Mother's Own Milk Compared With Formula Milk for Feeding Preterm or Low Birth Weight Infants: Systematic Review and Meta-analysis

Comparative Growth Outcomes in Very Low Birth Weight Infants: Evaluating Different Feeding Strategies

OBJECTIVES

To assess the growth pattern of preterm, very low birth weight (VLBW) appropriate for gestational age (AGA) infants on three different feeding regimens.

METHODS

This prospective open label three-arm parallel randomized controlled trial was conducted at neonatal intensive care unit, Kasturba Hospital, Manipal. One hundred twenty VLBW (weight between 1000-1500 g and gestational age 28-32 wk) preterm AGA infants admitted from April 2021 through September 2022 were included. Three feeding regimens were compared: Expressed breast milk (EBM); EBM supplemented with Human milk fortifier (HMF); EBM supplemented with Preterm formula feed (PTF). Primary outcome measure was assessing the growth parameters such as weight, length, head circumference on three different feeding regimens at birth 2, 3, 4, 5 and 6 wk/discharge. Secondary outcomes included incidence of co-morbidities and cost-effectiveness.

RESULTS

Of 112 infants analyzed, Group 2 supplemented with HMF showed superior growth outcomes by 6th wk/discharge of intervention, with mean weight of 2053±251 g, mean length of 44.6±1.9 cm, and mean head circumference of 32.9±1.4 cm. However, infants in Group 3, supplemented with PTF, registered mean weight of 1968±203 g, mean length of 43.6±2.0 cm, and mean head circumference of 32.0±1.6 cm. Infants exclusively on EBM presented with mean weight of 1873±256 g, mean length of 43.0±2.0 cm and mean head circumference of 31.4±1.6 cm.

CONCLUSIONS

Addition of 1 g of HMF to 25 ml of EBM in neonates weighing 1000-1500 g showed better weight gain and head circumference at 6 wk/discharge, which was statistically significant. However, no significant differences in these parameters were observed at postnatal or 2, 3, 4, and 5 wk.

Nutritional Management of Low Birth Weight and Preterm Infants in Low- and Low Middle-Income Countries

INTRODUCTION

Preterm and low birth weight (LBW) infants are at an increased risk of morbidity and mortality compared with their term counterparts, with more than 20 million LBW infants born each year, the majority in lower middle-income countries (LMICs). Given the increased vulnerability and higher nutritional needs of these infants, optimizing feeding strategies may play a crucial role in improving their health outcomes.

METHODS

We updated evidence of Every Newborn Series published in The Lancet 2014 by identifying relevant systematic reviews, extracting low-income country (LIC) and LMIC data, and conducting revised meta-analysis for these contexts.

RESULTS

We found 15 reviews; the evidence showed that early initiation of enteral feeding reduced neonatal mortality overall, but not in LIC/LMIC settings. Breastfeeding promotion interventions increased the prevalence of early initiation of breastfeeding and exclusive breastfeeding at 3 and 6 months of age in LMIC settings. There was an increased risk of neonatal mortality with formula milk in LIC/LMIC settings. Despite contributing to greater weight gain, there was a higher risk of necrotizing enterocolitis with formula milk overall. Breast milk fortification and nutrient-enriched formula improved growth outcomes. Iron and vitamin A supplementation reduced anemia and mortality rates (LMIC), respectively. The evidence also suggested that benefits of various different micronutrient supplementation interventions such as zinc, calcium/phosphorous, and vitamin D, outweigh the risks since our review demonstrates little to no adverse effects deriving from their supplementation, particularly for a breastfed preterm and/or LBW infant.

CONCLUSION

Early adequate nutritional support of preterm or LBW infant is paramount to averse adverse health outcomes, contribute to normal growth, resistance to infection, and optimal development. Breast milk feeding and micronutrient supplementation are crucial to reduce diarrhea incidence and mortality respectively while feed fortification or nutrient-enriched formula, when breast milk is not available, to enhance better growth especially in LMICs where there is higher population of growth restriction and stunting. This review also highlights need for randomized trials in LMICs at large scale to further strengthen the evidence.

