Promoting the exclusive feeding of own mother's milk through the use of hindmilk and increased maternal milk volume for hospitalized, low birth weight infants (< 1800 grams) in Nigeria: a feasibility study

Hindmilk as a Rescue Therapy in Very Preterm Infants with Suboptimal Growth Velocity

Despite advances in neonatal nutrition, very preterm infants remain at increased risk of extrauterine growth faltering. This prospective study aimed to examine the effect of hindmilk, the milk at the end of a breast expression session, on growth and plasma fatty acids (FAs) of infants born <30 weeks' gestation who had been on full enteral feeds for ≥2 weeks and had a weight gain of <15 g/kg/day despite optimizing energy and protein intakes. Weight and plasma FAs were assessed before and two weeks after feeding hindmilk. Growth anthropometrics were assessed weekly for four weeks. Paired t-tests and multiple linear regression were used for statistical analyses of data from 34 infants and their 29 mothers. There was a significant increase in weight gain in the two weeks after feeding hindmilk (MD 3.9, 95%CI 1.2-6.5 g/kg/day). Weight Z-scores were larger at two weeks (MD 0.61, 95%CI 0.02-1.20) and onwards. Head circumference Z-scores were larger at three weeks (MD 0.83, 95%CI 0.20-1.47) and onwards. Plasma linoleic acid (LA) and α-linolenic acid (ALA) increased after feeding hindmilk. In conclusion, hindmilk may improve weight and head growth and increase LA and ALA in very preterm infants with suboptimal growth. A large randomized controlled trial is required to examine and validate the potential benefits of hindmilk.

Short Communication: Differences in Levels of Free Amino Acids and Total Protein in Human Foremilk and Hindmilk

Free amino acids (FAAs) in human milk are indicated to have specific functional roles in infant development. Studies have shown differences between human milk that is expressed at the beginning of a feed (i.e., foremilk) and the remainder of the milk expressed (i.e., hindmilk). For example, it is well established that human hindmilk is richer in fat and energy than foremilk. Hence, exclusively feeding hindmilk is used to enhance weight gain of preterm, low birthweight infants. Whether FAAs occur differently between foremilk and hindmilk has never been reported, but given their bioactive capacities, this is relevant to consider especially in situations where hindmilk is fed exclusively. Therefore, this study analyzed and compared the FAA and total protein content in human foremilk and hindmilk samples donated by 30 healthy lactating women. The total protein content was found to be significantly higher in hindmilk (p < 0.001), whereas foremilk contained a significantly higher total content of FAAs (p = 0.015). With regards to individual FAAs, foremilk contained significantly higher levels of phenylalanine (p = 0.009), threonine (p = 0.003), valine (p = 0.018), alanine (p = 0.004), glutamine (p < 0.001), and serine (p = 0.012) than hindmilk. Although statistical significance was reached, effect size analysis of the milk fraction on FAA levels in milk revealed that the observed differences were only small. To what extent these differences are of physiological importance for infant development remains to be examined in future research.

"Breastfeeding" by feeding expressed mother's milk

This article provides the pediatric community with a practical overview of milk expression and an update on the recent literature. Approaches for working mothers, preterm infants, critically ill infants, and mothers before lactogenesis II are presented separately, as these groups may benefit from practices tailored to individual needs.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Evaluation of an educational intervention to promote breast pump use among women with infants in a special care nursery in Kenya

OBJECTIVES

Development of an educational program for women of special care nursery (SCN) infants in Kenya about the use and cleaning of breast pumps through culturally appropriate teaching tools as well as conduction of an evaluation of change in knowledge, attitudes, beliefs, and practical ability in pump use following the educational intervention.

DESIGN

An evaluation of an educational intervention.

SAMPLE

40 women with infants in the SCN unable to directly breastfeed.

INTERVENTION

Educational intervention instructing electric or pedal breast pump use and cleaning with a pre- and posttest evaluation.

RESULTS

Paired t test scores of the combined practically oriented questions were significantly increased from 1.8 to 4.6 (p<.001) from pre- to posttest scores. Likewise, the practical demonstration of learned pump use skills significantly improved from 0.08 preintervention to 4.8 postintervention ( p<.001).

