Energy and Fat Intake for Preterm Infants Fed Donor Milk Is Significantly Impacted by Enteral Feeding Method

Human milk-derived fortifiers are linked with feed extension due to Hypoglycemia in infants <1250 g or <30 weeks: a matched retrospective chart review

OBJECTIVE

To investigate differences in hypoglycemia and extended feed prescriptions among premature infants provided bovine-derived human milk fortifiers (Bov-fort) with mother's milk or formula vs human milk-derived human milk fortifiers (HM-fort) with mother's milk or donor human milk.

STUDY DESIGN

This was a retrospective chart review (n = 98). Infants receiving HM-fort were matched with infants receiving Bov-fort. Blood glucose values and feed orders were retrieved from the electronic medical record.

RESULTS

Prevalence of ever having blood glucose <60 mg/dL was 39.1% in the HM-fort group vs. 23.9% in the Bov-fort group (p = 0.09). Blood glucose ≤45 mg/dL occurred in 17.4% of HM-fort vs 4.3% in Bov-fort (p = 0.07). Feeds were extended for any reason in 55% of HM-fort vs. 20% of Bov-fort (p < 0.01). Feed extension due to hypoglycemia occurred in 24% of HM-fort vs. 0% of Bov-fort (p < 0.01).

CONCLUSION

Predominately HM-based feeds are associated with feed extension due to hypoglycemia. Prospective research is warranted to elucidate underlying mechanisms.

Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts

OBJECTIVES

To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g.

METHODS

The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached.

RESULTS

In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier.

CONCLUSIONS

We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants.

Perspective: Human Milk Composition and Related Data for National Health and Nutrition Monitoring and Related Research

National health and nutrition monitoring is an important federal effort in the United States and Canada, and the basis for many of their nutrition and health policies. Understanding of child exposures through human milk (HM) remains out of reach due to lack of current and representative data on HM's composition and intake volume. This article provides an overview of the current national health and nutrition monitoring activities for HM-fed children, HM composition (HMC) and volume data used for exposure assessment, categories of potential measures in HM, and associated variability factors. In this Perspective, we advocate for a framework for collection and reporting of HMC data for national health and nutrition monitoring and programmatic needs, including a shared vision for a publicly available Human Milk Composition Data Repository (HMCD-R) to include essential metadata associated with HMC. HMCD-R can provide a central, integrated platform for researchers and public health officials for compiling, evaluating, and sharing HMC data. The compiled compositional and metadata in HMCD-R would provide pertinent measures of central tendency and variability and allow use of modeling techniques to approximate compositional profiles for subgroups, providing more accurate exposure assessments for purposes of monitoring and surveillance. HMC and related metadata could facilitate understanding the complexity and variability of HM composition, provide crucial data for assessment of infant and maternal nutritional needs, and inform public health policies, food and nutrition programs, and clinical practice guidelines.

Is preterm donor milk better than preterm formula for very-low-birth-weight infants?

Background

Preterm human milk has advantages over preterm formula (PF), but it may compromise some functions after pasteurization.

Objective

To explore the effects of preterm donor milk (DM) on growth, feeding tolerance, and severe morbidity in very-low-birth-weight infants.

Method

This was a single-center, prospective cohort study that included 304 preterm infants weighing <1,500 g or of gestational age <32 weeks. If the mother's own milk was insufficient, the parents decided to use PF (n = 155) or DM (n = 149). The two groups were uniformly managed according to the standard NICU protocol. Growth parameters, feeding tolerance, and severe morbidity such as necrotizing enterocolitis, were compared between the two groups.

Results

The daily weight gain and weekly head growth in the DM group were not different from those in the PF group (P > 0.05). Feeding intolerance in the DM group was significantly lower than that in PF group (P < 0.05), and parenteral nutrition time and hospitalization time were also shorter than that in the PF group (P < 0.05). Moreover, the incidence of necrotizing enterocolitis and sepsis was also significantly lower in the DM group (P < 0.05).

Conclusion

The study indicated that preterm DM does not affect the growth of very-low-birth-weight infants. Further, it significantly reduces feeding intolerance, helps achieve full enteral feeding early, and has protective effects against necrotizing enterocolitis and sepsis. Thus, compared with formula, preterm DM can lower the rate of infection in preterm infants and is worthy of promotion.

Factors Influencing Breast Milk Fat Loss during Administration in the Neonatal Intensive Care Unit

The objective of this study was to investigate factors influencing fat loss during tube feeding of breast milk to preterm infants. An experimental study with 81 feeding simulations was performed, with nine continuous infusions in each of six modalities: Horizontal Higher, Horizontal Matched, Horizontal Lower, Tilted Higher, Tilted Matched, and Tilted Lower, and for comparison, 27 bolus feedings: nine flushed with air, nine with water, and nine that were not flushed, done at matched height. Each simulation utilized 16 mL of breast milk given over four hours. Continuous infusions were given with a flow rate of 4 mL/h. Bolus was given as 8 mL over the course of 15–20 min every other hour. Analysis for fat, true protein, carbohydrate, total solids, and energy was performed before and after each simulation. The percent of macronutrient loss was compared between all simulations. Continuous infusion resulted in an average fat loss of 40%. Bolus feedings resulted in an average fat loss of 11% (p ≤ 0.001). Considerable fat loss is seen during continuous tube feeding. Neither height in relation to the infant nor tilting of the pump reduce fat loss. To limit fat loss, the bolus feeding method should be utilized.