INTRODUCTION

Preterm and low birth weight (LBW) infants are at an increased risk of morbidity and mortality compared with their term counterparts, with more than 20 million LBW infants born each year, the majority in lower middle-income countries (LMICs). Given the increased vulnerability and higher nutritional needs of these infants, optimizing feeding strategies may play a crucial role in improving their health outcomes.

METHODS

We updated evidence of Every Newborn Series published in The Lancet 2014 by identifying relevant systematic reviews, extracting low-income country (LIC) and LMIC data, and conducting revised meta-analysis for these contexts.

RESULTS

We found 15 reviews; the evidence showed that early initiation of enteral feeding reduced neonatal mortality overall, but not in LIC/LMIC settings. Breastfeeding promotion interventions increased the prevalence of early initiation of breastfeeding and exclusive breastfeeding at 3 and 6 months of age in LMIC settings. There was an increased risk of neonatal mortality with formula milk in LIC/LMIC settings. Despite contributing to greater weight gain, there was a higher risk of necrotizing enterocolitis with formula milk overall. Breast milk fortification and nutrient-enriched formula improved growth outcomes. Iron and vitamin A supplementation reduced anemia and mortality rates (LMIC), respectively. The evidence also suggested that benefits of various different micronutrient supplementation interventions such as zinc, calcium/phosphorous, and vitamin D, outweigh the risks since our review demonstrates little to no adverse effects deriving from their supplementation, particularly for a breastfed preterm and/or LBW infant.

CONCLUSION

Early adequate nutritional support of preterm or LBW infant is paramount to averse adverse health outcomes, contribute to normal growth, resistance to infection, and optimal development. Breast milk feeding and micronutrient supplementation are crucial to reduce diarrhea incidence and mortality respectively while feed fortification or nutrient-enriched formula, when breast milk is not available, to enhance better growth especially in LMICs where there is higher population of growth restriction and stunting. This review also highlights need for randomized trials in LMICs at large scale to further strengthen the evidence.

A systematic review and meta-analysis of breastfeeding and neurodevelopmental outcomes in preterm infant

Background

Prematurity significantly impacts neonatal health worldwide, necessitating effective interventions to improve outcomes for these vulnerable infants. While breastfeeding has emerged as a cornerstone of preterm care, its precise impact on neurodevelopment remains a subject of ongoing inquiry and debate. This systematic review aims to investigate the existing evidence in this area.

Methods

On December 17, 2023, online databases including PubMed, The Cochrane Library, Embase, Web of Science, CNKI, VIP, CBM, and Wan Fang Data were searched. Comparisons were classified into several categories: never breastfeeding (Never-BF) versus exclusive breastfeeding, Never-BF versus any breastfeeding (Any-BF), predominant preterm formula (Pre-PTF) versus predominant breastfeeding (Pre-BF), and Pre-PTF versus predominant donor breast milk (Pre-DBM) groups. Randomized controlled trials and observational studies were analyzed separately through meta-analyses. Each study's risk of bias was assessed, and the GRADE system was utilized to evaluate the certainty of the findings.

Results

Sixteen studies met the inclusion criteria, comprising one RCT and 15 cohort studies. The key findings indicated that infants in the Any-BF groups demonstrated superior long-term cognitive scores compared to those in the Never-BF groups, particularly evident in infants assessed before 18 months in the Pre-BF groups versus Pre-PTF groups. A reduced risk of neurodevelopmental impairment was also observed in preterm infants in the Any-BF groups. Evidence regarding the effect of breastfeeding on motor development was inconclusive, except for potential motor improvement in extremely low birth weight infants in the Any-BF groups. Neither exclusive breastfeeding nor pre-DBM exhibited clear superiority over Pre-PTF in terms of neurodevelopmental outcomes for preterm infants. Caution is warranted due to potential publication bias impacting the assessment of breastfeeding's impact on motor skills.

Conclusion

Our systematic review supports current recommendations for breastfeeding in preterm infants, emphasizing its positive effects on cognitive abilities and reduced risk of neurodevelopmental disorders. Further studies are needed to clarify if DHM provides neurodevelopmental benefits comparable to maternal milk, as current evidence does not sufficiently address this question. Additionally, future investigations should prioritize refining our understanding of the influence of breastfeeding on motor development in this vulnerable population.

