Infant feeding in the neonatal unit

Factors associated with in-hospital mortality of newborns admitted to a special care newborn unit of a tertiary care hospital in southern Bangladesh: a retrospective cohort study

OBJECTIVES

The objective of this study was to identify factors associated with in-hospital deaths of newborns admitted to a special care newborn unit (SCANU) in southern Bangladesh.

DESIGN

Retrospective cohort.

SETTING

SCANU of Patuakhali Medical College Hospital, Patuakhali, Bangladesh.

PARTICIPANTS

Records of 930 neonates admitted to the SCANU from August to December 2022 were included in the study. The inclusion criteria consisted of neonates admitted during the specified period, while the exclusion criteria excluded records of newborns who were referred to intensive care units or who left against medical advice.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: In-hospital neonatal mortality.

SECONDARY OUTCOMES

Specific conditions or factors affecting the in-hospital deaths.

RESULTS

Of the 930 neonates analysed, 3.44% died in the hospital. Factors significantly associated with shorter survival time and increased in-hospital mortality included low birth weight (p=0.004), preterm delivery (p=0.022) and respiratory distress syndrome (RDS) (p=0.002). RDS showed an independent association with death in the hospital (adjusted HR: 3.39; 95% CI: 1.11 to 10.35). Newborns delivered at home or in an ambulance had a 2.90 times higher hazard of dying in the hospital (95% CI: 1.17 to 7.17) compared with those delivered at the hospital.

CONCLUSIONS

Addressing preterm birth, low birth weight and respiratory distress, along with promoting institutional deliveries, is crucial for reducing neonatal mortality rates in resource-limited settings like Bangladesh.

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.

The impact of neonatal unit policies on breast milk feeding at discharge of moderate preterm infants: The EPIPAGE-2 cohort study

Facilitating factors and barriers to breast milk feeding (BMF) for preterm infants have been mainly studied in very preterm populations, but little is known about moderate preterm infants. We aimed to analyze hospital unit characteristics and BMF policies associated with BMF at discharge for infants born at 32 to 34 weeks' gestation. EPIPAGE-2, a French national cohort of preterm births, included 883 infants born at 32 to 34 weeks' gestation. We investigated kangaroo care in the first 24 hr, early involvement of parents in feeding support, volume of the unit, BMF information given to mothers hospitalized for threatened preterm delivery, protocols for BMF, presence of a professional trained in human lactation, unit training in neurodevelopmental care, and regional BMF initiation rates in the general population. Multilevel logistic regression analysis was used to investigate associations between unit policies and BMF at discharge, adjusted for individual characteristics and estimating odds ratios (ORs) and 95% confidence intervals (CIs). Overall, 59% (490/828) of infants received BMF at discharge (27% to 87% between units). Rates of BMF at discharge were higher with kangaroo care (adjusted OR 2.03 [95% CI 1.01, 4.10]), early involvement of parents in feeding support (1.94 [1.23, 3.04]), unit training in a neurodevelopmental care programme (2.57 [1.18, 5.60]), and in regions with a high level of BMF initiation in the general population (1.85 [1.05, 3.28]). Creating synergies by interventions at the unit and population level may reduce the variability in BMF rates at discharge for moderate preterm infants.

The Type of Feeding at Discharge of Very Preterm Infants: Neonatal Intensive Care Units Policies and Practices Make a Difference

Objective: To assess the influence of neonatal intensive care units (NICUs) on feeding practices at discharge of Portuguese very preterm infants. Materials and Methods: We analyzed data from 580 very preterm infants (<32 gestational weeks) discharged home from NICUs of two Portuguese regions and enrolled during 2011-2012 in Effective Perinatal Intensive Care in Europe population-based cohort. Maternal and infant characteristics were abstracted from medical records, and heads of NICUs provided the units characteristics. Feeding at discharge was classified as exclusive formula, exclusive breast milk or mixed, and differences among NICUs were obtained by comparison with pooled geometric mean odds of all NICUs, using multinomial logistic regression. Median odds ratios (MOR) were calculated to quantify variability among NICUs using multilevel logistic regression. Results: At discharge, 25.2% very preterm infants were exclusively on breast milk, 34.1% exclusively on formula, and 40.7% had mixed feeding, with a wide variation among NICUs. Exclusive breast milk increased in NICUs that had higher numbers of admissions, provided parents eating facilities, and by having designated members to support mothers who were breastfeeding. The individual NICU odds of mixed versus exclusive formula feeding ranged from 0.36 to 2.07 and for exclusive breast milk versus exclusive formula ranged from 0.16 and 5.11. Adjusting for individual and unit characteristics, heterogeneity across NICUs remained evident, being the MOR 1.33 for mixed feeding and 1.35 for exclusive breast milk. Conclusions: NICUs influence feeding practices independently of individual characteristics, highlighting the importance of institution-based interventions to promote breast milk.

Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort

Breast milk feeding (BMF) is associated with lower neonatal morbidity in the very preterm infant (<32 weeks gestation) and breastfeeding is beneficial for maternal health. Previous studies show large variations in BMF after very preterm birth and recognize the need for targeted breastfeeding support in the neonatal intensive care units (NICU). In a European collaboration project about evidence-based practices after very preterm birth, we examined the association between maternal, obstetric, and infant clinical factors; neonatal and maternal care unit policies; and BMF at discharge from the NICU. In multivariable analyses, covariates associated with feeding at discharge were first investigated as predictors of any BMF and in further analysis as predictors of exclusive or partial BMF. Overall, 58% (3,826/6,592) of the infants received any BMF at discharge, but there were large variations between regions (range 36-80%). Primiparity, administration of antenatal corticosteroids, first enteral feed <24 hr after birth, and mother's own milk at first enteral feed were predictors positively associated with any BMF at discharge. Vaginal delivery, singleton birth, and receiving mother's own milk at first enteral feed were associated with exclusive BMF at discharge. Units with a Baby Friendly Hospital accreditation improved any BMF at discharge; units with protocols for BMF and units using donor milk had higher rates of exclusive BMF at discharge. This study suggests that there is a high potential for improving BMF through policies and support in the NICU.

Current Knowledge of Necrotizing Enterocolitis in Preterm Infants and the Impact of Different Types of Enteral Nutrition Products

Preterm infants are extremely vulnerable to a range of morbidities and mortality. Underdeveloped cardiac, respiratory, gastrointestinal, and immune systems in the preterm period increase the risk of necrotizing enterocolitis (NEC), a serious disease of the gut. NEC affects 5-12% of very-low birth-weight infants, leads to surgery in 20-40% of cases, and is fatal in 25-50% of cases. There are multiple factors that may contribute to NEC, but the exact cause is not yet fully understood. Severe cases can result in intestinal resection or death, and the health care costs average >$300,000/infant when surgical management is required. Different types of nutrition may affect the onset or progression of NEC. Several studies have indicated that bovine milk-based infant formulas lead to a higher incidence of NEC in preterm infants than does human milk (HM). However, it is not clear why HM is linked to a lower incidence of NEC or why some infants fed an exclusively HM diet still develop NEC. An area that has not been thoroughly explored is the use of semielemental or elemental formulas. These specialty formulas are easy to digest and absorb in the gut and may be an effective nutritional intervention for reducing the risk of NEC. This review summarizes what is known about the factors that contribute to the onset and progression of NEC, discusses its health care cost implications, and explores the impact that different formulas and HM have on this disease.

Approaches to supporting lactation and breastfeeding for very preterm infants in the NICU: a qualitative study in three European regions

OBJECTIVES

To explore differences in approaches to supporting lactation and breastfeeding for very preterm infants in neonatal intensive care units (NICU) in 3 European regions.

DESIGN

Qualitative cross-sectional study carried out by means of face-to-face semistructured interviews. Verbatim transcripts were coded using a theoretical framework derived from the literature and supplemented by data-driven concepts and codes.

SETTING

4 purposively selected NICUs in each of 3 European regions in 2010 (Ile-de-France in France, Lazio in Italy, and the former Trent region in the UK).

PARTICIPANTS

NICU staff members (n=22).

RESULTS

Policies and practices for managing mother's own milk for very preterm babies differed between regions, and were much more complex in Ile-de-France than in the Trent or Lazio regions. Staff approaches to mothers to initiate lactation differed by region, with an emphasis on the nutritional and immunological value of human milk in the Trent region and on the 'normalising' effect of breastfeeding on the mother-child relationship in Lazio. French and English staff expressed conflicting opinions about the use of bottles, which was routine in Italy. Italian informants stressed the importance of early maternal milk expression and feeding, but also mentioned discharging infants home before feeding at the breast was established. In Ile-de-France and Trent, successful feeding from the breast was achieved before discharge, although this was seen as a factor that could prolong hospitalisation and discourage continued breastfeeding for some women.

CONCLUSIONS

Targeted health promotion policies in the NICU are necessary to increase the number of infants receiving their mother's milk and to support mothers with transfer of the infant to the breast. Integrating knowledge about the different approaches to lactation and breastfeeding in European NICUs could improve the relevance of recommendations in multiple cultural settings.

Hospital outcomes of extremely low birth weight infants after introduction of donor milk to supplement mother's milk

AIM

This study evaluated the impact of an exclusive human milk diet to nourish extremely low birth weight infants in the neonatal intensive care unit.

MATERIALS AND METHODS

This multicenter pre-post retrospective study included all inborn infants <1,000 g admitted to four Level IV neonatal intensive care units either before or after implementing a donor human milk policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and enteral intake as mother's own milk, donor milk, and formula.

