Human milk is the only milk for premies in the NICU!

High protein content in breast milk from South African mothers of preterm infants

AIM

Macronutrient and energy content of human milk are largely assumed for fortification practices. The aim was to explore macronutrient and energy content of transition and mature human milk from South African mothers of preterm infants with a birth weight <1800 g. Secondary objectives compared day to night milk; and explored associations with selected innate factors.

METHODS

In this single-centre, observational study macronutrient and energy content of day, night and mixed samples of transition (first 14 days of life) and mature (from Day 15 of life) human milk were analysed with mid-infrared spectroscopy.

RESULTS

In total, 116 samples (38 days; 37 night; 41 mixed) from 47 mothers were retained for statistical analysis. Mean true protein, carbohydrate, fat and energy content of mixed samples per 100 mL were 1.5 ± 0.4 g, 7.2 ± 0.7 g, 3.5 ± 0.9 g and 69.4 ± 9.9 kcal, respectively. Mixed transition milk (n = 9) had 1.9 ± 0.3 g protein and 67.4 ± 9.6 kcal and mixed mature milk (n = 32) 1.4 ± 0.4 g protein and 70.0 ± 10.1 kcal, per 100 mL.The protein content of transition (p = 0.004) and mature (p = 0.004) milk were significantly higher than published data. Transition milk: 1.5 g protein, 65 kcal; mature milk: 1.2 g protein, 72 kcal per 100 mL. Night samples had less fat (p = 0.014) and energy (p = 0.033) than day samples. With increasing day of life protein content declined (p = 0.003).

CONCLUSION

The protein content of human milk from South African mothers of preterm babies differs from published data and has implications for human milk fortification practises.

Exploring Human Milk, Nutrition, Growth, and Breastfeeding Rates at Discharge(HUMMINGBIRD Study): a protocol for a pilot randomised controlled trial

INTRODUCTION

Mother's own breast milk (MOM) is the optimal nutrition for preterm infants as it reduces the incidence of key neonatal morbidities and improves long-term outcomes. However, MOM shortfall is common and either preterm formula or pasteurised donor human milk (DHM) may be used, although practice varies widely. Limited data suggest that the use of DHM may impact maternal beliefs and behaviours and therefore breastfeeding rates. The aim of this pilot study is to determine if longer duration of DHM exposure increases breastfeeding rates, and if a randomised controlled trial (RCT) design is feasible.

METHODS AND ANALYSIS

The Human Milk, Nutrition, Growth, and Breastfeeding Rates at Discharge (HUMMINGBIRD) Study is a feasibility and pilot, non-blinded RCT with a contemporaneous qualitative evaluation. Babies born less than 33 weeks' gestation or with birth weight <1500 g whose mothers intend to provide MOM are randomly assigned to either control (DHM used to make up shortfall until full feeds and preterm formula thereafter) or intervention (DHM used for shortfall until 36 weeks' corrected age or discharge if sooner). The primary outcome is breast feeding at discharge. Secondary outcomes include growth, neonatal morbidities, length of stay, breastfeeding self-efficacy and postnatal depression using validated questionnaires. Qualitative interviews using a topic guide will explore perceptions around use of DHM and analysed using thematic analysis.

ETHICS APPROVAL AND DISSEMINATION

Nottingham 2 Research Ethics Committee granted approval (IRAS Project ID 281071) and recruitment commenced on 7 June 2021. Results will be disseminated in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN57339063.

"What are you carrying?" Experiences of mothers with preterm babies in low-resource setting neonatal intensive care unit: a qualitative study

INTRODUCTION

Babies born preterm often have challenges in feeding, temperature control and breathing difficulty and are prone to infection during the neonatal period. These usually necessitate admission to the neonatal intensive care unit (NICU). Admission to NICU disrupts the mother-baby bonding.

OBJECTIVE

This study explored the lived experiences of mothers with preterm babies admitted to NICU in a low-resource setting.

STUDY DESIGN

This was a qualitative study where 16 participants took part in indepth interviews and 35 in focus group discussions. We included mothers who delivered and were caring for preterm babies at the NICU of Mulago National Referral Hospital.

STUDY SETTING

Data were collected from a public hospital, which works as a district and national referral hospital located in the capital of Uganda.