Systematic review registration

PROSPERO, identifier CRD42023492274, Available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023492274.

Mother's own milk and bronchopulmonary dysplasia in appropriate for gestational age preterm infants

OBJECTIVE

To evaluate the association between mother's own milk (MOM) and bronchopulmonary dysplasia (BPD) in appropriate for gestational age (AGA) preterm infants <32 weeks.

METHODS

Clinical data of AGA preterm infants (24+0/7-31+6/7 weeks) were reviewed. Infants with ≥66% of cumulative prescribed enteral volumes as MOM from birth to 36 weeks were allocated to the high provision of MOM group (H-MOM), whereas those with <66% were assigned to the low provision of MOM group (L-MOM). Multiple regressions were used to assess the association of H-MOM with BPD and oxygen saturation to fraction inspired oxygen ratio (SFR) at 36 weeks.

RESULTS

A total of 1041 infants met the inclusion criteria, with a median provision of cumulative enteral nutrition volumes of 5721 (IQR 2616) mL/kg. Among them, 517 (49.7%) were H-MOM and 524 (50.3%) L-MOM infants. H-MOM showed a reduction in the incidence of BPD to 31.6% compared to L-MOM infants. H-MOM had a lower risk of BPD than L-MOM infants after the adjustment for gestational age, sex, cesarean section, mean SFR at the first hours of life, surfactant administration, patent ductus arteriosus, sepsis, prolonged ventilatory supports/oxygen exposure, and cumulative energy intakes from birth to 36 weeks [aOR: 0.613, p = 0.047]. H-MOM was also associated with a lower risk of SFR in the first quartile at 36 weeks [aOR: 0.616, p = 0.028] than L-MOM.

CONCLUSION

A high provision (≥66%) of enteral volume as MOM from birth to 36 weeks is associated with a reduced risk of both BPD and low SFR at 36 weeks in AGA preterm infants <32 weeks.

[Expert consensus on enteral nutrition management of preterm infants (2024)]

Providing adequate and balanced nutrition for preterm infants, especially extremely/very preterm infants, is the material basis for promoting their normal growth and development and improving long-term prognosis. Enteral nutrition is the best way to feed preterm infants. Previous systematic reviews have shown that using evidence-based standardized feeding management strategies can effectively promote the establishment of full enteral feeding, reduce the duration of parenteral nutrition, improve the nutritional outcomes of preterm infants, and not increase the risk of necrotizing enterocolitis or death. Based on relevant research in China and overseas, the consensus working group has developed 20 recommendations in 5 aspects including the goal of enteral nutrition, transitioning to enteral nutrition, stable growth period enteral nutrition, supplementation of special nutrients, and monitoring of enteral nutrition for preterm infants, using the Grading of Recommendations Assessment, Development and Evaluation. The aim is to provide recommendations for healthcare professionals involved in the management of enteral nutrition for preterm infants, in order to improve the clinical outcomes of preterm infants.

Human Milk-The Biofluid That Nourishes Infants from the First Day of Life

Human milk is a biofluid with a unique composition among mammalian milks. Besides this milk's major components, its bioactive compounds, like hormones, immune factors, and oligosaccharides, are unique and important for infant growth and development. The best form of nutrition for term and preterm infants is the mother's own milk. However, in the absence of the mother's own milk, donor milk should be made available. Milk banks support neonatal intensive care units by providing preterm infants with human milk that generally has reasonable nutritive value for this sensitive population. However, neither mother's own milk nor donor milk has sufficient energy content for the growth of preterm babies, so adequate human milk supplementation is crucial for their progress. Due to the different characteristics of human breast milk, as well as ubiquitous environmental pollutants, such as microplastics, new methods are required for monitoring the quality and characteristics of human milk, which will lay a solid foundation for the further development and progress of human milk research.

