Associations between Bronchopulmonary Dysplasia, Insulin-like Growth Factor I and Nutrition

Insulin-like growth factor I (IGF-I) has been suggested as an important factor in the pathogenesis of bronchopulmonary dysplasia (BPD). In turn, nutrition has been associated with IGF-I levels and could be of importance in the pathogenesis of BPD. This study aimed to explore the association between nutrition, the IGF-I axis and the occurrence of BPD. Eighty-six preterm infants (44 male, mean gestational age: 29.0 weeks (standard deviation: 1.7 weeks)) were enrolled in an observational study. Serum IGF-I (µg/L) and insulin-like growth factor binding protein 3 (IGFBP-3; mg/L) were measured at birth and at 2, 4 and 6 weeks postnatal age. BPD was diagnosed at 36 weeks postmenstrual age. Twenty-nine infants were diagnosed with BPD. For every µg/L per week increase in IGF-I, the odds of BPD decreased (0.68, 95% CI 0.48-0.96, corrected for gestational age). The change in IGF-I in µg/L/week, gestational age in weeks and a week of predominant donor human milk feeding were associated with the occurrence of BPD in the multivariable analysis (respectively, OR 0.63 (0.43-0.92), OR 0.44 (0.26-0.76) and 7.6 (1.2-50.4)). IGFBP-3 was not associated with the occurrence of BPD in the multivariable analysis. In conclusion, a slow increase in IGF-I levels and a lower gestational age increase the odds of BPD. Donor human milk might increase the odds of BPD and should be further explored.

International expert meeting on the donation and use of human milk: Brief report

Where a mother's own milk is not available or is insufficient, donor human milk (DHM) processed by a human milk bank (HMB) is the recommended next best alternative. HMBs exist in over 65 countries. However, most countries have yet to establish national policies or programmes that support the provision of DHM. In July 2019, a group of international experts in fields relevant to human milk banking gathered at a meeting organised by the Institute of Biomedical Ethics, University of Zurich, and co-sponsored by the World Health Organisation. Prompted by the growing interest globally in creating and sustaining HMBs and addressing current safety and ethical concerns and standards, the aims of the meeting were to define knowledge gaps, determine the need for and scope of global guidelines and provide recommendations on steps that need to be taken at the international level. Following wide-ranging discussions that included the integration of milk banks into health care systems, strategy and policy, quality and safety, the use of DHM and associated ethical considerations, the overall conclusion of the meeting was that in the absence of global recommendations on the implementation, operation and regulation of HMBs, evidence-based guidance is urgently needed.

Microbiological Screening of Donor Human Milk

Mother's own milk is recognized as the optimal feeding not only for term but also for preterm infants. In addition to risk reduction for sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, and retinopathy of prematurity in the early infancy, feeding preterm infants with mother's own milk is also associated with a better neurodevelopmental outcome; lower rates of otitis media, gastroenteritis, and respiratory infections; and a reduced risk of cardiovascular disease, obesity, and diabetes later in life. Donor human milk is the best alternative if mother's own milk is not available or with short supply. There is growing evidence that the benefits of human milk are mediated by the human milk microbiota and by human milk oligosaccharides through their influence on the infant's gut microbiota. Unfortunately, although human milk contains beneficial bacteria, it may also contain pathogenic bacteria. The antimicrobial properties of human milk protect those infants fed with their own mother's raw milk. In donor human milk, however, the antimicrobial activity is diminished due to storage and in particular by pasteurization, hereby lowering the resistance against bacterial infections. Subsequently, microbiological screening of donor human milk might enhance its safety for preterm infants. Up to date, a consensus on recommendations for the microbiological testing of donor human milk is lacking. Existing local and national guidelines for the microbiological screening vary significantly in terms of timing and frequency of testing as well as their specific acceptance and discard criteria. We reviewed the literature about microbiological testing of donor human milk to provide evidence-based recommendations for donor human milk.

A Quality Improvement Initiative to Increase the Milk Donation to the Human Milk Bank Post-Coronavirus Disease-19 Pandemic

Background and Objective: Donor human milk (DHM) from the human milk bank (HMB) is the next best alterative in circumstances when mother's own milk is not available. There was a steep decline in the volume of DHM collected during the coronavirus disease-19 (COVID-19) pandemic due to various factors, while DHM demand increased. Hence, a quality improvement (QI) study was conducted to increase the volume of milk donation to HMB from postpandemic baseline of 300-400 to 1,000 mL/day over 8 weeks. Materials and Methods: Fish bone analysis was used to identify the potential barriers, and four Plan-Do-Study-Act (PDSA) cycles were conducted from January 2021 to March 2021 to address the key barriers. In the first PDSA cycle, training of health care providers was done. Sessions for educating mothers in the second PDSA cycle and individualized one-to-one counseling of mothers by a mother support group were done in the third PDSA cycle. The availability of breast pump was increased in the fourth PDSA cycle. Sustainability of the interventions was studied for 6 months and data were analyzed. Results: The average DHM collected per day at the end of each PDSA cycle was 900, 1,500, 1,000, and 1,100 mL. Although the sustenance phase was affected by the second COVID-19 wave, prompt identification of the issues and timely interventions prevented the donated volume from dropping to preintervention levels. Conclusion: QI initiatives customized for local settings can result in significant improvement in voluntary milk donation in HMB, which can result in more availability of DHM to premature babies.

Comparison of Breastfeeding and Pumping Experiences of Milk Bank Donors in the United States and United Kingdom

Background/Objective: As human milk banking services expand, information about lifestyle characteristics and infant feeding experiences of milk bank donors is relatively limited. Our goal was to describe and compare milk bank donors' demographic, clinical, and lifestyle characteristics, and breastfeeding experiences in a variety of geographic settings. Methods: A cross-sectional online survey was conducted from August 2022 to December 2022 with approved donors from three milk banks in the United States (n = 369), and one milk bank in United Kingdom (n = 187). Results: Donors in all settings were predominantly in their early 30s, White, married, educated, and identified as female. U.K. donors reported more frequently being on maternity leave (33% versus 5%, p < 0.001), predominantly feeding directly at the breast in the first 3 months postpartum (51% versus 28%, p < 0.001), and breastfeeding a single child longer (21.2 versus 13.3 months, p < 0.001) than U.S. donors. Significantly more U.S. donors reported pumping due to work (34% versus 11%, p < 0.001) and pumping multiple times per day (57% versus 36%, p < 0.001). Most donors reported receiving information about breastfeeding from a health care provider (94% United States and 88% United Kingdom, p = 0.022), while the internet was the most popular source of information about pumping (65% United States and 64% United Kingdom, p = 0.751). Conclusion: Factors not directly related to milk banking (e.g., maternity leave, sources of breastfeeding/pumping assistance) may have an impact on how donors feed their children and ultimately on their milk donation pattern. The impact of donor characteristics and feeding practices on donation patterns warrants further investigation.

Characteristics and factors influencing the volume of breastmilk donated by women to the first human milk bank in Vietnam

Background

Donor human milk (DHM) is essential to the operation of human milk banks (HMB). This study examined characteristics and factors associated with higher volumes of DHM donation at the first HMB in Vietnam.

Method

Data from an online HMB monitoring system collected between February 2017 and July 2022 included demographic characteristics, child information, the timing of donation, and the volume of DHM. Higher volume is defined as equal to or greater than the median DHM volume per donor of 14.4 liters (L). Potential contributors to higher DHM volume were examined using the chi-square test in univariate and multivariable logistic regression analysis.

Results

During the 5.5-year operation, this HMB recruited 517 donors with an average age of 28.6 years. Approximately 60.9% of donors had a college or higher degree and 97.3% gave birth in Da Nang city. Of these donors, the prevalence of cesarean birth was 48.2%, preterm births was 40.2%, and 27.9% had babies with a birth weight of less than 1,500 g. There was a similar proportion of donors between the hospital (48.2%) and community (51.8%). On average, hospital donors started their donations 15 days after birth when their newborns were 33.9 weeks corrected age compared to 63 days and 47.7 weeks among community-based donors. The overall median volume of DHM per donor was 14.4 L over a period of 46 days. The amount and duration were higher in community-based donors (17.5 L in 72 days, 300 ml/day) than those in the hospital (8.4 L in 30 days, 258 ml/day). More than 37% of donors contacted the HMB themselves; the remainder were introduced by health professionals. Factors associated with higher volumes of DHM included higher education (OR: 1.77; 95% CI: 1.09, 2.87), having a full-term newborn (OR: 2.46; 95% CI: 1.46, 4.13), and community-based donors (OR: 2.15; 95% CI: 1.22, 3.78).