PARTICIPANTS

Fifty-one mothers with preterm babies in the NICU were sampled and recruited after informed consent. Data were analysed using manual thematic analysis.

RESULTS

There were six themes on the experiences of mothers of preterm babies in NICU: constant worry and uncertainty about the survival of their babies, baby feeding challenges, worries of discharge, communication gaps between mothers and nurses, community acceptability and disdain for preterm babies, and financial challenges.

CONCLUSIONS AND RECOMMENDATIONS

Mothers of preterm babies admitted to NICU in a low-resource setting still need a lot of support other than the medical care given to their babies. Support groups in the hospital and community are recommended to help in dealing with these challenges.

In-hospital Growth of Very Low Birth Weight Preterm Infants: Comparative Effectiveness of 2 Human Milk Fortifiers

OBJECTIVE

Amidst a high prevalence of prematurity, limited research on the growth of very low birth weight (VLBW) preterm infants and the availability of a reformulated fortifier c(RF), the study aimed to compare in-hospital growth of such infants receiving exclusively human milk fortified with either of 2 different formulations in a tertiary South African hospital.

METHODS

In a prospective comparative effectiveness design, intakes and growth of VLBW infants on the Original Fortifier (OF; 2016-2017) were compared with those receiving RF (2017-2018). Daily intake was calculated using published composition of preterm and mature milk with fortifier (OF: 0.2 g protein, 3.5kcal/g powder; RF: 0.4 g protein, 4.4 kcal/g powder). Change in z scores from start to end of fortification for weight (WFAZ), length (LFAZ), and head circumference (HCFAZ) for age was the primary outcome. Additionally, weight gain velocity (g · kg-1 · day-1) and gain in length and head circumference (HC) (cm/week) were calculated.

RESULTS

Fifty-eight infants (52% girls; gestational age: 30 ± 2 weeks; birth weight: 1215 ± 187 g) received OF for 16 days and 59 infants (56% girls; gestational age: 29 ± 2 weeks; birth weight 1202 ± 167 g) received RF for 15 days. Protein intake of RF (3.7 ± 0.4 g · kg-1 · day-1) was significantly higher (P < 0.001) than of OF (3.4 ± 0.2 g · kg-1 · day-1). Protein-to-energy ratio of RF (2.6 ± 0.2 g/100 kcal) was significantly higher (P < 0.001) than of OF (2.3 ± 0.1 g/100 kcal). In both groups, WFAZ and LFAZ decreased; HCFAZ improved slightly. No significant differences (P > 0.05) were noted between the 2 groups for change in z scores, weight gain velocity, length or HC gain.

CONCLUSIONS

Despite a modest increase in protein intake and protein-to-energy ratio, the growth of VLBW infants on RF was not better than on OF during their hospital stay.

Troubling care in the neonatal intensive care unit

The neonatal intensive care unit (NICU) is a site of medical treatment for premature and critically ill infants. It is a space populated by medical teams and their patients, as well as parents and family. Each actor in this space negotiates providing and practicing care. In this paper, we step away from thinking about the NICU as only a space of medical care, instead, taking an anti-essentialist view, re-read care as multiple, while also troubling the community of care that undergirds it. Through an examination of the practice of kangaroo care (skin-to-skin holding), human milk production and feeding, as well as, practices related to contact/touch, we offer a portrait of the performance of the community of care in the space of the NICU. We argue that caring practices taking place in the NICU are multiple and co-produced, while simultaneously being subject to power and knowledge differentials between actors. Here we analyze the negotiations over the knowledge and practice of care(s) to open up the NICU as a particular community of care, and consider care as a both a joint accomplishment and a gatekeeping practice.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

OBJECTIVE

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge.

STUDY DESIGN

This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors.

RESULTS

Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits.

CONCLUSIONS

Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Macronutrient analysis of donor human milk labelled as 24 kcal/oz

OBJECTIVE

To measure the macronutrient content (MNC) of donor human milk labelled as 24 kcal/oz ("high-calorie DHM," hcDHM), compare to bank-labelled MNC, and examine variability of hcDHM MNC among milk banks.

STUDY DESIGN

MNC was measured with near-infrared spectroscopy for 75 convenience samples from five milk banks collected during September 2016-July 2017. Concordance of measured MNC with labelled values was evaluated using three different thresholds: within ±20%, similar to FDA labelling standards for class II nutrients in foods; ±10%; and ±5%.

