Outcomes improved with human milk intake in preterm and full-term infants

Association of Enteral Feed Type with Neurodevelopmental and Neonatal Outcomes among Infants Born Preterm

OBJECTIVE

To examine associations between enteral feed type with neurodevelopmental and neonatal outcomes among infants born preterm.

STUDY DESIGN

This was a retrospective study of enteral feeds in the first 28 postnatal days in infants born <29 weeks of gestation from 2015 through 2020 in neonatal units of the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network. Feeds were examined as a compositional variable comprised of the proportion of days fed mother's milk, donor milk, mixed feeds, and nil per os (NPO), the proportions of which sum to 1. Associations between enteral feed type with neurodevelopmental outcomes at 18 to 24 months of corrected age and neonatal morbidities were examined.

RESULTS

Our cohort included 2104 infants with a mean (SD) gestational age of 26.2 (1.5) weeks (52.9% male). Compositional data analysis revealed a 1-day reallocation from mother's milk to donor milk was associated with greater odds of cognitive (aOR 1.028, 95% CI 1.001-1.056) and language impairment (aOR 1.024, 95% CI 1.002-1.047). Replacing 1 day of mixed feeds, donor milk or NPO with mother's milk was associated with improved cognitive, language and motor development. A 1-day reallocation of NPO to either mother's milk, mixed feeds or donor milk decreased odds of significant neurodevelopmental impairment, cerebral palsy and/or necrotizing enterocolitis.

CONCLUSIONS

Donor milk in place of mother's milk was associated with poorer cognitive and language development. Providing any human milk reduced neurodevelopmental impairment and necrotizing enterocolitis with reallocations involving mother's milk yielding the most benefit. Promoting early enteral nutrition with mother's milk should be a priority in the care of infants born preterm.

Historical Perspectives and the Road to Current Breakthroughs in Human Milk Research

Human milk (HM) research has its origins in the early 20th century, emerging from the field of dairy science. Early pioneers such as Drs. David Forsyth, Lucy Naish, and Disney Cran were among the first to formally study HM, building on centuries of recognition of its importance. Clinicians such as Dr. Ruth A. Lawrence, a true "giant" in the field, played a pivotal role in translating HM research into medical education and clinical practice. This commentary highlights the milestones, key contributors, technical advancements, and future directions of HM research, tracing its journey from modest beginnings to its establishment as a rapidly evolving scientific discipline.

Adjusted versus Targeted Fortification in Extremely Low Birth Weight Preterm Infants: Fortin Study-A Randomized Clinical Trial

Fortified human milk is the first choice for preterm infants. Although individualized fortification is recommended, the optimal method for this population remains uncertain. We conducted a comparative study assessing the growth effects of adjusted (AF) and targeted fortification (TF) in extremely low birth weight (ELBW) infants. This single-center, randomized, controlled clinical trial was conducted at a tertiary neonatal unit in Spain. Eligible participants were premature infants with a birthweight of <1000 g exclusively fed with human milk. A total of 38 patients were enrolled, 15 of them randomized to AF group and 23 to TF group. AF was based on blood urea nitrogen (BUN) concentration and TF on human milk analysis. The primary outcome was weight gain velocity (g/kg/day). No significant differences were found in weight gain velocity at 28 days, at 36 weeks of postmenstrual age, at discharge, nor during the intervention. Protein intake was significantly higher in the AF group (5.02 g/kg/day vs. 4.48 g/kg/day, p = 0.001). No differences were found in the lipid, carbohydrate, and energy intake; in the weight z score change between the different time points; nor in the length and head circumference growth. Both AF and TF are comparable methods of fortification and provide the appropriate growth rate in ELBW infants.

Multi-prong quality improvement approach for increasing mother's own milk use for very low birth weight infants

OBJECTIVE

Evaluate a single center quality improvement (QI) collaborative designed to increase the provision of mother's own milk (MOM) at discharge to premature infants through evidence-based practices while targeting perinatal health disparities.

DESIGN

This QI initiative was designed for preterm infants admitted to a single-center NICU within 24 h of life. Interventions were implemented between March 2022 and June 2022. MOM provision rates were compared between baseline (August 2021-February 2022), and after interventions (March 2022-December 2022).

RESULTS

The percentage of mothers who discontinued pumping during the infant hospitalization decreased from 49% to 35% (p < 0.01). Infant discharge diet with MOM improved from 36% to 58% (p < 0.001). Pump frequency at two weeks increased from 4.0 ± 2.6 to 5.1 ± 2.4 (p = 0.026).