Conclusions

Mothers with higher education and from the community donate more breastmilk over a longer duration than those with lower education and from the hospital. Breastfeeding protection, promotion, and support should be offered to all mothers with specialized breastfeeding support for mothers of preterm and sick infants. This will ensure mothers have sufficient breastmilk for their newborns and potentially surplus breastmilk for donation.

[Operating models and organizational structures: opportunities and challenges for human milk banking in Germany]

BACKGROUND

Donor human milk is the recommended alternative for feeding preterm infants if mother's own milk is unavailable. Human milk banks collect, screen, store and distribute donated human milk according to pre-specified standard operating procedures to premature infants without mothers own milk.

AIM

  Herein we characterize current operating models and the structural organisation of German milk bank institutions. The analysis of current and future opportunities and challenges may support the development of a comprehensive donor milk service within Germany.

MATERIAL AND METHODS

Summary of the panel discussion entitled "Operating models and organizational structures: opportunities and risks for donor human milk bank in Germany" during the 3rd Scientific Symposium of the German Human Milk Bank Initiative (FMBI), November 25th to 26th 2022, in Nuremberg, Germany.

RESULTS AND DISCUSSION

Differing operator models may facilitate the use of donor human milk by incorporating unique site-specific factors, pre-existing infrastructure, and individual needs. In addition to the establishment of milk banks serving single neonatal units, high-capacity milk banks should be enabled to provide donor human milk using several hub-and-spoke systems. This may create a nationwide network for a sustainable human milk supply for preterm infants that is based on qualified breastfeeding and lactation support.

Understanding the current and future usage of donor human milk in hospitals: An online survey of UK neonatal units

The use of donor human milk (DHM) where there is a shortfall of maternal milk can benefit both infant and maternal outcomes but DHM supply is not always assured. This study aimed to understand current DHM usage in UK neonatal units and potential future demand to inform service planning. An online survey was disseminated to all UK neonatal units using Smart Survey or by telephone between February and April 2022 after development alongside neonatal unit teams. Surveys were completed by 55.4% of units (108/195) from all 13 Operational Delivery Networks. Only four units reported not using DHM, and another two units only if infants are transferred on DHM feeds. There was marked diversity in DHM implementation and usage and unit protocols varied greatly. Five of six units with their own milk bank had needed to source milk from an external milk bank in the last year. Ninety units (84.9%) considered DHM was sometimes (n = 35) or always (n = 55) supportive of maternal breastfeeding, and three units (2.9%) responded that DHM was rarely supportive of breastfeeding. Usage was predicted to increase by 37 units (34.9%), and this drive was principally a result of parental preference, clinical trials and improved evidence. These findings support the assumption that UK hospital DHM demand will increase after updated recommendations from the World Health Organization (WHO) and the British Association of Perinatal Medicine. These data will assist service delivery planning, underpinned by an ongoing programme of implementation science and training development, to ensure future equity of access to DHM nationally.

Human milk banking acceptability among pregnant and nursing mothers in Southwest Nigeria

Background

Human milk bank is a sustainable source of donor human milk (DHM) which is an acceptable alternative to the mother's milk and it is not routinely available in Nigeria, a multi-ethnically diverse country.The study aimed to assess the willingness to donate or accept human milk among pregnant women and mothers attending the antenatal, immunization, outpatient, under-five, and neonatal follow-up clinics in selected health facilities in Ekiti State, Southwest Nigeria.

Study Design and Methods

A descriptive cross-sectional, mixed methods study design was used to collect data in selected health facilities in Ekiti State. Questionnaires and focus group discussions were used to collect quantitative and qualitative data respectively while data analysis was done using the IBM® Statistical Package for Social Science SPSS version 26® and thematic analysis respectively.

Results

Of the 798 respondents, 529 (66.3%) and 626 (78.4%) did not know about wet nursing or human milk banking (HMB) respectively and 139 (17.4%) were willing to donate their breastmilk for a stipend. In the focus group discussion, 50% had heard about wet nursing but none heard about HMB. Maternal educational level had a significant impact on their willingness to donate or accept DHM (p < 0.00). Wholesomeness, cultural, and religious biases were major reasons affecting HMB acceptability.

Conclusions

Awareness and perception of HMB are poor. Appropriate information, education, and counselling on HMB are needed to drive the adoption and establishment of HMB in Nigeria.

The Effects of Refrigerated Storage of Donor Human Milk with Limited Bacterial Presence After Holder Pasteurization on Nutrient Concentration and Bacterial Growth

Background: The Human Milk Banking Association of North America (HMBANA) sets the purity and quality standards for donor human milk (DHM) in the United States, which includes zero bacterial presence after Holder pasteurization. This study aimed to determine if nutrient and bacterial composition of DHM with limited bacterial presence after pasteurization change over 4 days of refrigerated storage. Methods: Twenty-five unique samples of DHM with limited bacterial growth postpasteurization were collected from two HMBANA milk banks. Infant formula was used as a comparison. Samples were stored in the refrigerator and a portion of milk was removed at 24-hour intervals beginning at hour 0 to 96 for analysis. Aerobic bacteria, protein, lactose, and immunoglobulin A (IgA) content were measured. Longitudinal changes between 0 and 96 hours were analyzed using repeated measures analysis of variance and mixed models test. p < 0.05 was deemed significant. Results: There was no significant difference in lactose, protein, bacteria, or IgA content over storage duration (p = 0.649, p = 0.690, and p = 0.385, p = 0.805, respectively). Total aerobic bacteria were less than 10² colony-forming units (CFUs) in 81% of the time points tested for DHM samples. Total aerobic bacteria were too many to count (>300 CFUs) in the infant formula sample at all time points. Conclusion: In periods of high demand for DHM, DHM with low bacteria growth postpasteurization may be an option as a supplemental food for the growing number of healthy infants who receive DHM. Future studies should investigate the bacterial strains in this milk.

Protein and Immune Component Content of Donor Human Milk in Japan: Variation with Gestational and Postpartum Age

Donor human milk (DHM) is the second-best nutrition for preterm infants when their own mother's milk is unavailable. The nutrient content of human milk is influenced by various factors, including gestational and postpartum age, but there are no data regarding DHM composition in Japan. The aim of this study was to determine the protein and immune component content of DHM in Japan and to elucidate the effects of gestational and postpartum age on nutrient composition. From September 2021 to May 2022, 134 DHM samples were collected from 92 mothers of preterm and term infants. Protein concentrations in preterm DHM (n = 41) and term DHM (n = 93) were analyzed using a Miris Human Milk Analyzer. The concentrations of secretory immunoglobulin A (sIgA) and lactoferrin, major immune components, were measured using enzyme-linked immunosorbent assays. Preterm DHM exhibited higher protein content than term DHM (1.2 g/dL and 1.0 g/dL, respectively, p < 0.001), whereas sIgA content was higher in term DHM than in preterm DHM (110 μg/mL and 68.4 μg/mL, respectively, p < 0.001). Gestational age was negatively correlated with protein levels and positively correlated with sIgA and lactoferrin levels. Furthermore, a negative correlation was found between postpartum week and protein, sIgA, and lactoferrin concentrations. Our data suggest that gestational and postpartum age affects protein, sIgA, and lactoferrin concentrations in DHM. These results indicate the importance of nutritional analysis for the appropriate use of DHM in preterm infants.