RESULTS

Protein and caloric content differed significantly between measured and labelled values and varied significantly among milk banks. Measured caloric content ranged from 16.50 to 30.27 kcal/oz, with 89.3% of hcDHM samples within ±20%, 58.7% within ±10%, and 18.7% within ±5% of labelled content.

CONCLUSIONS

MNC of hcDHM used in clinical practice shows variation that may result in differences from desired diet. The clinical implications of such differences are unexplored.

Maternal Milk and Relationships to Early Neurobehavioral Outcome in Preterm Infants

The purpose of this study was to (1) define medical and sociodemographic factors related to maternal milk feedings and (2) explore relationships between maternal milk feeding and early neurobehavioral outcome. Ninety-two preterm infants born ≤ 32 weeks gestation had maternal milk feeding and breastfeeding tracked in this retrospective analysis. At 34 to 41 weeks postmenstrual age (PMA), neurobehavior was assessed with the NICU Network Neurobehavioral Scale. Maternal milk feeding was often delayed by the use of total parenteral nutrition, administered for a median of 11 (7-26) days, impacting the timing of gastric feeding initiation. Seventy-nine (86%) infants received some maternal milk during neonatal intensive care unit (NICU) hospitalization. Twenty-one (27%) infants continued to receive maternal milk at 34 to 41 weeks PMA, with 10 (48%) of those receiving maternal milk exclusively. Among mothers who initiated maternal milk feeds, 20 (25%) put their infants directly at the breast at least once during hospitalization. Mothers who were younger (P = .02), non-Caucasian (P < .001), or on public insurance (P < .001) were less likely to provide exclusive maternal milk feedings by 34 to 41 weeks PMA. Infants who received maternal milk at 34 to 41 weeks PMA demonstrated better orientation (P = .03), indicating they had better visual and auditory attention to people and objects in the environment. Our findings demonstrate a relationship between maternal milk feedings and better neurobehavior, which is evident before the infant is discharged home from the NICU.

Predictors of Mother's Own Milk Feeding at Discharge in Preterm Infants

BACKGROUND

The dose-response benefits of human milk for preterm infants are well documented. Understanding factors that influence duration of mother's own milk (MOM) receipt may have important clinical implications.

PURPOSE

To identify variables that significantly affect whether or not preterm infants receive their own mother's milk at discharge.

METHODS

Maternal-infant dyads were eligible for inclusion if the infant was born between August 1, 2010, and July 31, 2015, was born at 32 weeks' gestation or less, or was 1800 g or less (institutional donor milk receipt criteria). Bivariate and multivariable regression analyses were performed.

RESULTS

Of 428 observations, 258 (60.3%) received MOM at discharge and 170 (39.7%) did not. Maternal characteristics that were protective for MOM receipt at discharge were non-Hispanic race, married, partner support, more educated, and private insurance. Protective infant characteristics were higher gestational age at birth, higher percentage of MOM feedings, fewer ventilator days, and more days of direct lactation. In multivariable logistic regression, the odds of receiving MOM at discharge significantly (odds ratio = 1.93; 95% confidence interval, 1.72-2.16; P < .001) increased with the increasing proportion of MOM. Regression analysis showed that gestational age and increased maternal age increased the likelihood of MOM receipt at discharge.

IMPLICATIONS FOR PRACTICE

Clinicians will understand the significant effects even small increases in milk volume have on duration of MOM receipt at discharge, informing them of the importance of strategies to encourage and improve milk expression.

IMPLICATIONS FOR RESEARCH

Future research studying critical time periods when mothers are most likely to reduce milk expression may have significant clinical importance.

Randomized Controlled Trial of Oropharyngeal Colostrum Administration in Very-low-birth-weight Preterm Infants

OBJECTIVE

The purpose of this study was to evaluate the effects of oropharyngeal colostrum administration in the incidence of late-onset clinical and proven sepsis and in concentrations of immunoglobulin A (IgA) in very-low-birth-weight (VLBW) infants.

METHODS

We conducted a double-blinded, randomized, placebo-controlled trial and assigned 113 VLBW infants to receive 0.2 mL of maternal colostrum or sterile water (placebo) via oropharyngeal route every 2 hours for 48 hours, beginning in the first 48 to 72 hours of life. Neonates of both groups were fed breast milk from the first 3 days of life until a volume of at least 100 mL · kg · day. IgA was measured in serum and urine before and after treatment. Clinical data during hospitalization were collected.