CONCLUSION

Our collaborative increased the percentage of preterm infants receiving MOM at discharge and reduced the number of mothers who discontinue pumping during the NICU hospitalization.

Development of an exclusive breastfeeding intervention based on the theory of planned behavior for mothers with preterm infants: Study protocol for a mixed methods study

BACKGROUND

Despite the significance and benefits of exclusive breastfeeding, its rate among infants, especially preterm infants, is not optimal. Based on evidence, the mother's attitude toward breastfeeding, the subjective norm, and the mother's perceived behavioral control play a role in initiation and continuation of breastfeeding; so the interventions that consider these factors may be useful for breastfeeding premature infants. The aim of this study is to design and develop an exclusive breastfeeding intervention based on the theory of planned behavior for mothers with preterm infants.

MATERIALS AND METHODS

This exploratory, sequential, mixed methods study will be conducted in three phases. In the first phase, a qualitative study will be conducted based on the theory of planed behavior, to describe the exclusive breastfeeding beliefs of the mothers with preterm infants, the barriers to breastfeeding, and to explain the ways to overcome them. Moreover, the items of the Predictors Of Exclusive Breastfeeding Questionnaire are prepared based on the theory of planned behavior. In the second phase, the intervention plan is designed based on the literature review and the findings of the qualitative study, and it is approved by a panel of experts. Additionally, the psychometric properties of the questionnaire are evaluated and confirmed qualitatively and quantitatively. In the third phase, the developed intervention is implemented and evaluated.

CONCLUSION

Implementation of supportive educational interventions based on scientific theories can be a step toward improving the rate of onset and continuation of breastfeeding in mothers with preterm infants. Development of interventions based on evidence, identified beliefs, and perceived barriers of the mothers with preterm infants can provide the foundation for more effective interventions according to cultural, social, and religious contexts.

Potential Epigenetic Effects of Human Milk on Infants' Neurodevelopment

The advantages of human milk feeding, especially in preterm babies, are well recognized. Infants' feeding with breast milk lowers the likelihood of developing a diverse range of non-communicable diseases later in life and it is also associated with improved neurodevelopmental outcomes. Although the precise mechanisms through which human milk feeding is linked with infants' neurodevelopment are still unknown, potential epigenetic effects of breast milk through its bioactive components, including non-coding RNAs, stem cells and microbiome, could at least partly explain this association. Micro- and long-non-coding RNAs, enclosed in milk exosomes, as well as breast milk stem cells, survive digestion, reach the circulation and can cross the blood-brain barrier. Certain non-coding RNAs potentially regulate genes implicated in brain development and function, whereas nestin-positive stem cells can possibly differentiate into neural cells or/and act as epigenetic regulators in the brain. Furthermore, breast milk microbiota contributes to the establishment of infant's gut microbiome, which is implicated in brain development via epigenetic modifications and key molecules' regulation. This narrative review provides an updated analysis of the relationship between breast milk feeding and infants' neurodevelopment via epigenetics, pointing out how breast milk's bioactive components could have an impact on the neurodevelopment of both full-term and preterm babies.

Medicaid and newborn care: challenges and opportunities

Since its creation in 1965, Medicaid has operated as a federal-state partnership that provides a robust set of medical benefits to low-income families, including pregnant people and infants. In many ways, Medicaid has met its initial promise. However, medical benefits, provider payments, and key administrative procedures regarding eligibility, enrollment, and access to care vary substantially among state Medicaid programs. These variations have created profound inequities across states in the care of parents and children, particularly during pregnancy and in the postpartum and neonatal periods. Here we review select aspects of the Medicaid program pertinent to newborns and infants that contribute to eligibility and enrollment gaps, variations in benefits coverage and payment rates, and racial disparities in both access to healthcare and infant health outcomes. We outline a number of structural reforms of the Medicaid program that can improve newborn and infant access to care and outcomes and redress existing inequities.

