breastfeeding support during the infants' whole hospital stay are important. Mother's own milk or donor milk (when available) is the optimal nutrition. Efforts should be made to minimize parent-infant separation and facilitate parents' unrestricted presence with their infants. The initiation and continuation of breastfeeding should be guided only by infant competence and stability, using a semi-demand feeding regimen during the transition to exclusive breastfeeding. Pacifiers are appropriate during tube-feeding, for pain relief, and for calming infants. Nipple shields can be used for facilitating establishment of breastfeeding, but only after qualified support and attempts at the breast. Alternatives to bottles should be used until breastfeeding is well established. The discharge program should include adequate preparation of parents, information about access to lactation and breastfeeding support, both professional and peer support, and a plan for continued follow-up.

Multinutrient fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with multinutrient fortified breast milk rather than unfortified breast milk may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding preterm infants following hospital discharge with multinutrient fortified human breast milk versus unfortified breast milk on growth and development.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included electronic searches of the Cochrane Central Register of Controlled Trials Register (CENTRAL, The Cochrane Library, 2012, Issue 3), MEDLINE, EMBASE and CINAHL (until August 2012), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors and synthesis of data using risk ratio, risk difference and mean difference.

MAIN RESULTS

We identified two small trials involving a total of 246 infants. These did not provide evidence that multinutrient fortification of breast milk for three to four months after hospital discharge affected rates of growth during infancy. One trial assessed infants at 18 months corrected age and did not find any statistically significant effects on neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

The limited available data do not provide convincing evidence that feeding preterm infants with multinutrient fortified breast milk compared with unfortified breast milk following hospital discharge affects important outcomes including growth rates during infancy. There are no data on long-term growth. Since fortifying breast milk for infants fed directly from the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.

Definition and outpatient management of the very low-birth-weight infant with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease of prematurity, is the major cause of pulmonary disease in infants. The pathophysiology and management of BPD have evolved over the past four decades as improved neonatal intensive care unit (NICU) modalities have increased survival rates. The likelihood for developing BPD increases with the degree of prematurity and reaches 25-35% in very low-birth-weight and extremely low-birth-weight infants. BPD affects many organ systems, and infants with BPD are at increased risk for rehospitalization and numerous complications following NICU discharge. The management of BPD and medically related problems, particularly during the first 2 years of life, remains a continuing challenge for parents and healthcare providers. It is important that a multidisciplinary team consisting of the neonatologist/attending physician, primary care physician, and other specialized support staff work in concert and meet regularly to provide continuity of care and accurate patient assessments.

Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula rather than standard term formula might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with standard term formula on growth and development for preterm infants following hospital discharge.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011, Issue 4), MEDLINE, EMBASE, and CINAHL (to September 2011), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm infants following hospital discharge with nutrient-enriched formula (post-discharge formula or preterm formula) compared with standard term formula.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We found 15 eligible trials in which a total of 1128 preterm infants participated. The trials were of variable methodological quality with lack of allocation concealment and incomplete follow-up in some trials being the major potential sources of bias. The trials (N = 10) that compared feeding infants with "post-discharge formula" (energy density about 74 kcal/100 ml) versus standard term formula (about 67 kcal/100 ml) did not find consistent evidence of effects on growth parameters up to 12 to 18 months corrected age. The trials (N = 5) that compared feeding with "preterm formula" (about 80 kcal/100 ml) versus term formula found some evidence of higher rates of growth through infancy: weighted mean differences at 12 to 18 months corrected age about 500 g in weight, 5 to10 mm in length, and 5 mm in head circumference. Few trials assessed neurodevelopmental outcomes and these did not detect any statistically significant differences in developmental indices at 18 months corrected age. There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

Current recommendations to prescribe "post-discharge formula" for preterm infants following hospital discharge are not supported by the available evidence. Some limited evidence exists that feeding preterm infants following hospital discharge with "preterm formula" (which is generally only available for in-hospital use) may increase growth rates up to 18 months corrected age.