Comparison of the Effect of Direct Breastfeeding, Expressed Human Milk, and Infant Formula Feeding on Infant Weight Trajectories: A Systematic Review

Background: Formula and breastfeeding are known factors associated with infant weight trajectories. Evidence exploring the effect of expressed human milk feeding on infant weight in the community setting has not been well synthesized. Objectives: This systematic review examined (1) weight changes among infants fed expressed human milk and (2) differences in weight change between infants fed expressed human milk and infants fed at the breast or infant formula via bottle. Methods: A comprehensive search of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of each study was appraised using the Joanna Briggs Critical Appraisal Tools. Results: A total of six studies met the eligibility criteria and included a total of 5,152 infants. The within-subject analysis identified only 31 infants strictly or predominantly fed expressed human milk. The between-subject analysis comparing expressed human milk feeding to the available comparison groups (formula-fed or direct at the breastfed) revealed that higher weight gains were observed in the weight trajectories among infants in the bottle or formula-fed conditions in four of the six included studies. Conclusions: Findings from the few studies included in this review found a difference in the infant weight gain patterns among expressed human milk-fed infants when compared with their respective feeding groups (directly breastfed or formula-fed). Further research is needed to corroborate these findings and elucidate the clinical significance of the differences in weight gain patterns observed across infant feeding groups.

New World Health Organization recommendations for care of preterm or low birth weight infants: health policy

Approximately 11% of infants are born preterm, and complications of prematurity are the most common cause of death in children aged under five years. Almost one million preterm infants die each year across low, high and middle income countries. In 2021, the World Health Organization (WHO) convened a Guideline Development Group (GDG) to examine evidence and formulate recommendations for care of preterm or low birthweight (LBW) infants according to WHO Guideline Review Committee (GRC) criteria. GRADE methods were used to assess the certainty of evidence and the GDG developed judgements using the DECIDE (Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence) framework. Twenty-five recommendations were made; 11 recommendations were new, and 16 were for preventive and promotive care. Kangaroo Mother Care (KMC) was recommended to start immmediately after birth as routine care for all preterm or LBW newborns (except for critically ill infants who are in shock, unable to breath spontaneously after resuscitation, or require ventilatory support) both in the facility and at home. New recommendations were also made for caffeine to treat apnoea and for extubation; family involvement in routine care for preterm or LBW infants; and for post-discharge home-visit follow-up care. New recommendations were also made to consider use of probiotics, emollient therapy, caffeine for prevention of apnoea, continuous positive airway pressure (CPAP) immediately after birth (with or without respiratory distress) in infants less than 32 weeks gestational age; and for family support to enable the care of preterm or LBW infants. The recommendations confirm the pivotal role of preventive and promotive care for preterm and LBW infants, especially the importance of keeping the baby and mother together, and empowering and supporting families to care for their preterm or LBW infant. WHO is now working to help scale up care for small and sick newborns, including organizational shifts in all 'health system building blocks' such as infrastructure, commodities, workforce and monitoring.

Funding

Nil.

“Breastfeeding at Night Is Awesome” Mothers’ Intentions of Continuation of Breastfeeding Extreme and Very Preterm Babies upon Discharge from a Kangaroo Mother Care Unit of a Tertiary Hospital in South Africa

Kangaroo mother care (KMC) is effective in increasing mothers’ initiation and maintenance of breastfeeding (BF) for extreme and very preterm (VLBW) infants. Although South Africa has implemented KMC for more than two decades, little is known about mothers’ perspectives on KMC. The purpose of this study was to describe the BF intentions and practices of mothers of VLBW infants at home following discharge and assess the role long stay in KMC has on their decision to BF beyond discharge. This qualitative study was conducted at the KMC unit of a tertiary hospital in Pretoria, South Africa. Focus group interviews were conducted with 38 mothers of VLBW infants who had transitioned from neonatal intensive care (NICU) to KMC. We analysed transcripts following the five steps for qualitative thematic data analysis. Mothers were knowledgeable of the importance and value of BF preterm infants and conceded that breast milk has advantages over formula. Mothers had positive feelings toward BF their preterm infants. The stay in KMC increased the direct BF of their preterm infants, mothers’ BF efficacy, and had a positive influence on mothers’ intentions to continue BF following discharge and to exclusively breastfeed for six months. Their BF intentions, efficacy, and practices were influenced by the skilful BF counselling, training, and support they received from the nursing staff. High intention to BF among these mothers is suggestive of their knowledge and confidence in BF for their VLBW infants. It is important that nursing staff in NICU and KMC appreciate the significant role they play in mothers’ readiness and confidence to breastfeed beyond discharge.