Pooling Strategies to Modify Macronutrient Content of Pasteurized Donor Human Milk

Background: Donor human milk (DHM) is the recommended feeding for preterm infants when mother's own milk is unavailable or insufficient. DHM macronutrient's variability may have significant implications on preterm growth. Different pooling strategies could be used to improve the macronutrient content, facilitating the achievement of nutritional requirements of preterm. Objective: The aim was to compare the impact of random pooling (RP) and target pooling (TP) strategies on the macronutrient content of DHM and to identify which RP practice allows the achievement of a macronutrient composition as similar as possible to that achievable with TP. Methods: The macronutrient content of 1,169 single-donor pools was analyzed, and a TP strategy combining 2,3,4, or 5 single-donor pools was adopted. On the bases of single-donor pools' analyses, a simulation of 10,000 randomly selected pools for each configuration of donor considered and for different milk volume proportions was performed. Results: Regardless of the type of strategy and milk volume, as the number of donor per pool increases, the percentage of pools with a macronutrient content equal or higher than the reference values for human milk increases. Conclusion: When a TP strategy is not feasible, a RP strategy combining at least five donors should be performed to obtain a better macronutrient content of DHM.

Exclusive Human Milk Diet for Extremely Premature Infants: A Novel Fortification Strategy That Enhances the Bioactive Properties of Fresh, Frozen, and Pasteurized Milk Specimens

Background: Human milk (HM) fortification has been recommended for the nutritional optimization of very low-birthweight infants. This study analyzed the bioactive components of HM and evaluated fortification choices that could accentuate or attenuate the concentration of such components, with special reference to human milk-derived fortifier (HMDF) offered to extremely premature infants as an exclusive human milk diet. Materials and Methods: An observational feasibility study analyzed the biochemical and immunochemical characteristics of mothers' own milk (MOM), both fresh and frozen, and pasteurized banked donor human milk (DHM), each supplemented with either HMDF or cow's milk-derived fortifier (CMDF). Gestation-specific specimens were analyzed for macronutrients, pH, total solids, antioxidant activity (AA), α-lactalbumin, lactoferrin, lysozyme, and α- and β-caseins. Data were analyzed for variance applying general linear model and Tukey's test for pairwise comparison. Results: DHM exhibited significantly lower (p < 0.05) lactoferrin and α-lactalbumin concentrations than fresh and frozen MOM. HMDF reinstated lactoferrin and α-lactalbumin and exhibited higher protein, fat, and total solids (p < 0.05) in comparison to unfortified and CMDF-supplemented specimens. HMDF had the highest (p < 0.05) AA, suggesting the potential capability of HMDF to enhance oxidative scavenging. Conclusion: DHM, compared with MOM, has reduced bioactive properties, and CMDF conferred the least additional bioactive components. Reinstatement and further enhancement of bioactivity, which has been attenuated through pasteurization of DHM, is demonstrated through HMDF supplementation. Freshly expressed MOM fortified with HMDF and given early, enterally, and exclusively (3E) appears an optimal nutritional choice for extremely premature infants.

Comparative Growth Outcomes in Preterm Infants Fed Either Mother's Own Milk or Donor Human Milk

Objective: To compare growth velocity (GV) in preterm infants fed mother's own milk (MOM) fortified with human milk-based fortifier (HMBF) to those who received donor human milk (DHM) fortified with HMBF. Study Design: A retrospective study of preterm infants with birth weight <1,250 g receiving an exclusive human milk diet. Maternal and infant charts were reviewed for feeding, growth, and short-term neonatal morbidities. Results: On regression analysis, after adjusting (gestational age, multiple births, antenatal steroids, and small for gestational age), no significant difference was observed between the two groups in GV from birth to 32 weeks postmenstrual age (β-coefficient 0.83, 95% confidence interval [CI]: -0.47 to 2.14, p = 0.21), GV from the day of regaining of birth weight to discharge (β-coefficient -0.015, 95% CI: -1.08 to 1.05, p = 0.98). The rate of Grade 3 and 4 intraventricular hemorrhage was significantly higher in the DHM group (19.6% compared to 5.5% in MOM, p = 0.03). Conclusion: At our institution, there was no difference in GV of preterm infants fed HMBF-fortified MOM versus HMBF-fortified DBM.

Differences in the Microbiological Profile of Raw and Pasteurized Breastmilk from Hospital and Community-Based Donors at the First Human Milk Bank in Vietnam

Background: Microbiological quality is one of the key safety standards in human milk bank (HMB) operations. We describe the profiles of bacteria in donor human milk (DHM) before and after the pasteurization of samples collected from breastfeeding women in the hospital and from the community in the first HMB in Vietnam. Methods: Data were collected between February 2017 and January 2022 from an online HMB monitoring system. First, DHM samples were cultured, and the number of colony-forming units (CFU) were counted before (n = 708) and after pasteurization (n = 1146). The gram-staining method combined with the Vitek 2 Compact system were used to identify types of organisms at the Da Nang Hospital for Women and Children’s Laboratory. Passing criteria for DHM included pre-pasteurization samples had a total colony count <105 CFU/mL and post-pasteurization was <10 CFU/mL. Results: During five years of operation, Da Nang HMB had 491 donors (48.7% were hospital and the rest community donors) who donated an average amount of 14.2 L over 45 days. Of this DHM volume, 84.9% of donor samples passed the pre- and post-pasteurization microbiological tests. DHM from community donors had a higher pass rate (87.8%) compared to that from hospital donors (79.5%). Before pasteurization, 15.4% of DHM samples had a bacteria count <103 CFU/mL, 63.0% had 103-<105 CFU/mL, and 21.6% had ≥105 CFU/mL. Most of the unpasteurized DHM samples (93.0%) had microorganism growth: with one organism (16.4%), two (33.9%), three or more (43.6%). After pasteurization, 17.9% samples had a bacteria count of 1−9 CFU/mL and 7.2% had ≥10 CFU/mL. DHM samples from community donors had a lower bacterial count and number of organisms than those from hospital donors both before and after pasteurization. The highest microorganisms from unpasteurized DHM samples were Staphylococcus epidermidis (74.2%), Acinetobacter sp. (52.1%), gram-positive bacillus (51.7%), Staphylococcus coagulase-negative (15.8%), and Staphylococcus aureus (10.5%). Common microorganisms from pasteurized DHM were gram-positive bacillus (21.0%), Staphylococcus epidermidis (3.9%), and Acinetobacter sp. (0.9%). Samples from the hospital tended to have a higher contamination with those microorganisms than those from community donors. Conclusions: The majority of DHM samples in Da Nang passed microbiological testing criteria. DHM from community donors had higher pass rates than hospital donors. Corrective actions are needed to improve HMB operations and hospital microbiological quality standards, as well as general improvements in water and sanitation.

Fact-based nutrition for infants and lactating mothers-The NUTRISHIELD study

Background

Human milk (HM) is the ideal source of nutrients for infants. Its composition is highly variable according to the infant's needs. When not enough own mother's milk (OMM) is available, the administration of pasteurized donor human milk (DHM) is considered a suitable alternative for preterm infants. This study protocol describes the NUTRISHIELD clinical study. The main objective of this study is to compare the % weight gain/month in preterm and term infants exclusively receiving either OMM or DHM. Other secondary aims comprise the evaluation of the influence of diet, lifestyle habits, psychological stress, and pasteurization on the milk composition, and how it modulates infant's growth, health, and development.

Methods and design

NUTRISHIELD is a prospective mother-infant birth cohort in the Spanish-Mediterranean area including three groups: preterm infants <32 weeks of gestation (i) exclusively receiving (i.e., >80% of total intake) OMM, and (ii) exclusively receiving DHM, and (iii) term infants exclusively receiving OMM, as well as their mothers. Biological samples and nutritional, clinical, and anthropometric characteristics are collected at six time points covering the period from birth and until six months of infant's age. The genotype, metabolome, and microbiota as well as the HM composition are characterized. Portable sensor prototypes for the analysis of HM and urine are benchmarked. Additionally, maternal psychosocial status is measured at the beginning of the study and at month six. Mother-infant postpartum bonding and parental stress are also examined. At six months, infant neurodevelopment scales are applied. Mother's concerns and attitudes to breastfeeding are registered through a specific questionnaire.

Discussion

NUTRISHIELD provides an in-depth longitudinal study of the mother-infant-microbiota triad combining multiple biological matrices, newly developed analytical methods, and ad-hoc designed sensor prototypes with a wide range of clinical outcome measures. Data obtained from this study will be used to train a machine-learning algorithm for providing dietary advice to lactating mothers and will be implemented in a user-friendly platform based on a combination of user-provided information and biomarker analysis. A better understanding of the factors affecting milk's composition, together with the health implications for infants plays an important role in developing improved strategies of nutraceutical management in infant care.