RESULTS

We found no statistically significant differences between colostrum and placebo groups in the incidence of late-onset clinical sepsis (odds ratio 0.7602; CI 95% 0.3-1.6) and proven sepsis (odds ratio 0.7028; CI 95% 0.3-1.6). The measurement of IgA was similar in serum before (P value 0.87) and after treatment (P value 0.26 day 4 and 0.77 day 18). No differences were also observed in IgA in urine before (P value 0.8) and after treatment (P value 0.73 day 4 and 0.52).

CONCLUSIONS

This study could not confirm the hypothesis that oropharyngeal administration of maternal colostrum to VLBW could reduce the incidence of late-onset sepsis and increase the levels of IgA. We believe that this finding can be justified by the practice of feeding VLBW infants exclusively with breast milk in the first days of life and reinforces the prior knowledge of the importance of early nutrition, especially, with human milk. It also suggests that oropharyngeal administration of colostrum should be reserved for neonates who cannot be fed in first few days of life.

Factors affecting body composition in preterm infants: Assessment techniques and nutritional interventions

Limited research has been conducted that elucidates the growth and body composition of preterm infants. It is known that these infants do not necessarily achieve extra-utero growth rates and body composition similar to those of their term counterparts. Preterm infants, who have difficulty in achieving these growth rates, could suffer from growth failure. These infants display an increased intra-abdominal adiposity and abnormal body composition when they achieve catch-up growth. These factors affect the quality of weight gain, as these infants are not only shorter and lighter than term infants, they also have more fat mass (FM) and less fat-free mass (FFM), resulting in a higher total fat percentage. This could cause metabolic syndrome and cardiovascular problems to develop later in a preterm infant's life. The methods used to determine body composition in preterm infants should be simple, quick, non-invasive and inexpensive. Available literature was reviewed and the Dauncey anthropometric model, which includes skinfold thickness at two primary sites and nine body dimensions, is considered in this review the best method to accurately determine body composition in preterm infants, especially in resource-poor countries. It is imperative to accurately assess the quality of growth and body composition of this fragile population in order to determine whether currently prescribed nutritional interventions are beneficial to the overall nutritional status and quality of life-in the short- and long-term-of the preterm infant, and to enable timely implementation of appropriate interventions, if required.

Feeding Intervals in Premature Infants ≤1750 g: An Integrative Review

BACKGROUND

The timely establishment of enteral feeds and a reduction in the number of feeding interruptions are key to achieving optimal nutrition in premature infants. Nutritional guidelines vary widely regarding feeding regimens and there is not a widely accepted consensus on the optimal feeding interval.

PURPOSE

To critically examine the evidence to determine whether there is a relationship to feeding intervals and feeding outcomes in premature infants.

METHODS

A systematic review of the literature in the following databases: PubMed, CINAHL, Embase and the Cochrane Library. The search strategy used the terms infant premature, low birth weight, enteral feeding, feed tolerance and feed intervals.

RESULTS

Search results yielded 10 studies involving 1269 infants (birth weight ≤1750 g). No significant differences in feed intolerance, growth, or incidence of necrotizing enterocolitis were observed. Evidence suggests that infants fed at 2 hourly intervals reached full feeds faster than at 3 hourly intervals, had fewer days on parenteral nutrition, and fewer days in which feedings were withheld. Decrease in the volume of gastric residuals and feeding interruptions were observed in the infants fed at 3 hourly intervals than those who were continuously fed.

IMPLICATIONS FOR PRACTICE

Reducing the feed interval from 3 to 2 hourly increases nurse workload, yet may improve feeding outcomes by reducing the time to achieve full enteral feeding.

IMPLICATIONS FOR RESEARCH

Studies varied greatly in the definition and management of feeding intolerance and in how outcomes were measured, analyzed, and reported. The term "intermittent" is used widely but can refer to a 2 or 3 hourly interval.