The Impacts of Single Preterm Human Donor Milk Compared to Mother's Own Milk on Growth and Body Composition

(1) If mother´s own milk (MOM) is not available, pooled term human donor milk (HDM) is commonly used. Compared to MOM, term HDM contains less protein and fat and is associated with impaired growth. HDM from mothers of preterm infants is an alternative source and contains higher protein levels compared to term HDM, but the impacts on growth and body composition are unclear. (2) Methods: Infants born below 32 weeks of gestation and below 1500 g between 2017-2022, who underwent air displacement plethysmography (Pea Pod^®) to determine body composition (FFM: fat-free mass; FM: fat mass) at term-equivalent age, were included. A comparison between infants fed with MOM > 50% (MOM-group) and single preterm HDM > 50% (HDM-group) was conducted. (3) Results: In total, 351 infants (MOM-group: n = 206; HDM-group: n = 145) were included for the analysis. The median FFM-Z-score (MOM-group: -1.09; IQR: -2.02, 1.11; HDM-group: -1.13; IQR: -2.03, 1.12; p = 0.96), FM-Z-score (MOM-group: 1.06; IQR: -0.08, 2.22; HDM-group: 1.19; IQR: -0.14, 2.20; p = 0.09), and median growth velocity (MOM-group: 23.1 g/kg/d; IQR: 20.7, 26.0; HDM: 22.5 g/kg/d; IQR: 19.7, 25.8; p = 0.15) values were not significantly different between the groups. (4) Conclusion: Single preterm HDM is a good alternative to support normal growth and body composition.

Growth after implementing a donor breast milk program in neonates <33 weeks gestational age or birthweight <1500 grams: Retrospective cohort study

BACKGROUND

Donor breast milk (DBM) feeding has been associated with less growth than formula in preterm infants. Zinc content in DBM is insufficient to support growth in preterm infants.

OBJECTIVE

To compare growth from birth to discharge, macro- and micronutrient intake and the frequency of poor growth before (Epoch-1) and after (Epoch-2) implementing a DBM program.

METHODS

Retrospective cohort study of 1069 infants born at < 33 weeks' gestational age or birthweight < 1500 g and fed using our adjustable feeding protocol with accurate serial length measurements. Growth was assessed by changes in Z-scores of weight, length and fronto-occipital circumference from birth to discharge.

RESULTS

Growth did not decrease significantly in Epoch-2. However, energy and protein intake increased by 5% and frequency of zinc and vitamin D supplementation increased by >30%.

CONCLUSIONS

DBM implementation did not significantly decrease growth from birth to discharge using our adjustable feeding protocol.

Impact of Breastfeeding on Low Birthweight Infants, Weight Disorders in Infants, and Child Development

Infancy has been proven as the best time to improve health outcomes for the later stage of life. The composition of human breast milk has evolved over millennia to support and maintain the infant's life during the early years of life. To achieve life-sustaining effects, human breast milk is packed with fats, proteins, carbohydrates, and a wide range of bioactive compounds such as immunoglobulins, lactoferrin, and cytokines. The immunological compounds in breast milk have been shown to curtail gastrointestinal tract infections, respiratory tract infections, hospital admissions, acute otitis media, allergic reactions, and urinary tract infections. Although breastfeeding causes newborns to gain less weight at the beginning of their lives than formula milk does, breast milk improves body composition by low adiposity. A higher adipose deposition in infants is linked with an increased risk of child obesity in the future. Due to significant health benefits, the World Health Organization (WHO) recommends initiating breastfeeding within one hour after birth and continuing for at least six months. Breastfeeding has emerged as a superior source of nutrition that can promote healthy physiological and cognitive development and protect against disease challenges in low birthweight infants. This review summarizes potential evidence that highlights the potential health impact of breast milk in low birthweight infants.