Lactobacillus plantarum mitigates sexual-reproductive deficits by modulating insulin receptor expression in the hypothalamic-pituitary-testicular axis of hyperinsulinemic mice

OBJECTIVES

Hyperinsulinemia increases the risk factor of diabetes and infertility at a manifold. Lactobacillus plantarum has several medical significances with limited reports. Hence, this study assessed the effect of L. plantarum on sexual-reproductive functions and distribution of insulin receptors in the hypothalamic-pituitary-testicular axis of hyperinsulinemic mice.

METHODS

Forty male adult mice were divided into five groups as follows: control, high-fat diet (HFD) + streptozotocin (STZ), therapeutic, co-administration group type 1 (CO-AD) and probiotics. They were either simultaneously exposed to an HFD and L. plantarum treatment for 28 days with a dose of STZ injection to induce hyperinsulinemia on day 28 or treated with L. plantarum for 14 days, and following induction of hyperinsulinemia. Mice were subjected to a sexual behavioural test and thereafter sacrificed under euthanasia condition. Blood, brain and testes were collected for biochemical and immunohistochemical assays.

RESULTS

Treatment with L. plantarum ameliorated reproductive hormones activity disruption, sexual behavioural defects, antioxidant imbalance, insulin dysregulation and lipid metabolism dysfunction following exposure to HFD + STZ when compared to the hyperinsulinemic untreated mice.

CONCLUSIONS

Taken together, data from this study reveal that L. plantarum abrogated hyperinsulinemia-induced male sexual and reproductive deficits by modulating antioxidant status, lipid metabolism and insulin signalling in the hypothalamic-pituitary-testicular axis of mice.

Changes in macronutrients of human milk after bolus feeding: a simulation study

BACKGROUND

Enteral nutrition supply to preterm infants requires feeding through a feeding tube. The aim of this study was to evaluate changes in macronutrient composition of human milk (HM) while passing through a gastric feeding tube.

METHODS

Simulated real-life practice tube feeding was performed by using an infusion pump connected to a feeding tube. A human milk analyzer was used to compare the pre infusion and post infusion macronutrient contents of HM.

RESULT

There was a significant decrease in fat (from 4.06 ± 0.6 g/100 ml to 3.95 ± 0.6 g/100 ml), carbohydrates (from 7.51 ± 0.4 g/100 ml to 7.33 ± 0.5 g/100 ml), and energy content (from 70.77 ± 5.4 kcal/100 ml to 69.72 ± 0.5 kcal/100 ml) after passing through the feeding tube (P < 0.001).

CONCLUSION

A simulated real-life bolus tube feeding model demonstrated small but significant decreases in fat, carbohydrate, and energy content. The biological significance of our results to the very low birth weight infants should be further studied.

Effects of milk banking procedures on nutritional and bioactive components of donor human milk

Pasteurized donor human milk is in wide use for preterm infants in neonatal intensive care units when maternal milk is unavailable. Pasteurization of donor milk is required to prevent bacterial contamination, and multiple methods are used in the non-profit and commercial milk banking industries. Pasteurization results in changes in the nutrient and bioactive components in donor milk compared to unpasteurized human milk, and these changes vary by the type of pasteurization process. Other milk bank practices including freezing of milk, pooling of milk from multiple donors and use of pre-processing macronutrient analysis also affect the nutritional composition of donor milk. This review compiles evidence regarding three common pasteurization techniques for donor milk: Holder pasteurization, vat pasteurization, and retort pasteurization and their effects on the nutritional content and bioactive factors in human milk. It also includes review of literature investigating the impact of freezing and storage, and best practices for multi-donor milk pooling.

High-Temperature Short-Time and Holder Pasteurization of Donor Milk: Impact on Milk Composition

Holder pasteurization (HoP; 62.5 °C, 30 min) is commonly used to ensure the microbiological safety of donor human milk (DHM) but diminishes its nutritional properties. A high-temperature short-time (HTST) system was designed as an alternative for human milk banks. The objective of this study was to evaluate the effect of this HTST system on different nutrients and the bile salt stimulated lipase (BSSL) activity of DHM. DHM was processed in the HTST system and by standard HoP. Macronutrients were measured with a mid-infrared analyzer. Lactose, glucose, myo-inositol, vitamins and lipids were assayed using chromatographic techniques. BSSL activity was determined using a kit. The duration of HTST treatment had a greater influence on the nutrient composition of DHM than did the tested temperature. The lactose concentration and the percentage of phospholipids and PUFAs were higher in HTST-treated than in raw DHM, while the fat concentration and the percentage of monoacylglycerides and SFAs were lower. Other nutrients did not change after HTST processing. The retained BSSL activity was higher after short HTST treatment than that following HoP. Overall, HTST treatment resulted in better preservation of the nutritional quality of DHM than HoP because relevant thermosensitive components (phospholipids, PUFAs, and BSSL) were less affected.