Human milk peptides differentiate between the preterm and term infant and across varying lactational stages

Variations in endogenous peptide profiles, functionality, and the enzymes responsible for the formation of these peptides in human milk are understudied. Additionally, there is a lack of knowledge regarding peptides in donor human milk, which is used to feed preterm infants when mother's own milk is not (sufficiently) available. To assess this, 29 human milk samples from the Dutch Human Milk Bank were analyzed as three groups, preterm late lactation stage (LS) (n = 12), term early (n = 8) and term late LS (n = 9). Gestational age (GA) groups were defined as preterm (24-36 weeks) and term (≥37 weeks). LS was determined as days postpartum as early (16-36 days) or late (55-88 days). Peptides, analyzed by LC-MS/MS, and parent proteins (proteins from matched peptide sequences) were identified and quantified, after which peptide functionality and the enzymes responsible for protein cleavage were determined. A total of 16 different parent proteins were identified from human milk, with no differences by GA or LS. We identified 1104 endogenous peptides, of which, the majority were from the parent proteins β-casein, polymeric immunoglobulin receptor, α_s1-casein, osteopontin, and κ-casein. The absolute number of peptides differed by GA and LS with 30 and 41 differing sequences respectively (p < 0.05) Odds likelihood tests determined that 32 peptides had a predicted bioactive functionality, with no significant differences between groups. Enzyme prediction analysis showed that plasmin/trypsin enzymes most likely cleaved the identified human milk peptides. These results explain some of the variation in endogenous peptides in human milk, leading to future targets that may be studied for functionality.

Composition and Variation of Macronutrients, Immune Proteins, and Human Milk Oligosaccharides in Human Milk From Nonprofit and Commercial Milk Banks

BACKGROUND

When human milk is unavailable, banked milk is recommended for feeding premature infants. Milk banks use processes to eliminate pathogens; however, variability among methods exists. Research aim: The aim of this study was to compare the macronutrient (protein, carbohydrate, fat, energy), immune-protective protein, and human milk oligosaccharide (HMO) content of human milk from three independent milk banks that use pasteurization (Holder vs. vat techniques) or retort sterilization.

METHODS

Randomly acquired human milk samples from three different milk banks ( n = 3 from each bank) were analyzed for macronutrient concentrations using a Fourier transform mid-infrared spectroscopy human milk analyzer. The concentrations of IgA, IgM, IgG, lactoferrin, lysozyme, α-lactalbumin, α antitrypsin, casein, and HMO were analyzed by mass spectrometry.

RESULTS

The concentrations of protein and fat were significantly ( p < .05) less in the retort sterilized compared with the Holder and vat pasteurized samples, respectively. The concentrations of all immune-modulating proteins were significantly ( p < .05) less in the retort sterilized samples compared with vat and/or Holder pasteurized samples. The total HMO concentration and HMOs containing fucose, sialic acid, and nonfucosylated neutral sugars were significantly ( p < .05) less in retort sterilized compared with Holder pasteurized samples.

CONCLUSION

Random milk samples that had undergone retort sterilization had significantly less immune-protective proteins and total and specific HMOs compared with samples that had undergone Holder and vat pasteurization. These data suggest that further analysis of the effect of retort sterilization on human milk components is needed prior to widespread adoption of this process.

Maternal Mental Health and Neonatal Intensive Care Unit Discharge Readiness in Mothers of Preterm Infants

OBJECTIVE

To evaluate associations between maternal mental health disorders (MHDs) and discharge readiness for mothers of infants born preterm (<37 weeks). We hypothesized that mothers with a history of MHDs would report decreased perceptions of neonatal intensive care unit (NICU) discharge readiness compared with mothers without a history.

STUDY DESIGN

Mothers of infants born preterm in the NICU >5 days between 2012 and 2015 and participating in a transition home program completed a discharge readiness questionnaire measuring perceptions of staff support, infant well-being (medical stability), maternal well-being (emotional readiness/competency), and maternal comfort (worry about infant). Greater scores are more optimal (range 0-100). Social workers obtained a history of MHDs. Group comparisons and regression analyses were run to predict decreased scores and maternal discharge readiness.