Clinical trial registration

https://register.clinicaltrials.gov, identifier: NCT05646940.

Comparing early life nutritional sources and human milk feeding practices: personalized and dynamic nutrition supports infant gut microbiome development and immune system maturation

Exclusive breastfeeding is recommended for the first six months of life, but many infants receive pumped milk, formula, donor human milk, or other nutritional sources during this critical period. Substantive evidence shows early nutrition influences development of the microbiome and immune system, affecting lifelong health. However, the underlying mechanisms are unclear and the nuances of human milk feeding are rarely considered. This review synthesizes evidence from human studies and model systems to discuss the impact of different nutritional sources on co-development of the gut microbiome, antigen tolerance, and immunity. We highlight two key mechanisms: epigenetics and the so-called "weaning reaction". Collectively, this evidence highlights i) the fundamental role of parents' own milk, fed directly at the breast, as a dynamic and personalized nutrition source that drives developmental programming, and ii) the deficiencies of alternative nutritional sources and priority research areas for improving these alternatives when direct breastfeeding is not possible.

Donor human milk processing and its impact on infant digestion: A systematic scoping review of in vitro and in vivo studies

When there is an inadequate supply of mother's milk, pasteurized donor human milk is preferred over formula to supplement feeds for preterm infants. Although providing donor milk helps to improve feeding tolerance and reduce necrotizing enterocolitis, changes to its composition and reductions in bioactivity during processing, are thought to contribute to the slower growth often exhibited by these infants. To improve the clinical outcomes of recipient infants by maximizing the quality of donor milk, research is currently investigating strategies to optimize all aspects of processing, including pooling, pasteurization, and freezing; however, reviews of this literature typically only summarize the impact of a processing technique on composition or bioactivity. Reviews of published research investigating the impact of donor milk processing on infant digestion/absorption are lacking and thus, was the objective for this systematic scoping review, Open Science Framework (https://doi.org/10.17605/OSF.IO/PJTMW). Databases were searched for primary research studies evaluating donor milk processing for pathogen inactivation or other rationale and subsequent effect on infant digestion/absorption. Non-human milk studies or those assessing other outcomes were excluded. Overall, 24 articles from 12,985 records screened were included. Most studied thermal methods to inactivate pathogens, predominantly Holder pasteurization (HoP) (62.5°C, 30 min) and high-temperature short-time. Heating consistently decreased lipolysis and increased proteolysis of lactoferrin and caseins; however, protein hydrolysis was unaffected from in vitro studies. The abundance and diversity of released peptides remain unclear and should be further explored. Greater investigation into less-harsh methods for pasteurization, such as high-pressure processing, is warranted. Only 1 study assessed the impact of this technique and found minimal impact on digestion outcomes compared with HoP. Fat homogenization appeared to positively impact fat digestion (n = 3 studies), and only 1 eligible study investigated freeze-thawing. Identified knowledge gaps regarding optimal methods of processing should be further explored to improve the quality and nutrition of donor milk.

Factors That Influence the Sustainability of Human Milk Donation to Milk Banks: A Systematic Review

Donor human milk is the recommended alternative for feeding preterm or low birth weight infants when the mother's own milk is unavailable or not in sufficient quantity. Globally, the needs of vulnerable infants for donor human milk exceed the supply. This review aimed to identify the factors impacting the sustainability of human milk donation to milk banks. A systematic review of the literature was performed on eight databases to retrieve articles published until December 2021. The study protocol is available in PROSPERO (#CRD42021287087). Among the 6722 references identified, 10 studies (eight quantitative observational and two qualitative) met the eligibility criteria for a total of 7053 participants. Thirty factors influencing the sustainability of the donations to milk banks were identified and categorized as follows: (1) donation duration, (2) donors' infant features (e.g., gestational age, birth weight), (3) donors' features (e.g., socio-demographic characteristics, milk donation history), and (4) factors related to the milk bank and health care systems (awareness and support). The available evidence suggests that larger volumes of donated milk are associated with a longer duration of donation, as are early donation, previous milk donation, and donors with an infant of smaller weight and gestational age. Supporting and encouraging early donation and recruiting donors with infants of low birth weight and low gestational age could support longer donation times and greater volumes of milk donated. To identify efficient strategies and to draw appropriate recommendations to improve donor milk access, future studies should further explore the issues of the sustainability of human milk donation to milk banks.

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records

INTRODUCTION

The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs).

MATERIALS AND METHODS

A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery.

RESULTS

Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers.

CONCLUSIONS

Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

Assessment of Iodine Concentration in Human Milk from Donors: Implications for Preterm Infants

Preterm infants are particularly vulnerable to developing iodine deficiency. Donor human milk (DHM) is the preferred feeding option if the mother’s own milk (MOM) is not available, but information on DHM iodine concentration (DHMIC) is lacking. Hence, we aimed to assess DHMIC to further evaluate the adequacy of iodine provision in preterm infants. Finally, associations that might influence DHMIC were studied. In 113 donors, we measured iodine intake by evaluating dietary records for five consecutive days with the DIAL® Software. From the second day of dietary record, donors provided human milk samples (at least one per day) for four consecutive days. Daily human milk samples were analyzed for DHMIC. A DHMIC ≥ 200 µg/L was considered an adequate iodine content for preterm infants. DHMIC and urine iodine concentration (UIC) were determined using ICP-MS. In our study, 83.2% of donors had a full-term infant. Breastfeeding time range was 1.5−49.4 months. During the dietary record, 55.8% took iodine-containing supplements, providing 40−200 µg/day of iodine. The medians (p25, p75) UIC and DHMIC were 112.4 (75.8, 160.1) and 148.5 (97.6, 206.1) µg/L, respectively. In this iodine-sufficient population, 70% had a DHMIC of <200 µg/L. Donors’ intake of iodine-containing supplements was associated with higher DHMIC.

The Association Between Type of Supplementation in the Newborn Nursery and Breastfeeding Outcomes at 2 and 6 Months of Age

BACKGROUND

Supplementation in the newborn nursery has been associated with shorter breastfeeding duration. However, supplementation may at times be necessary.

RESEARCH AIM

To determine the association between type of supplementation in the newborn nursery (mother's own milk, formula, donor human milk) and breastfeeding outcomes at 2 and 6 months of age.

METHODS

This was a prospective, longitudinal, observational multi-group cohort study. In total, 2,343 surveys were sent to parents who, prior to delivery, indicated intent to exclusively breastfeed. Participants were grouped by type of nursery supplementation. Surveys asked about breastfeeding outcomes when infants were 2 and 6 months old. Our final analytic sample included data from 1,111 healthy newborns ≥ 35 weeks. We used multiple logistic regression to compare future breastfeeding outcomes for infants who were exclusively directly breastfed or who received supplementation during their birth hospitalization.

RESULTS

Both the donor human milk and formula groups had decreased breastfeeding at 2 and 6 months compared to the exclusively directly breastfed group. Notably, for infants who received formula compared to donor human milk, the odds of breastfeeding at 2 and 6 months were 74% and 58% lower, respectively (OR = 0.26, 95% CI [0.12, 0.56] at 2 months; OR = 0.42, 95% CI [0.19, 0.94] at 6 months). The donor human milk group had lower odds of breastfeeding at both follow up times compared to the mother's own milk group.

CONCLUSION

Among those who intend to breastfeed, supplementation with donor human milk instead of formula in the newborn nursery may support longer breastfeeding.