Skin to Skin Contact Correlated with Improved Production and Consumption of Mother's Own Milk

Background: Human milk diet, preferably mother's own milk (MOM) over donor milk (DM), is recommended for preterm infants. Expression of MOM in proximity to preterm infants, especially during or immediately after skin-to-skin contact (SSC), is associated with greater milk production. However, the correlation between SSC and MOM production during hospital admission in preterm infants has not yet been studied. Our study investigated the relationship between SSC and MOM production and consumption in preterm infants during the first postnatal month of life. Materials and Methods: This was a prospective cohort study. Mothers and their preterm infants born at <35 weeks by gestational age (GA) and eligible for SSC within the first 5 postnatal days were eligible for the study. Mothers were given a binder to document pumped breast milk volumes and SSC sessions. Pumped breast milk volumes, enteral feeding type and volume, and SSC duration and frequency were collected daily over the first 28 days of life, along with demographic, perinatal, and feeding data from electronic medical records (EMR). Results: Mean birth GA and weight were 30 ± 3 weeks and 1,443 ± 576 g, respectively. SSC duration was inversely correlated with GA and weight. The SSC duration was positively correlated with ingested MOM volume after correcting for birth GA. The SSC duration was predictive of increased volumes of pumped MOM. Conclusion: Our findings suggest that SSC duration is associated with improved MOM production and consumption. SSC can be a useful tool to increase MOM exposure and improve long-term health outcomes in preterm infants.

The influence of nutrition on white matter development in preterm infants: a scoping review

White matter (WM) injury is the most common type of brain injury in preterm infants and is associated with impaired neurodevelopmental outcome (NDO). Currently, there are no treatments for WM injury, but optimal nutrition during early preterm life may support WM development. The main aim of this scoping review was to assess the influence of early postnatal nutrition on WM development in preterm infants. Searches were performed in PubMed, EMBASE, and COCHRANE on September 2022. Inclusion criteria were assessment of preterm infants, nutritional intake before 1 month corrected age, and WM outcome. Methods were congruent with the PRISMA-ScR checklist. Thirty-two articles were included. Negative associations were found between longer parenteral feeding duration and WM development, although likely confounded by illness. Positive associations between macronutrient, energy, and human milk intake and WM development were common, especially when fed enterally. Results on fatty acid and glutamine supplementation remained inconclusive. Significant associations were most often detected at the microstructural level using diffusion magnetic resonance imaging. Optimizing postnatal nutrition can positively influence WM development and subsequent NDO in preterm infants, but more controlled intervention studies using quantitative neuroimaging are needed. IMPACT: White matter brain injury is common in preterm infants and associated with impaired neurodevelopmental outcome. Optimizing postnatal nutrition can positively influence white matter development and subsequent neurodevelopmental outcome in preterm infants. More studies are needed, using quantitative neuroimaging techniques and interventional designs controlling for confounders, to define optimal nutritional intakes in preterm infants.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

Human Breast Milk: The Key Role in the Maturation of Immune, Gastrointestinal and Central Nervous Systems: A Narrative Review

Premature birth is a major cause of mortality and morbidity in the pediatric population. Because their immune, gastrointestinal and nervous systems are not fully developed, preterm infants (<37 weeks of gestation) and especially very preterm infants (VPIs, <32 weeks of gestation) are more prone to infectious diseases, tissue damage and future neurodevelopmental impairment. The aim of this narrative review is to report the immaturity of VPI systems and examine the role of Human Breast Milk (HBM) in their development and protection against infectious diseases, inflammation and tissue damage. For this purpose, we searched and synthesized the data from the existing literature published in the English language. Studies revealed the significance of HBM and indicate HBM as the best dietary choice for VPIs.

Human Milk Extracellular Vesicles: A Biological System with Clinical Implications

The consumption of human milk by a breastfeeding infant is associated with positive health outcomes, including lower risk of diarrheal disease, respiratory disease, otitis media, and in later life, less risk of chronic disease. These benefits may be mediated by antibodies, glycoproteins, glycolipids, oligosaccharides, and leukocytes. More recently, human milk extracellular vesicles (hMEVs) have been identified. HMEVs contain functional cargos, i.e., miRNAs and proteins, that may transmit information from the mother to promote infant growth and development. Maternal health conditions can influence hMEV composition. This review summarizes hMEV biogenesis and functional contents, reviews the functional evidence of hMEVs in the maternal–infant health relationship, and discusses challenges and opportunities in hMEV research.