RESULTS

A total of 37% (315/850) of mothers reported a MHD. They were more likely to be white (64% vs 55% P = .05), single (64% vs 45% P ≤ .001), on Medicaid (61% vs 50% P = .002), and less likely to be non-English speaking (10% vs 22%, P  ≤ .001). Mothers with MHD perceived less NICU support (92 ± 13 vs 94 ± 12, P = .005), less emotional readiness for discharge (78 ± 17 vs 81 ± 14, P = .04), and lower family cohesion (81 ± 24 vs 86 ± 19, P = .02) compared with mothers without MHD. Regression modeling (OR; CI) indicated that maternal history of MHDs predicted mother's decreased perception of infant well-being (1.56; 1.05-2.33) and her own well-being (1.99; 1.45-2.8) at discharge.

CONCLUSION

One-third of mothers reported a history of MHDs. This vulnerable group perceive themselves as less ready for discharge home with their infant, indicating an unmet need for provision of enhanced transition services.

Lactational Stage of Pasteurized Human Donor Milk Contributes to Nutrient Limitations for Infants

BACKGROUND

Mother's own milk is the first choice for feeding preterm infants, but when not available, pasteurized human donor milk (PDM) is often used. Infants fed PDM have difficulties maintaining appropriate growth velocities. To assess the most basic elements of nutrition, we tested the hypotheses that fatty acid and amino acid composition of PDM is highly variable and standard pooling practices attenuate variability; however, total nutrients may be limiting without supplementation due to late lactational stage of the milk.

METHODS

A prospective cross-sectional sampling of milk was obtained from five donor milk banks located in Ohio, Michigan, Colorado, Texas-Ft Worth, and California. Milk samples were collected after Institutional Review Board (#07-0035) approval and informed consent. Fatty acid and amino acid contents were measured in milk from individual donors and donor pools (pooled per Human Milk Banking Association of North America guidelines). Statistical comparisons were performed using Kruskal-Wallis, Spearman's, or Multivariate Regression analyses with center as the fixed factor and lactational stage as co-variate.

RESULTS

Ten of the fourteen fatty acids and seventeen of the nineteen amino acids analyzed differed across Banks in the individual milk samples. Pooling minimized these differences in amino acid and fatty acid contents. Concentrations of lysine and docosahexaenoic acid (DHA) were not different across Banks, but concentrations were low compared to recommended levels.

CONCLUSIONS

Individual donor milk fatty acid and amino acid contents are highly variable. Standardized pooling practice reduces this variability. Lysine and DHA concentrations were consistently low across geographic regions in North America due to lactational stage of the milk, and thus not adequately addressed by pooling. Targeted supplementation is needed to optimize PDM, especially for the preterm or volume restricted infant.

Human milk is the feeding strategy to prevent necrotizing enterocolitis!

Human milk is the preferred diet for preterm infants as it protects against a multitude of NICU challenges, specifically necrotizing enterocolitis. Infants who receive greater than 50% of mother's own milk (MOM) in the 2 weeks after birth have a significantly decreased risk of NEC. An additional factor in the recent declining rates of NEC is the increased utilization of donor human milk (DHM). This creates a bridge until MOM is readily available, thus decreasing the exposure to cow milk protein. Preterm infants are susceptible to NEC due to the immaturity of their gastrointestinal and immune systems. An exclusive human milk diet compensates for these immature systems in many ways such as lowering gastric pH, enhancing intestinal motility, decreasing epithelial permeability, and altering the composition of bacterial flora. Ideally, preterm infants should be fed human milk and avoid bovine protein. A diet consisting of human milk-based human milk fortifier is one way to provide the additional nutritional supplements necessary for adequate growth while receiving the protective benefits of a human milk diet.

Changes in the Immune Components of Preterm Human Milk and Associations With Maternal and Infant Characteristics

OBJECTIVE

To describe difference in cytokines, chemokines, and growth factors (CCGFs) and secretory immunoglobulin A (sIgA) in the breast milk of mothers who gave birth preterm and maternal or infant characteristics related to these immune components.

DESIGN

A prospective, repeated-measures, one-group design.

SETTING

Data were collected at an 82-bed NICU in West Central Florida.

PARTICIPANTS

Seventy-six very-low-birth-weight infants weighing less than 1,500 g and their mothers.

METHODS

Daily aliquots of breast milk from mothers of preterm infants were collected from the daily infants' feedings and pooled at the end of each week, and CCGFs and sIgA were measured weekly with MagPix multiplexing (Luminex, Austin, TX) and enzyme-linked immunosorbent assay.