A Pilot Study on Donor Human Milk Microbiota: A Comparison with Preterm Human Milk Microbiota and the Effect of Pasteurization

Human milk (HM) is the best feeding option for preterm infants; however, when mother’s own milk (MOM) is not available, pasteurized donor human milk (DHM) is the best alternative. In this study, we profiled DHM microbiota (19 samples) using 16S rRNA amplicon sequencing and compared its compositional features with the MOM microbiota (14 samples) from mothers who delivered prematurely (PT-MOM). As a secondary study aim, we assessed the specific effect of pasteurization on the characteristics of the DHM microbiota. DHM showed significantly higher alpha diversity and significant segregation from PT-MOM. Compositionally, the PT-MOM microbiota had a significantly higher proportion of Staphylococcus than DHM, with Streptococcus tending to be and Pseudomonas being significantly overrepresented in DHM compared with the PT-MOM samples. Furthermore, pasteurization affected the HM microbiota structure, with a trend towards greater biodiversity and some compositional differences following pasteurization. This pilot study provided further evidence on the HM microbial ecosystem, demonstrating that the DHM microbiota differs from the PT-MOM microbiota, possibly due to inherent differences between HM donors and mothers delivering prematurely, and that pasteurization per se impacts the HM microbiota. Knowledge about HM microbiota needs to be acquired by investigating the effect of DHM processing to develop strategies aimed at improving DHM quality while guaranteeing its microbiological safety.

Experience using donor human milk: A single-center cohort study in Japan

BACKGROUND

Donor human milk (DHM) became available in Japan when the first human milk bank was established in 2017. This study investigated the effects of DHM on enteral nutrition (EN) in very low birth weight (VLBW) infants in the single center in Japan.

METHODS

Seventy-six VLBW infants hospitalized between April 2017 and March 2020 at Showa University Hospital were included in the study. We retrospectively evaluated age (hours) at which EN was initiated and age (days) until complete feeding (EN > 100 mL/kg/day) was achieved. We compared the DHM and non-DHM groups, or the early human milk (EHM) and non-EHM groups. The EHM group was defined as those in which EN was initiated with the mother's own milk or DHM within 12 h of birth.

RESULTS

In 30 extremely low birth weight (ELBW) infants, EN was initiated at significantly earlier postnatal hours in the DHM group compared to those in the non-DHM group. Complete feeding was achieved at significantly earlier ages in the EHM group after adjusting for gastrointestinal complications and gestational age. Additionally, the changes in body weight z-scores from birth to term-equivalent age were significantly greater in the EHM group after adjusting for exclusive breastfeeding and small for gestational age, compared to the non-EHM group. Statistical significance was not noted in 46 subjects (birth weight, 1000-1500 g).

CONCLUSION

The use of DHM may contribute to earlier initiation and achievement of EN, resulting in greater early postnatal growth in ELBW infants in Japan.

Questionnaire survey on donor human milk programs targeting NICUs in Japan

BACKGROUND

Since 2019, neonatal intensive care units (NICUs) with access to human milk banks (HMBs) have increased in Japan. In this study, using a questionnaire survey, we explored an understanding of the purpose, status, and problems of donor human milk (DHM) use and the status of enteral nutrition (EN) in very-low-birthweight infants (VLBWIs) in NICUs with access to HMBs.

METHODS

A questionnaire was sent to 47 NICUs that had access to HMBs. Participants were surveyed from the begining of January to the end of February 2022.

RESULTS

In total, 37 of 47 (78.9%) NICUs responded to the questionnaire. The most common indications for DHM were gestational age of less than 28 weeks (78.3%) and birthweight of less than 1500 g (100%). Informed consent was obtained from the physicians and most parents accepted DHM. All NICUs responded that EN for VLBWIs should start ideally within 24 h of birth, but in reality, nine NICUs (25%) and 18 NICUs (50%) began EN within 12 and 24 h of birth, respectively. Additionally, seven of the nine NICUs that started EN within 12 h after birth routinely used DHM for VLBWIs. For infants with birthweights of 1000-1499 g, it was not uncommon to start EN within 24 h of birth with formula milk.

CONCLUSION

All NICUs responded that the indication for DHM was very-low birthweight and that such infants would receive health benefits from DHM. In Japan, there is a trend of starting EN early in VLBWIs. Accessibility to HMB may be important for starting EN within 24 h of birth.

Effects of High-Pressure Processing, UV-C Irradiation and Thermoultrasonication on Donor Human Milk Safety and Quality

Holder pasteurization (HoP) is the current recommended treatment for donor human milk. Although this method inactivates microbial contaminants, it also negatively affects various milk components. High-pressure processing (HPP, 400, 500, and 600 MPa), ultraviolet-C irradiation (UV-C, 2,430, 3,645, and 4,863 J/L) and thermoultrasonication (TUS, 1,080 and 1,620 kJ/L) were investigated as alternatives to thermal pasteurization (HoP). We assessed the effects of these methods on microbiological safety, and on concentration and functionality of immunoglobulin A, lactoferrin, lysozyme and bile salt-stimulated lipase, with LC-MS/MS-based proteomics and activity assays. HoP, HPP, TUS, and UV-C at 4863 J/L, achieved >5-log₁₀ microbial reduction. Native protein levels and functionality showed the highest reduction following HoP, while no significant reduction was found after less intense HPP and all UV-C treatments. Immunoglobulin A, lactoferrin, and lysozyme contents were also preserved after low intensity TUS, but bile salt-stimulated lipase activity was significantly reduced. This study demonstrated that HPP and UV-C may be considered as suitable alternatives to HoP, since they were able to ensure sufficient microbial inactivation while at the same time better preserving the bioactive components of donor human milk. In summary, our results provide valuable insights regarding the evaluation and selection of suitable processing methods for donor human milk treatment, which may replace HoP in the future.

The Effects of Thermal Pasteurisation, Freeze-Drying, and Gamma-Irradiation on the Antibacterial Properties of Donor Human Milk

The most common pasteurisation method used by human milk banks is Holder pasteurisation. This involves thermal processing, which can denature important proteins and can potentially reduce the natural antimicrobial properties found in human milk. This study assesses the application of a hybrid method comprised of freeze-drying followed by low-dose gamma-irradiation for nonthermal donor human milk pasteurisation. Freeze-drying donor human milk followed by gamma-irradiation at 2 kGy was as efficient as Holder pasteurisation in the reduction of bacterial inoculants of Staphylococcus aureus (10⁶ cfu/mL) and Salmonella typhimurium (10⁶ cfu/mL) in growth inhibition assays. These assays also demonstrated that human milk naturally inhibits the growth of bacterial inoculants S. aureus, S. typhimurium, and Escherichia coli. Freeze drying (without gamma-irradiation) did not significantly reduce this natural growth inhibition. By contrast, Holder pasteurisation significantly reduced the milk’s natural antimicrobial effect on S. aureus growth after 6 h (−19.8% p = 0.01). Freeze-dried and then gamma-irradiated donor human milk showed a strong antimicrobial effect across a dose range of 2–50 kGy, with only a minimal growth of S. aureus observed after 6 h incubation. Thus, a hybrid method of freeze-drying followed by 2 kGy of gamma-irradiation preserves antimicrobial properties and enables bulk pasteurisation within sealed packaging of powderised donor human milk. This work forwards a goal of increasing shelf life and simplifying storage and transportation, while also preserving functionality and antimicrobial properties.

The Current State of Donor Human Milk Use and Practice

Human milk contains nutrients and immune factors that promote health and growth of an infant. Donor human milk is recommended as the best alternative for infants whose mothers' breast milk is unavailable. This article describes the current status of donor human milk practice and suggests the areas of educational and research needs. Articles published in the last 10 years were reviewed, and findings were summarized under 4 themes: (1) women's knowledge and concerns about donor human milk use, (2) hospital practices, (3) cost-effectiveness, and (4) access and affordability of donor human milk. Women were concerned about donor human milk contamination, disease transmission, cost, and access to bank donor human milk, due to lack of knowledge and awareness of donor human milk benefits and its processing procedures. The absence of health care providers' support for donor human milk adds to the confusion. There is a rising trend of donor human milk use in hospitals for both healthy and vulnerable newborns and infants with varying policies on screening for donor human milk use, cost coverage, or consent procedure. However, a shortage of safe and affordable donor human milk is a barrier to its adoption. A standardized guideline is needed for hospitals regarding donor human milk implementation and cost coverage. Education programs for health care providers are needed to improve knowledge and understanding of donor human milk benefits and safety to provide guidance to parents. It is crucial to develop legislation expanding insurance coverage to achieve donor human milk equity and optimizing long-term human milk diet outcomes.