A Simple Intervention to Decrease Nutrient Losses in Continuous Feeds With Human Milk

OBJECTIVES

Current evidence suggests that a significant amount of human milk fat is lost because of tubing adsorption. The objective was to evaluate the effect of reintroducing tubing leftover milk on the quality of macronutrient content of delivered milk.

METHODS

This was an in vitro study. The standard method of preparing and delivering fortified human milk includes preparing a small extra volume that would be used for priming the connection tubes. At the end of the infusion, the tubes and any milk leftover would be discarded. This method was compared with a new method where by the exact milk volume was prepared and used to prime the connection tubes. Leftover tubing milk was pushed with air.

RESULTS

The standard method was associated with significant losses in fat, protein, and calories of 16.7%, 3.4%, and 9.2% compared with the new method of 8.2%, 0%, and 3.3%, respectively. These losses in the standard method were predominantly explained by the significant gains in the left over milk contents of fat 6.3 ± 1.1 g/dL, protein 3.5 ± 0.4 g/dL, and calories 28 ± 2.6 kcal/oz as compared with prepared milk of 4.8 ± 0.3, 2.9 ± 0.3 g/dL, and 24.0 ± 0.8 kcal/oz respectively, P = 0.002.

CONCLUSIONS

Traditional continuous delivery methods of human milk are associated with significant losses of fat and protein. By preparing the exact amount of ordered milk and then pushing through the residual milk left in the tubing with a small amount of air, this study offers a simple intervention that would significantly decrease these losses.

Formula versus donor breast milk for feeding preterm or low birth weight infants

BACKGROUND

When sufficient maternal breast milk is not available, alternative forms of enteral nutrition for preterm or low birth weight (LBW) infants are donor breast milk or artificial formula. Donor breast milk may retain some of the non-nutritive benefits of maternal breast milk for preterm or LBW infants. However, feeding with artificial formula may ensure more consistent delivery of greater amounts of nutrients. Uncertainty exists about the balance of risks and benefits of feeding formula versus donor breast milk for preterm or LBW infants.

OBJECTIVES

To determine the effect of feeding with formula compared with donor breast milk on growth and development in preterm or low birth weight (LBW) infants.

SEARCH METHODS

We used the Cochrane Neonatal search strategy, including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5), Ovid MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (3 May 2019), as well as conference proceedings, previous reviews, and clinical trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) comparing feeding with formula versus donor breast milk in preterm or LBW infants.

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 (RRs) and risk differences (RDs) 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 in subgroup analyses. We assessed the certainty of evidence for the main comparison at the outcome level using GRADE methods.

MAIN RESULTS

Twelve trials with a total of 1879 infants fulfilled the inclusion criteria. Four trials compared standard term formula versus donor breast milk and eight compared nutrient-enriched preterm formula versus donor breast milk. Only the five most recent trials used nutrient-fortified donor breast milk. The trials contain various weaknesses in methodological quality, specifically concerns about allocation concealment in four trials and lack of blinding in most of the trials. Most of the included trials were funded by companies that made the study formula.Formula-fed infants had higher in-hospital rates of weight gain (mean difference (MD) 2.51, 95% confidence interval (CI) 1.93 to 3.08 g/kg/day), linear growth (MD 1.21, 95% CI 0.77 to 1.65 mm/week) and head growth (MD 0.85, 95% CI 0.47 to 1.23 mm/week). These meta-analyses contained high levels of heterogeneity. We did not find evidence of an effect on long-term growth or neurodevelopment. Formula feeding increased the risk of necrotising enterocolitis (typical risk ratio (RR) 1.87, 95% CI 1.23 to 2.85; risk difference (RD) 0.03, 95% CI 0.01 to 0.05; number needed to treat for an additional harmful outcome (NNTH) 33, 95% CI 20 to 100; 9 studies, 1675 infants).The GRADE certainty of evidence was moderate for rates of weight gain, linear growth, and head growth (downgraded for high levels of heterogeneity) and was moderate for neurodevelopmental disability, all-cause mortality, and necrotising enterocolitis (downgraded for imprecision).

AUTHORS' CONCLUSIONS

In preterm and LBW infants, moderate-certainty evidence indicates that feeding with formula compared with donor breast milk, either as a supplement to maternal expressed breast milk or as a sole diet, results in higher rates of weight gain, linear growth, and head growth and a higher risk of developing necrotising enterocolitis. The trial data do not show an effect on all-cause mortality, or on long-term growth or neurodevelopment.