RESULTS

The CCGFs showed high individual variability, but the levels of most CCGFs and sIgA fell over time. Immune variables were generally greater in milk from mothers of infants smaller than 1,000 g. The breast milk of mothers of male preterm infants had significantly greater sIgA than the breast milk of mothers of female preterm infants. We found relationships between age, body mass index, parity, sIgA, and some of the CCGFs in the breast milk of women who gave birth preterm.

CONCLUSION

Immune molecules declined in concentration over time in the breast milk of mothers who give birth preterm during the NICU stay, and maternal and infant factors appeared to play some role in the levels of these immune molecules. Further exploration of this relationship is warranted.

Implementation of a Donor Milk Program Is Associated with Greater Consumption of Mothers' Own Milk among VLBW Infants in a US, Level 3 NICU

BACKGROUND

It is unclear whether use of donor milk (DM) changes the provision of mothers' own milk (MOM) to very low birth weight (VLBW) infants in the neonatal intensive care unit (NICU).

OBJECTIVES

To determine whether (1) the rates of any MOM and human milk consumption at feeding initiation and discharge and (2) the proportion of VLBW infants who stopped consuming any MOM and human milk during hospitalization changed in the 2 years after versus before implementation of a DM program in a US, inner-city, level 3 NICU.

METHODS

We studied VLBW infants admitted to Boston Medical Center in the 2 years before (n = 74) and after (n = 80) implementation of a DM program (June 2011). We used multivariable logistic regression to compare milk consumption at feeding initiation and discharge and Cox proportional hazards to compare the proportion of infants that stopped consuming milk during the hospitalization pre and post our DM program.

RESULTS

After adjustment for maternal race, age, insurance, delivery type, gestational age, and birth weight, we found a 6.0-fold increased odds (95% CI, 2.0-17.7) of consuming MOM at discharge and a 49% reduction in the cessation of MOM consumption during hospitalization (hazard ratio [HR], 0.51; 95% CI, 0.28-0.93) in the 2 years after versus before our DM program.

CONCLUSION

Implementation of a DM program was associated with greater consumption of MOM throughout hospitalization and at discharge among VLBW infants. Implementation of DM programs may augment support of mothers to provide breast milk in level 3 NICUs.

When has enough evidence accumulated to change neonatal practice?

Randomized clinical trials are the best method to assess the safety and efficacy of therapeutic interventions. However, it is not always clear how much evidence from randomized trials is required to change clinical practice. Throughout the history of neonatal medicine, some therapies were subject to excessive and unnecessary testing through replication of clinical trials. Other therapies were adopted into clinical practice with insufficient evidence. In only a few cases was the right amount of evidence accumulated to drive a change in practice. Here we present a case history for each of these three scenarios. Arising from these, we suggest principles to identify when enough evidence exists for a therapy to become standard practice.

Human Milk Warming Temperatures Using a Simulation of Currently Available Storage and Warming Methods

Human milk handling guidelines are very demanding, based upon solid scientific evidence that handling methods can make a real difference in infant health and nutrition. Indeed, properly stored milk maintains many of its unique qualities and continues to be the second and third best infant feeding alternatives, much superior to artificial feeding. Container type and shape, mode of steering, amount of air exposure and storage temperature may adversely affect milk stability and composition. Heating above physiological temperatures significantly impacts nutritional and immunological properties of milk. In spite of this knowledge, there are no strict guidelines regarding milk warming. Human milk is often heated in electrical-based bottle warmers that can exceed 80°C, a temperature at which many beneficial human milk properties disappear. High temperatures can also induce fat profile variations as compared with fresh human milk. In this manuscript we estimate the amount of damage due to overheating during warming using a heat flow simulation of a regular water based bottle warmer. To do so, we carried out a series of warming simulations which provided us with dynamic temperature fields within bottled milk. We simulated the use of a hot water-bath at 80°C to heat bottled refrigerated milk (60 ml and 178 ml) to demonstrate that large milk portions are overheated (above 40°C). It seems that the contemporary storage method (upright feeding tool, i.e. bottle) and bottle warming device, are not optimize to preserve the unique properties of human milk. Health workers and parents should be aware of this problem especially when it relates to sick neonates and preemies that cannot be directly fed at the breast.

Predictors of sustained maternal milk feeds in extremely preterm infants

OBJECTIVE

To investigate the predictors of maternal milk feeds (MMFs) in extremely preterm (EPT) infants during neonatal stay.