Free Fatty Acid and α-Lactalbumin-Oleic Acid Complexes in Preterm Human Milk Are Cytotoxic to Fetal Intestinal Cells in vitro

Human milk, the best enteral selection for a preterm infant, becomes altered during freezing and soluble free fatty acid is generated over time. Free fatty acids may form complexes, such as the oleic acid-bound protein called HAMLET (human α-lactalbumin made lethal to tumor cells). We determined the in vitro biological activity of preterm human milk protein-oleic complexes (HAMLET-like complexes) and tested the hypothesis that laboratory-synthesized HAMLET exhibits cytotoxicity in human immature epithelial intestinal cell culture. Thirty-four milk samples from 15 mothers of hospitalized preterm infants were donated over time. Milk fractions were tested repeatedly for FHs 74 Int and HIEC-6 fetal cell cytotoxicity, using a sensitive viability assay. Protein and fatty acid identities were confirmed by Western blot, high performance liquid chromatography, and mass spectrometry. Cytotoxicity of intestinal cells exposed to milk increased respective to milk storage time (p < 0.001) and was associated with free oleic acid (p = 0.009). Synthesized HAMLET was cytotoxic in cultures of both lines. Preterm milk samples killed most cells in culture after an average 54 days in frozen storage (95% C.I. 34–72 days). After prolonged storage time, preterm milk and HAMLET showed a degree of cytotoxicity to immature intestinal cells in culture.

DHA Supplementation Attenuates Inflammation-Associated Gene Expression in the Mammary Gland of Lactating Mothers Who Deliver Preterm

BACKGROUND

In a randomized trial of DHA supplementation to lactating mothers who delivered preterm, there were significant increases in DHA status in the mother and her infant.

OBJECTIVES

Our objective here was to characterize the mammary gland transcriptomes from the above study. We hypothesized that proinflammatory gene expression would be attenuated in the increased DHA group compared with the standard DHA group.

METHODS

In the original trial, mothers delivering at <29 wk gestation at the University of Cincinnati Medical Center and intending to express their milk were randomly assigned to supplementation with 200 mg/d DHA (standard group: STD) or 1000 mg/d DHA (experimental group: EXP) within 7 d of delivery. Here, we conducted RNA-seq transcriptome analysis of n = 5 EXP and n = 4 STD extracellular mammary mRNA samples extracted from the fat layer of milk samples obtained 4 wk postenrollment. Transcripts were assessed for differential expression (false discovery rate adjusted P value <0.05) and clustering between EXP compared with STD groups. Ontological analysis of all differentially expressed genes (DEGs) was performed with Toppcluster.

RESULTS

There were 409 DEGs. We observed 5 main groups of biological processes that were upregulated, including those associated with improved immune regulation and management of oxidative stress; and 3 main groups of biological processes that were downregulated, including 1 associated with immune dysregulation. For example, we observed upregulation of inflammation-inhibiting genes including NFKB inhibitor alpha (NFKBIA; fold-change (FC), adjusted P value: FC = 1.70, P = 0.007) and interleukin-18 binding protein (IL18BP: FC = 2.2, adjusted P = 0.02); and downregulation of proinflammatory genes including interleukin 7 receptor (IL7R: FC = -1.9, adjusted P = 0.02) and interleukin 1 receptor like 1 (IL1RL1: FC = -13.0, adjusted P = 0.02).

CONCLUSIONS

Increased DHA supplementation during lactation can modulate the expression of inflammation-related genes within the mammary gland. This might translate to milk composition with a more optimal inflammasome profile. Future research with a larger clinical trial and greater interrogation of clinical outcomes is warranted.

Enteral Nutrition: The Intricacies of Human Milk from the Immune System to the Microbiome

In 2012, the American Academy of Pediatrics stated that all preterm infant diets should consist of human milk (mother's own milk or pasteurized donor human milk). The clinical reasons supporting this policy are many, including reducing infections and retinopathy of prematurity, decreased neonatal intensive care unit length of stay, subsequent readmissions, a decrease in mortality, and improved neurodevelopmental outcomes. This article focuses on human milk, its composition and bioactive factors, and how it affects the gut-brain axis through the microbiome. We examine how differences between mother's own milk and pasteurized donor human milk affect the premature infant.

Identifying single-strain growth patterns of human gut microbes in response to preterm human milk and formula

The intestinal microbiota of the preterm neonate has become a major research focus, with evidence emerging that the microbiota influences both short and long-term health outcomes, in the neonatal intensive care unit and beyond. Similar to the term microbiome, the preterm gut microbiome is highly influenced by diet, specifically formula and human milk use. This study aims to analyze next-generation products including preterm formula, human milk-oligosaccharide term formula, and preterm breastmilk. We used a culture-based model to differentially compare the growth patterns of individual bacterial strains found in the human intestine. This model probed 24 strains of commensal bacteria and 8 pathobiont species which have previously been found to cause sepsis in preterm neonates. Remarkable differences between strain growth and culture pH were noted after comparing models of formulas and between human milk and formula. Both formula and human milk supported the growth of commensal bacteria; however, the formula products, but not human milk, supported the growth of several specific pathogenic strains. Computational analysis revealed potential connections between long-chain fatty acid and iron uptake from formula in pathobiont organisms. These findings indicate that there is a unique profile of growth in response to human milk and formula and shed light into how the infant gut microbiota could be influenced.