Predicting Protein and Fat Content in Human Donor Milk Using Machine Learning

BACKGROUND

Donor milk is the standard of care for hospitalized very low birth weight (VLBW) infants when mother's milk is unavailable; however, growth of donor milk-fed infants is frequently suboptimal. Variability in nutrient composition of donated milk complicates the production of a uniform pooled product and, subsequently, the provision of adequate nutrition to promote optimal growth and development of VLBW infants. We reasoned a machine learning approach to construct batches using characteristics of the milk donation might be an effective strategy in reducing the variability in donor milk product composition.

OBJECTIVE

The objective of this study was to identify whether machine learning models can accurately predict donor milk macronutrient content. We focused on predicting fat and protein, given their well-established importance in VLBW infant growth outcomes.

METHODS

Samples of donor milk, consisting of 272 individual donations and 61 pool samples, were collected from the Rogers Hixon Ontario Human Milk Bank and analyzed for macronutrient content. Four different machine learning models were constructed using independent variable groups associated with donations, donors, and donor-pumping practices. A baseline model was established using lactation stage and infant gestational status. Predictions were made for individual donations and resultant pools.

RESULTS

Machine learning models predicted protein of individual donations and pools with a mean absolute error (MAE) of 0.16 g/dL and 0.10 g/dL, respectively. Individual donation and pooled fat predictions had an MAE of 0.91 g/dL and 0.42 g/dL, respectively. At both the individual donation and pool levels, protein predictions were significantly more accurate than baseline, whereas fat predictions were competitive with baseline.

CONCLUSIONS

Machine learning models can provide accurate predictions of macronutrient content in donor milk. The macronutrient content of pooled milk had a lower prediction error, reinforcing the value of pooling practices. Future research should examine how macronutrient content predictions can be used to facilitate milk bank pooling strategies.

Maintaining human milk bank services throughout the COVID-19 pandemic: A global response

If maternal milk is unavailable, the World Health Organization recommends that the first alternative should be pasteurised donor human milk (DHM). Human milk banks (HMBs) screen and recruit milk donors, and DHM principally feeds very low birth weight babies, reducing the risk of complications and supporting maternal breastfeeding where used alongside optimal lactation support. The COVID-19 pandemic has presented a range of challenges to HMBs worldwide. This study aimed to understand the impacts of the pandemic on HMB services and develop initial guidance regarding risk limitation. A Virtual Collaborative Network (VCN) comprising over 80 HMB leaders from 36 countries was formed in March 2020 and included academics and nongovernmental organisations. Individual milk banks, national networks and regional associations submitted data regarding the number of HMBs, volume of DHM produced and number of recipients in each global region. Estimates were calculated in the context of missing or incomplete data. Through open-ended questioning, the experiences of milk banks from each country in the first 2 months of the pandemic were collected and major themes identified. According to data collected from 446 individual HMBs, more than 800,000 infants receive DHM worldwide each year. Seven pandemic-related specific vulnerabilities to service provision were identified, including sufficient donors, prescreening disruption, DHM availability, logistics, communication, safe handling and contingency planning, which were highly context-dependent. The VCN now plans a formal consensus approach to the optimal response of HMBs to new pathogens using crowdsourced data, enabling the benchmarking of future strategies to support DHM access and neonatal health in future emergencies.

The impact of the Covid-19 pandemic on North American milk banks

This study aims to understand the impact of the Covid‐19 pandemic on human milk banking services in North America, with a focus on the United States. We triangulated questionnaire data with interviews and text‐based website data. Of the 30 human milk bank services from which data were obtained, the majority faced substantial internal organization change in terms of staffing and protocols and experienced financial hardship in particular because of decreases in donor human milk orders. At the same time, most banks reported an increase in their numbers of donors and in the volume of milk collected. These results show that the pandemic significantly affected the way in which many North American milk banks operate, some lactating mothers donate their milk and, at least during the first few months of the crisis, certain hospitals' donor human milk ordering patterns changed. It suggests in particular that stay‐at‐home orders and the turn to remote work created the potential for a surge in human milk available for donation as a number of parents no longer needed their surplus for their own children. Legal and policy reform should focus on replicating the positive effects of the pandemic on breastfeeding by guaranteeing paid parental leave and flexible work conditions. Initiatives should also aim at counteracting its negative effects by mandating the insurance coverage of donor human milk, supporting milk banks financially and, more generally, integrating lactation and human milk banking services within the health system.

Influence of Human Milk on Very Preterms' Gut Microbiota and Alkaline Phosphatase Activity

The FEEDMI Study (NCT03663556) evaluated the influence of infant feeding (mother's own milk (MOM), donor human milk (DHM) and formula) on the fecal microbiota composition and alkaline phosphatase (ALP) activity in extremely and very preterm infants (≤32 gestational weeks). In this observational study, preterm infants were recruited within the first 24 h after birth. Meconium and fecal samples were collected at four time points (between the 2nd and the 26th postnatal days. Fecal microbiota was analyzed by RT-PCR and by 16S rRNA sequencing. Fecal ALP activity, a proposed specific biomarker of necrotizing enterocolitis (NEC), was evaluated by spectrophotometry at the 26th postnatal day. A total of 389 fecal samples were analyzed from 117 very preterm neonates. Human milk was positively associated with beneficial bacteria, such as Bifidobacterium, Bacteroides ovatus, and Akkermancia muciniphila, as well as bacterial richness. Neonates fed with human milk during the first week of life had increased Bifidobacterium content and fecal ALP activity on the 26th postnatal day. These findings point out the importance of MOM and DHM in the establishment of fecal microbiota on neonates prematurely delivered. Moreover, these results suggest an ALP pathway by which human milk may protect against NEC.

Inadequate Content of Docosahexaenoic Acid (DHA) of Donor Human Milk for Feeding Preterm Infants: A Comparison with Mother's Own Milk at Different Stages of Lactation

A cross-sectional single-center study was designed to compare the fatty acids profile, particularly docosahexaenoic acid (DHA) levels, between milk banking samples of donor human milk and mother’s own milk (MOM) for feeding preterm infants born before 32 weeks’ gestation. MOM samples from 118 mothers included colostrum (1–7 days after delivery), transitional milk (9–14 days), and mature milk (15–28 days and ≥29 days). In the n-3 polyunsaturated fatty acids (PUFAs) group, the levels of α-linolenic acid (C18:3 n3) and DHA (C22:6 n3) showed opposite trends, whereas α-linolenic acid was higher in donor human milk as compared with MOM, with increasing levels as stages of lactation progressed, DHA levels were significantly lower in donor human milk than in MOM samples, which, in turn, showed decreasing levels along stages of lactation. DHA levels in donor human milk were 53% lower than in colostrum. Therefore, in preterm infants born before 32 weeks’ gestation, the use of pasteurized donor human milk as exclusive feeding or combined with breastfeeding provides an inadequate supply of DHA. Nursing mothers should increase DHA intake through fish consumption or nutritional supplements with high-dose DHA while breastfeeding. Milk banking fortified with DHA would guarantee adequate DHA levels in donor human milk.

Frozen Mother's Own Milk Can Be Used Effectively to Personalize Donor Human Milk

Feeding preterm infants mother's own milk (MOM) lowers rates of sepsis, decreases necrotizing enterocolitis, and shortens hospital stay. In the absence of freshly expressed MOM, frozen MOM (FMOM) is provided. When MOM is unavailable, preterm infants are often fed pasteurized donor human milk (DHM), rendering it devoid of beneficial bacteria. We have previously reported that when MOM is inoculated into DHM to restore the live microbiota [restored milk (RM)], a similar microbial diversity to MOM can be achieved. Yet, it is unknown if a similar diversity to MOM can be obtained when FMOM is inoculated into DHM. The goal of this study was to determine whether a similar microbial composition to MOM could be obtained when FMOM is used to personalize DHM. To this end, a fresh sample of MOM was obtained and divided into fresh and frozen fractions. MOM and FMOM were inoculated into DHM at different dilutions: MOM/FMOM 10% (RM/FRM10) and MOM/FMOM 30% (RM/FRM30) and incubated at 37°C. At different timepoints, culture-dependent and culture-independent techniques were performed. Similar microbiota expansion and alpha diversity were observed in MOM, RM10, and RM30 whether fresh or frozen milk was used as the inoculum. To evaluate if microbial expansion would result in an abnormal activation on the innate immune system, Caco-2 epithelial cells were exposed to RM/FRM to compare interleukin 8 levels with Caco-2 cells exposed to MOM or DHM. It was found that RM samples did not elicit a significant increase in IL-8 levels when compared to MOM or FMOM. These results suggest that FMOM can be used to inoculate DHM if fresh MOM is unavailable or limited in supply, allowing both fresh MOM and FMOM to be viable options in a microbial restoration strategy.