RESULTS

Two hundred one infants were enrolled. Infant growth and other clinical outcomes were similar in both groups. Exposure to mother's own milk at discharge was not different. Median time in oxygen and duration of mechanical ventilation were significantly higher among formula-fed infants (63 versus 192 hours [p=0.046] and 24 versus 60 hours [p=0.016], respectively).

CONCLUSIONS

Our results add evidence supporting the safety of donor milk. This study also found an association between exposure to formula in preterm infants and the requirement for respiratory support, a finding that warrants further investigation.

An ethical case for the provision of human milk in the NICU

Despite recommendations from the World Health Organization, the United Nations Children's Fund, the American Academy of Pediatrics Section on Breastfeeding, and others, only a small percentage of infants in the United States receive exclusive human milk for the first 6 months of life. In the United States, decisions related to infant feeding are determined by surrogate or proxy in place of the neonatal voice, using the "best interest principle" as the guiding ethical focus. Given the established research on the benefits of an exclusive human milk diet compared with artificial nutrition (infant formula), infant feeding decisions made for the critically ill neonate should rest entirely in the infant's best interest, not solely in parental authority. If the mother's own milk is not available or its use is contraindicated, the American Academy of Pediatrics recommends donor human milk. However, the preverbal voice of the neonate makes it difficult to isolate the best interest of the infant separated from the family unit. Using a case exemplar, it is proposed that the means in which infant feeding decisions are made for the critically ill infant should rest entirely in the infant's best interest, not parental authority, during the course of care in the hospital setting. The best interest principle, surrogate decision making, parental authority, and proxy consent are reviewed. Furthermore, a case for the best interest principle to further illustrate the importance of the infant's voice in relationship to enteral feeding decisions is provided. Finally, implications for clinical practice are offered.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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

The human milk project: a quality improvement initiative to increase human milk consumption in very low birth weight infants

OBJECTIVE

Human milk has well-established health benefits for preterm infants. We conducted a multidisciplinary quality improvement effort aimed at providing at least 500 mL of human milk/kg in the first 14 days of life to very low birth weight (VLBW) (< 1,500 g) infants in the neonatal intensive care unit.

SUBJECTS AND METHODS

Improvement activities included antenatal consults with at-risk mothers, staff and parent education, a breast pump loaner program for uninsured/underinsured mothers, pump logs, establishment of a donor milk program, and twice-daily physician evaluation of infants' ability to tolerate feedings.

RESULTS

The number of infants receiving at least 500 mL of human milk/kg in their first 14 days of life increased from 50% to 80% within 11 months of implementation, and this increase has been sustained for 4 years. Infants who met the feeding goal because they received donor milk increased each year. Since September 2007, infants have received, on average, 1,111 mL of human milk/kg. Approximately 4% of infants did not receive any human milk. Respiratory instability was the most frequent physiological reason given by clinicians for not initiating or advancing feedings in the first 14 days of life.

CONCLUSIONS

Our quality improvement initiative resulted in a higher consumption of human milk in VLBW infants in the first 14 days of life. Other clinicians can use these described quality improvement methods and techniques to improve their VLBW babies' consumption of human milk.

Mode of anaesthetic for category 1 caesarean sections and neonatal outcomes

BACKGROUND

Birth by emergency caesarean section (CS) is common and often considered urgent (category 1). In the UK, over half of all category 1 CS are performed under general anaesthesia (GA). In this setting, little is known about the effect of the mode of anaesthesia on the neonate.

METHODS

A retrospective cohort study was performed using routinely collected de-identified data from Mater Health Services, Brisbane, Australia. The data set included 533 term babies born by category 1 CS for presumed fetal compromise between 2008 and 2011. Bivariate and multivariate analyses were undertaken.

RESULTS

The outcomes of 81 babies born by GA CS were compared with 452 by CS under regional anaesthesia (RA). Compared with a category 1 CS under RA, the decision-to-delivery interval for a GA CS was almost eight minutes faster (24.7 vs 32.6 minutes; P < 0.001). When adjusted for confounders, babies born by category 1 GA CS were significantly more likely to have an Apgar score < 7 at five minutes (aOR 6.89; 95%CI 1.79-26.55; P = 0.005), to require Neopuff or bag/mask ventilation for > 60 seconds (aOR 2.34; 95%CI 1.13-4.84; P = 0.022) and to be admitted to a neonatal intensive care nursery (aOR 2.24; 95%CI 1.16-4.31; P = 0.016).

CONCLUSIONS

General anaesthesia was associated with short-term neonatal morbidity of term babies born by category 1 CS for presumed fetal compromise, despite enabling a more rapid delivery of the baby. These data should help inform the discussion between anaesthetist and obstetrician, in balancing the risks and benefits of the mode of anaesthesia.