STUDY DESIGN

Maternal characteristics, obstetrical data and infant characteristics were correlated to MMFs in 97 EPT infants during the first 6 weeks of life and at hospital discharge.

RESULT

High MMFs (>90%) at second week predicted sustained MMFs the first 6 weeks of life; nonuniversity education and non-Nordic origin were unfavorable predictors. The proportion of MMFs the first 6 weeks of life and maternal age were positively associated with MMFs at discharge, whereas overweight was an unfavorable predictor. High MMFs at second week, assisted reproduction technology and employment were predictive factors for exclusive MMFs at discharge.

CONCLUSION

High MMFs at week 2 promote sustained MMFs in EPT infants and exclusive MMFs at discharge. Mothers who are either young, overweight, non-Nordic or without university education may need special interventions to establish successful lactation.

Administration of Bifidobacterium breve PS12929 and Lactobacillus salivarius PS12934, two strains isolated from human milk, to very low and extremely low birth weight preterm infants: a pilot study

The preterm infant gut has been described as immature and colonized by an aberrant microbiota. Therefore, the use of probiotics is an attractive practice in hospitals to try to reduce morbidity and mortality in this population. The objective of this pilot study was to elucidate if administration of two probiotic strains isolated from human milk to preterm infants led to their presence in feces. In addition, the evolution of a wide spectrum of immunological compounds, including the inflammatory biomarker calprotectin, in both blood and fecal samples was also assessed. For this purpose, five preterm infants received two daily doses (~10⁹ CFU) of a 1 : 1 mixture of Bifidobacterium breve PS12929 and Lactobacillus salivarius PS12934. Bacterial growth was detected by culture-dependent techniques in all the fecal samples. The phylum Firmicutes dominated in nearly all fecal samples while L. salivarius PS12934 was detected in all the infants at numerous sample collection points and B. breve PS12929 appeared in five fecal samples. Finally, a noticeable decrease in the fecal calprotectin levels was observed along time.

A milk pump as a source for spreading Acinetobacter baumannii in a neonatal intensive care unit

Acinetobacter baumannii is a Gram-negative coccobacillus that has emerged as a troublesome pathogen causing institutional outbreaks. Environmental contamination is a distinctive characteristic of this microorganism, which brings a further difficulty in infection control. During A. baumannii outbreaks in intensive care units, a common contaminated object can be found as a reservoir. Finding out this source by epidemiological investigations is of particular importance in order to develop effective interventions. We describe an outbreak of A. baumannii and the results of epidemiological investigations in a neonatal intensive care unit. The outbreak strain was isolated from the outer surface of a breastmilk pump. We have successfully controlled the outbreak by careful reviewing of our milk collection process.

Predictors of low milk volume among mothers who delivered preterm

BACKGROUND

Factors associated with successful provision of mother's own milk (MOM) for premature infants in a Japanese neonatal intensive care unit (NICU) context are not well known.

OBJECTIVE

We determined the independent risk factors for low milk volume at day 4 postpartum and formula feeding at the time of NICU discharge.

METHODS

We reviewed the medical records of mothers who delivered at < 32 weeks' gestation. We determined maternal, premature infant, and milk expression variables predictive of (1) day 4 postpartum milk volume being less than the cohort median and (2) formula feeding at the time of NICU discharge, reported as adjusted odds ratios (95% confidence interval).

RESULTS

Among 85 dyads, median (quartile range) milk volume on day 4 postpartum was 153 (34-255) mL. The rate of formula feeding at discharge was 42%. Mothers delivering by cesarean (vs vaginal) delivery had 4.3-fold (1.5-12.4) greater odds of day 4 milk volume < median (P < .01). Pregnancy-induced hypertension, delayed milk expression initiation, and low pumping frequency were strongly associated with cesarean delivery. Subsequently, mothers with day 4 milk volume < median (vs ≥ median) had 7.1-fold (2.6-19.5) greater odds of formula feeding at discharge (P < .01).

CONCLUSION

Cesarean delivery is associated with lower milk volume on day 4 but may represent a composite of underlying risk factors for low milk volume in the early postpartum period. Further, low milk volume on day 4 is a strong correlate of lack of exclusive breast milk feeding at NICU discharge.