Relationship Between Milk Fat Globule-Epidermal Growth Factor 8 and Intestinal Cytokines in Infants Born Preterm

OBJECTIVES

To investigate the relationships between dietary intake and fecal concentrations of milk fat globule-epidermal growth factor 8 (MFG-E8), and between fecal concentrations of MFG-E8 and markers of intestinal inflammation in infants born preterm.

STUDY DESIGN

Fecal samples were collected daily and enteral feedings were sampled weekly. MFG-E8 in enteral feedings and feces, and cytokine concentrations in feces were quantified by enzyme-linked immunosorbent assay.

RESULTS

Milk MFG-E8 concentrations were significantly greater in unfortified mother's own milk (MOM) and MOM with human milk fortifier than either donor human milk or preterm formula. MFG-E8 concentrations in fecal samples were positively correlated with MFG-E8 concentrations in respective milks. High MFG-E8 exposure (≥60 mL/kg/day of feedings that include MOM or MOM with human milk fortifier) was associated with lower concentrations of proinflammatory cytokines (interleukin-8, tumor necrosis factor-α, and monocyte chemoattractant protein-1) and higher concentrations of the anti-inflammatory cytokine interleukin-4 in feces, compared with low MFG-E8 exposure.

CONCLUSIONS

Infants born preterm who were fed MOM had greater concentrations of MFG-E8 and lower concentrations of proinflammatory cytokines in fecal samples than other diets or no feedings. These data further support the protective role of MOM, possibly because of MFG-E8, against intestinal inflammation.

A systematic review of economic evaluations for donor human milk versus standard feeding in infants

Reviews on the cost/outcome of donor human milk (DHM) for infants requiring care in the neonatal intensive care unit (NICU) setting have been undertaken. However, the cost-effectiveness evidence is unclear. Therefore, we conducted a systematic review of published full economic evaluations of DHM versus standard feeding in infants in neonatal care with the aim of undertaking a narrative synthesis of the cost-effectiveness evidence and critical appraisal of the methods used. MEDLINE, EMBASE, Web of Science, Cochrane Library, Centre for Reviews and Dissemination (CRD) and PROSPERO databases were searched. Studies were included if they were full economic evaluations (model-based or trial-based), the participants were infants in neonatal units requiring nutritional support, the intervention was DHM and the comparator was any standard feeding option. There were no restrictions on outcome measures. Two authors independently assessed eligibility, extracted data, assessed quality and cross-checked results, with disagreements resolved by consensus. Information extracted focused on study context, and economic evaluation methods and results. Of 2861 studies, seven were included. Six (86%) studies originated from high-income countries. Four (57%) of the studies were model-based. Although we could not directly compare the different studies, due to the heterogenous nature of health and economic parameters used in the studies, all DHM interventions indicated cost-effective or cost saving results. This review suggests that economic evaluation of DHM interventions is an expanding area of research. Although these interventions show promise, future economic evaluations of DHM interventions need to explicitly provide more details on long-term costs and consequences.

Methods of mixing donor human milk during bottling results in fat differences between samples within a pool

The influence of milk-banking processes on nutrients in donor human milk (DHM) is largely unknown. Previous studies have measured nutrients between pools of DHM, but within-pool nutrient differences (between bottles from the same pool) have yet to be elucidated. The objective of this study was to gain a better understanding of the effect of different mixing characteristics on the distribution of fat, protein, IgA, and lysozyme in bottled, raw DHM. Pools of DHM were created in a laboratory setting according to published human milk-banking guidelines and assigned to a mixing treatment (mixing during bottling method, pooling container material, and refrigerated hold time). Four mixing protocols using glass pooling containers and a 1-h refrigerated hold time were tested: control (no mixing during bottling); manual-A (Man-A, hand swirl after pouring 3 bottles); manual-B (Man-B, hand swirl after pouring every bottle); and mechanical-G (Mech-G, continuous stirring with a magnet). As secondary objectives, we compared the effect of a glass and a plastic pooling container with mechanical mixing (mechanical-P, Mech-P), and compared refrigerated delays of 1 and 24 h before bottling with manual mixing (manual-A24, Man-A24). To control for differences in nutrient content, comparisons between treatments were made using absolute percent difference from the treatment-specific mean; and comparisons within a treatment were made using the ratio of fat content in a bottle to fat content in the first bottle of the same pool. We did not observe differences in nutrient distribution between Man-A, Man-B, and Mech-G in pools held for 1 h, but all were significantly different from the control for fat. There were no differences between glass or plastic pooling containers when mechanical mixing was used. Holding a pool in the refrigerator for 24 h before bottling created significantly greater fat distribution than holding a pool for 1 h. Outcomes were the result of controlled experiments. In summary, manual and mechanical mixing of 1,700-mL DHM pools produces similar fat and protein distributions when DHM is pooled and bottled after a 1-h hold time. When DHM is held for 24 h before bottling, more research is needed to determine the duration of initial mixing needed to reduce fat variability between bottles.

Term Infants Fed Exclusively With Donor Milk May Require Vitamin C Supplementation

BACKGROUND

When there is insufficient mother's milk for preterm infants, fortified human donor milk (DM) is the preferred supplement. Recently, there is growing interest in providing DM to term infants. Aside from vitamin D, mother's milk is a complete source of nutrition for term infants. It is unknown whether supplementation of micronutrients is required for term infants exclusively fed DM, particularly for nutrients affected by heat processing, such as vitamin C. The objective of this study was to determine the total vitamin C content in DM and whether it would be adequate for an infant exclusively fed DM.

METHODS

DM samples (n = 56) were collected at a Canadian milk bank from April to August 2018. Vitamin C concentration was determined by high-performance liquid chromatography.

RESULTS

DM samples had a vitamin C concentration of 17.7 ± 9.8 mg/L (mean ± SD) and were variable, ranging from 1.9 to 43.2 mg/L. Using these values and assuming an exclusive DM consumption of 780 mL/day, the estimated vitamin C intake would be 13.8 ± 8.6 mg (mean ± SD), falling below the adequate intake of 40 mg/day for infants (0-6 months old).

CONCLUSION

Vitamin C supplementation is required for all infants if DM is the sole source of nutrition. Future studies should investigate other heat- and light-sensitive nutrients.

The Interaction of Donor Human Milk Availability and Race/Ethnicity on Provision of Mother's Own Milk for Very Low Birth Weight Infants

Objective: To compare (1) differences in mother's own milk (MOM) provision and enteral feeding outcomes, (2) differences in preterm formula and donor human milk (DHM) uses as bridges to exclusive MOM feedings at discharge, and (3) MOM and enteral feeding outcomes for racial/ethnic subgroups before and after the implementation of a hospital DHM feeding program. Methods: Retrospective data from 313 very low birth weight (VLBW; birth weight <1,500 g) infants born between January 2011 to December 2012 (pre-DHM, n = 157) and April 2013 to March 2015 (DHM, n = 156) were analyzed. Results: For this predominantly low-income and minority VLBW infant cohort, the percent of enteral fed hospitalization days was higher in the DHM group (pre-DHM 94% [88, 97] versus DHM 98% [95, 99], p < 0.001). Although MOM remained the predominant first enteral feeding type, significantly fewer DHM infants received MOM (pre-DHM 89% versus DHM 75%, p = 0.001). During days of life 1-14, a lower percentage of DHM infants received 100% MOM (pre-DHM 68% versus DHM 55%, p = 0.02). For the entire cohort, the risk for MOM discontinuation was significantly associated with maternal young age, multiparity, non-Hispanic Black race/ethnicity, and low income. Implementation of a DHM program did not predict duration of MOM feedings. However, non-Hispanic White infants had a longer duration of MOM feedings with DHM availability. Conclusions: Our findings highlight the importance of using precise dose and exposure period methodology to determine the impact of DHM on MOM provision. In addition, DHM availability may be associated with varying effects on MOM provision among racial/ethnic groups.