US state policies for Medicaid coverage of donor human milk

Donor human milk is recommended by the American Academy of Pediatrics for high-risk infants when mother's own milk is absent or insufficient in quantity. Several factors may contribute to the inequitable use of or access to donor human milk, including a limited knowledge of its effects, cost, reimbursement, and regulatory barriers. The American Academy of Pediatrics and the United States Surgeon General have called for investigating barriers that prevent use of donor human milk for high-risk infants and for changes to public policy known to improve availability and affordability. We review the current legislative, regulatory, and economic landscape surrounding donor human milk use in the United States, as well as suggest state- and federal-level solutions to increase access to donor human milk.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.

Individualized Target Fortification of Breast Milk: Optimizing Macronutrient Content Using Different Fortifiers and Approaches

Background: Native breast milk composition displays significant inter- and intra-individual variation which persists after standard fortification with fixed doses and challenges target fortification. This study aims to analyze the macronutrient composition of different commercially available fortifiers and the effect of different fortification strategies on nutritional intake of preterm infants.

Methods: In 103 preterm infants, native breast milk samples were collected from 24-h feeding batches (n = 3,338) and fat, protein and carbohydrate contents were analyzed. Nutrient content was compared for breast milk that had undergone either (i) standard fortification, (ii) targeted fortification, (iii) selective batching according to breast milk composition, or (iv) partial lyophilization. For (i) eight commercially available standard fortifiers were tested. Targeted fortification (ii) involved the addition of single component modulars of either protein, fat or carbohydrates to standard fortified breast milk. Using a mathematical growth model, the combined effect of protein, fat and carbohydrate intake on growth was assessed. The best composition of standard fortifiers as the initial step for target fortification was explored assuming three clinical scenarios for milk analysis.

Results: Macronutrient content was highly variable between native breast milk samples, and this variation was still present after standard fortification, however at elevated macronutrient levels. Standard fortification, breast milk batching, as well as partial lyophilization of human milk resulted in deficient and imbalanced enteral intakes in a significant proportion of infants. Target fortification reduced this variation in a, respectively, higher percentage of samples. The effect size was dependent on the number of measurements per week. The optimum composition of standard fortifiers was dependent on the clinical scenario (measurement frequency) for target fortification.

Conclusions: To provide precise and accurate intakes of macronutrients, breast milk should be target fortified. Standard fortified breast milk can result in excess above recommended intakes of some macronutrients which limits the efficiency of target fortification. Standard fortifiers with improved composition are needed for target fortification.

Nutritional Intake, White Matter Integrity, and Neurodevelopment in Extremely Preterm Born Infants

Background: Determining optimal nutritional regimens in extremely preterm infants remains challenging. This study aimed to evaluate the effect of a new nutritional regimen and individual macronutrient intake on white matter integrity and neurodevelopmental outcome. Methods: Two retrospective cohorts of extremely preterm infants (gestational age < 28 weeks) were included. Cohort B (n = 79) received a new nutritional regimen, with more rapidly increased, higher protein intake compared to cohort A (n = 99). Individual protein, lipid, and caloric intakes were calculated for the first 28 postnatal days. Diffusion tensor imaging was performed at term-equivalent age, and cognitive and motor development were evaluated at 2 years corrected age (CA) (Bayley-III-NL) and 5.9 years chronological age (WPPSI-III-NL, MABC-2-NL). Results: Compared to cohort A, infants in cohort B had significantly higher protein intake (3.4 g/kg/day vs. 2.7 g/kg/day) and higher fractional anisotropy (FA) in several white matter tracts but lower motor scores at 2 years CA (mean (SD) 103 (12) vs. 109 (12)). Higher protein intake was associated with higher FA and lower motor scores at 2 years CA (B = −6.7, p = 0.001). However, motor scores at 2 years CA were still within the normal range and differences were not sustained at 5.9 years. There were no significant associations with lipid or caloric intake. Conclusion: In extremely preterm born infants, postnatal protein intake seems important for white matter development but does not necessarily improve long-term cognitive and motor development.