CONCLUSIONS

Results of the evaluation indicated the intervention significantly increased women's practical knowledge regarding use and cleaning of the breast pump and accessories. With knowledge of proper use of breast pumps, women will be more likely to successfully utilize pumps to provide adequate milk volumes for SCN infants. A culturally appropriate educational intervention in developing countries appears to be a feasible means of facilitating instruction of breast pump use.

Volume of foremilk, hindmilk, and total milk produced by mothers of very preterm infants born at less than 28 weeks of gestation

The purpose of this study is to describe foremilk volume (milk produced in the first 3 minutes of pumping), hindmilk volume (remainder of milk produced), and total milk volume produced by mothers of very preterm infants at 3 weeks postpartum and associated factors. Mothers (n = 24) mechanically pump their breasts a median (minimum, maximum) of 7 times (5, 9 times) per 24 hours for a total of 15 minutes (9.4, 23.9 minutes) each time. Foremilk, hindmilk, and total milk volumes are 183 mL per 24 hours (80, 810), 318 mL per 24 hours (98, 1007), and 545 mL per 24 hours (224, 1817), respectively. Milk volumes are not associated with mother's age, race or ethnic background, education, parity, reported prepregnancy body mass index, previous breastfeeding experience, frequency of milk pumping, longest time between pumps, infant birth weight, or multiple births. The degree of pre-maturity (<26 weeks vs 26(0/7)-27(6/7) weeks) is significantly related to the relative proportion of foremilk/hindmilk volumes (45:55 vs 36:65, respectively).

Hindmilk: a head start in preterm nutrition

BACKGROUND

During the neonatal period, nutrition has a crucial impact on preterm infants' survival, growth and development. Current nutritional practices for preterm infants often fail to meet their nutritional needs and thus have potential adverse consequences for their growth and development. Hindmilk represents a promising avenue to manage this nutritional challenge.

METHOD

The scientific literature was reviewed to determine the current state of knowledge about hindmilk and its effects on the growth and development of preterm infants.

RESULTS

Four studies evaluating the effects of hindmilk on the growth of preterm infants were found and included in this review. These studies report contradictory findings and present serious methodological shortcomings, limiting the evidence on the potential benefits of hindmilk in preterm infants.

CONCLUSIONS

A body of knowledge on the effects of hindmilk on the growth and development of preterm infants is accumulating but there is still a striking need for further investigation.

Bedside analysis of human milk for adjustable nutrition strategy

AIM

Mother's milk is optimum for preterm infants, but human milk fortifier is required at times, because some nutrients are sometimes insufficient for infant growth. It is important to measure the nutrients in breast milk at bedside so that the amount of nutrients that need to be supplemented can be determined. A human milk analyser (HMA, Miris) is currently available. We examined if the macronutrient values measured by human milk analyser are comparable with those measured by conventional methods. We also sought to discover whether we could dilute the milk sample used for the human milk analyser measurement if the amount of milk available for testing was insufficient.

SUBJECTS AND METHODS

First, the results of protein, fat and lactose content in breast milk samples obtained using the human milk analyser and conventional methods were compared. Second, we measured diluted samples and compared the values with nondiluted samples.

RESULTS

When comparing the human milk analyser and conventional methods, all three nutrients exhibited a significantly positive correlation (p < 0.001); lactose content was reliable on the condition that it is 6-7 g/dL. The lactose content measured by the HPLC method was obtained by 3.05 x human milk analyser value - 13.4. When comparing diluted and nondiluted samples, fat and protein had expected values after dilution whereas lactose did not.

CONCLUSION

The human milk analyser can inform us about the amount of major nutrients in breast milk: fat, protein and lactose. However, when human milk is diluted, the lactose content measured by the human milk analyser is overestimated.

Nutrient composition of hindmilk produced by mothers of very low birth weight infants born at less than 28 weeks' gestation

The objectives of this study were to describe and compare retinol, alpha-tocopherol and gamma-tocopherol, fat, energy, and nitrogen concentrations between the foremilk and hindmilk fractions of 24-hour milk collected by 24 mothers of very preterm (< 28 weeks' gestation) infants and to relate milk vitamins A and E content to maternal vitamin intake. Concentrations of retinol were significantly higher in hindmilk than in foremilk (1.6-fold), as were concentrations of alpha-tocopherol (1.6-fold), gamma-tocopherol (1.5-fold), fat (1.7-fold), energy (1.3-fold), and nitrogen (1.05-fold). Retinol, alpha-tocopherol, and gamma-tocopherol were positively related (P < .05) to milk fat and energy but not to maternal intake. Estimates of vitamins A and E intakes of infants fed hindmilk with added human milk fortifier surpassed current recommended upper level of intakes. The higher fat-soluble vitamin content of hindmilk produced by mothers of very low birth weight infants needs to be considered in the design and recommendations for use of human milk fortifier.

Hindmilk and weight gain in preterm very low-birthweight infants

BACKGROUND

Feeding of own mother's milk to preterm very low-birthweight infants often results in suboptimal weight gain in these infants for whom energy requirements are high but in whom volume tolerance is limited. Therefore the purpose of the present paper was to investigate the effect of selective hindmilk feeding on the growth of preterm very low-birthweight babies.

METHODS

Preterm very low-birthweight babies admitted into the Special Care Baby Unit of the Jos University Teaching Hospital, Nigeria between April 2000 and July 2001 were randomized to hindmilk and composite breast milk feeding for 2 weeks. End-points were weight, occipitofrontal head circumference and length.

RESULTS

For small-for-gestational-age babies, the infants fed on hindmilk gained weight at a mean rate of 12.92 +/- 10.95 g/kg per day as compared with a mean rate of 5.01 +/- 17.37 g/kg per day for their controls on composite milk (P < 0.0001). For appropriate-for-gestational-age babies, the mean rate of weight gain for the hindmilk group was 12.99 +/- 10.75 g/kg per day while that for their controls on composite milk was 8.29 +/- 20.56 g/kg per day (P < 0.01). There were no significant differences in the rates of increase in length and occipitofrontal head circumference between the groups. The lipid content of the hindmilk was 1.6-fold that of composite milk.

CONCLUSION

Preterm very low-birthweight babies fed hindmilk had a higher rate of weight gain compared to those fed composite milk. It is recommended that the hindmilk fraction of expressed breast milk be predominantly used for the feeding of preterm very low-birthweight babies while in hospital to help shorten their duration of hospital stay.

Accuracy of a user-friendly centrifuge for measuring creamatocrits on mothers' milk in the clinical setting

The creamatocrit (CRCT), a simple, accurate, and inexpensive technique for the estimation of lipid and caloric content in mothers' milk, has been used extensively in lactation research, but has not been integrated into the routine management of clinical lactation problems such as slow weight gain in mothers' milk-fed preterm and term infants. The Creamatocrit Plus is a lightweight, noiseless centrifuge with an embedded reader that automatically calculates lipid and calories from the CRCT value, making it ideal for use in the clinical setting. This study compared intra-user and inter-user reliability, the equivalence of the CRCT values obtained with the Creamatocrit Plus to the two standard techniques for performing CRCTs: the standard laboratory centrifuge with a hematocrit reader and the standard laboratory centrifuge with digital calipers, and the predictive accuracy of the Creamatocrit Plus for estimating the lipid and caloric content in mothers' milk. CRCTs were performed using the three techniques on 36 milk specimens from 12 women. Laboratory analyses of lipid and calories were performed by investigators blinded to CRCT values. The mean absolute intra-user and inter-user differences were all <1% CRCT, and the mean CRCT measures were nearly identical for the three measurement techniques. Linear correlations between CRCT and laboratory measures for lipid (r = 0.95) and calories (r = 0.94) were very high. The authors conclude that the Creamatocrit Plus can replace cumbersome laboratory equipment for measuring CRCTs in the clinical setting.

State of the science: use of human milk and breast-feeding for vulnerable infants

Human milk is the preferred form of nutrition for all infants including those born preterm or otherwise ill. However, without the commitment of knowledgeable healthcare providers to ensure success during mother-infant separation, many infants fail to receive their mother's own milk. Care of the mother-infant dyad during infant illness requires vigilant monitoring of the lactation experience and the commitment of healthcare providers to take a family through the step-by-step process needed to ensure positive outcomes related to the use of human milk and breast-feeding for vulnerable infants. The science tells us that human milk is the best form of nutrition for all infants. As practitioners we must be doing everything in our power to make sure the infants we care for are able to receive their mother's own milk.