Analysis of Thermal Sensitivity of Human Cytomegalovirus Assayed in the Conventional Conditions of a Human Milk Bank

One of the main concerns in human milk banks (HMB) is the transmission of human cytomegalovirus (HCMV) that could be present in the milk of infected women. There are consistent data showing that this virus is destroyed by Holder pasteurization (62.5°C for 30 min), but there is a lack of information about the response of the virus to the treatment at lower temperatures in strict HMB conditions. In order to analyze the effectiveness of different temperatures of pasteurization to eliminate HCMV in human milk, a preliminary assay was performed incubating HCMV-spiked raw milk samples from donor mothers at tested temperatures in a PCR thermocycler and the viral infectivity was assayed on cell cultures. No signs of viral replication were observed after treatments at temperatures equal or >53°C for 30, 20, and 10 min, 58°C for 5 min, 59°C for 2 min, and 60°C for 1 min. These data were confirmed in a pasteurizer-like model introducing HCMV-spiked milk in disposable baby bottles. No viral infectivity was detected on cell cultures after heating treatment of milk for 30 min at temperatures from 56 to 60°C. Thus, our results show that by using conventional pasteurization conditions, temperatures in the range of 56-60°C are enough to inactivate HCMV. Consequently, we consider that, in order to provide a higher quality product, the current recommendation to pasteurize both mother's own milk and donated milk at 62.5°C must be re-evaluated.

Donor Human Milk Use in Populations Other than the Preterm Infant: A Systematic Scoping Review

Introduction: Exclusive breastfeeding is recommended for an infant's first 6 months of life. If unable to breastfeed, expressed breast milk, including donor human milk (DHM), is recommended for optimal nutrition. Benefits of DHM in preterm infants have been established by extensive research. However, less is known about DHM use in other populations. Objective: To conduct a scoping review of the literature regarding DHM use in populations other than preterm infants. Materials and Methods: PubMed and Clinicaltrials.gov were used to search for articles and clinical trials published between January 1, 2000 and February 29, 2020. In total, 182 articles and reports were identified and screened by 2 independent reviewers. Results: Twenty-six articles met inclusion criteria and were reviewed. Studies were mostly observational in design and included infants born >35 weeks gestational age with health risks (9/26) and healthy infants (14/26). Most studies in infants with health risks (7/9) investigated clinical outcomes, with small, observational studies suggesting potential improvements in feeding tolerance and gastrointestinal health. Regarding healthy infants, no studies addressed growth, only one study measured clinical outcomes, and findings related to breastfeeding outcomes were conflicting. Over half of the studies reviewed (15/26) were not designed to establish a potential relationship between DHM use and relevant health-related outcomes. Conclusion: The current evidence of DHM use in populations other than preterm infants is limited by lack of direct health measures and infrequent use of randomized trials. More research is warranted to investigate clinical, growth, and breastfeeding outcomes.

High-Temperature Short-Time Preserves Human Milk's Bioactive Proteins and Their Function Better Than Pasteurization Techniques With Long Processing Times

Donor human milk is generally processed by holder pasteurization (HoP) at 62. 5°C for 30 min. This temperature-time combination is sufficient for eliminating pathogens in donor milk, but also negatively affects several bioactive milk components. Long heating up times may further affect the bioactive properties of pasteurized milk. High-Temperature-Short-Time (HTST), a treatment with shorter processing times (72°C for 15 sec), was investigated as a suitable alternative to HoP. In addition, pasteurization methods that follow the same temperature regime but with varying heating up times were compared. Human milk samples from four different donors were combined into one pool, which was then used to perform all analyses. The effects of these methods on the levels and functionality of immunoglobulin A, lactoferrin, lysozyme and bile salt-stimulated lipase, were evaluated with LC-MS/MS-based proteomics and activity assays, while the pasteurization efficacy was evaluated with an alkaline phosphatase test. HoP, a treatment with long processing times, times, caused the highest reduction in all proteins studied (reduced by 50-98%). Compounds such as lactoferrin and bile salt-stimulated lipase that are more sensitive to heat treatments were better retained with HTST, but their levels and functionality were still significantly lower than those of untreated donor milk (52 and 81% reduction of lactoferrin and bile salt-stimulated lipase activity, respectively). Our findings showed that a treatment with considerably shorter processing times, such as HTST, may reduce the thermal damage caused to the bioactive proteins compared to HoP, without affecting pasteurization efficacy. Since the vast majority of the donor human milk banks that are currently operating on a global level apply HoP to donor milk, our findings may provide relevant information for the optimization of donor milk processing.

Demographics and Geographic Distribution of Mothers Donating to a Nonprofit Milk Bank

Background: The Human Milk Banking Association of North America (HMBANA) is a nonprofit association that standardizes and facilitates the establishment and operation of nonprofit donor human milk banks in North America. Few studies have examined milk donor characteristics and geographic distribution, and little is known about how donor characteristics change with time. Materials and Methods: We performed a retrospective cohort study of mothers who donated to Mothers' Milk Bank Northeast (MMBNE) between January 1, 2011 and September 1, 2019. Data collected from MMBNE donor surveys and collection procedures were analyzed using descriptive and comparative statistics. Donor characteristics were examined for secular trends. Results: Donors (n = 3,764) were of mean age 32.5 years (median 32; IQR 30-35) and most donated more than once (median 2; IQR 1-3; range 1-41). The majority of donors gave birth to term infants and resided in New England; however, MMBNE donors were located in 39 states at the time of donation. Median total volume donated per donor was median 11,396 mL (380 Oz); IQR 6,020-24,242 mL. Mothers of preterm compared with term infants were more likely to be bereaved (p < 0.01) and donated larger volumes (p < 0.01). Over time, number of first-time donors increased, although donors became less likely to have preterm infants or to reside in Massachusetts or New England. Conclusions: Donors to MMBNE varied greatly in age and were broadly distributed geographically. Donor characteristics changed substantially over time. Enhanced understanding of the characteristics of donors may improve the efficiency of efforts to promote milk donation.

Evidence-Based Practices Reduce Necrotizing Enterocolitis and Improve Nutrition Outcomes in Very Low-Birth-Weight Infants

BACKGROUND

Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants. Survivors may suffer both short- and long-term morbidities. Current evidence suggests that the incidence of NEC can be reduced by standardizing the care delivery in addressing key risk factors including an altered gut microbiome, use of formula milk, hyperosmolar feeds, and unrestricted use of high-risk medications METHODS: Since 2014, the department has a workgroup who analyzed all cases of NEC within a month of diagnosis to identify preventable risk factors. Existing evidence-based quality improvement strategies were revised and new ones were implemented sequentially over the next 4 years. These strategies include (1) a standardized feeding protocol, (2) early initiation of enteral feeding using human milk, (3) optimization of the osmolality of preterm milk feeds using standardized dilution guidelines for additives, and (4) promotion of healthy microbiome by use of probiotics, early oral care with colostrum and by restricting high-risk medications and prolonged use of empirical antibiotics RESULTS: Baseline characteristics of the patients including sex, gestational age, and birth weight were similar during the study period. After implementing the evidence-based practices successively over 4 years, the incidence of NEC in very- low birth-weight (VLBW) infants dropped from 7% in 2014 to 0% (P < .001) in 2018. The duration of parenteral nutrition, use of central line, and days to full feeds were also reduced significantly (P < .05) CONCLUSION: Adopting evidence-based best practices resulted in a significant decrease in the incidence of NEC and improved the nutrition outcomes in VLBW infants.

Milk Bank Pooling Practices Impact Concentrations and Variability of Bioactive Components of Donor Human Milk

Background: Donor human milk (DHM) bank practices, such as pasteurization and pooling according to postpartum age of milk donations and number of donors included in a pool may impact the resulting concentration of bioactive components of DHM. Aims: We determined the impact of Holder pasteurization, postpartum milk age, and pool donor number (number of donors included in a pool) on resulting concentrations of total immunoglobulin A (IgA; which provides immune protection to the recipient infant) and insulin (an important hormone for gut maturation).We also documented inter-relationships between these bioactive components and macronutrients in DHM pools. Methods: Pre and post-pasteurization aliquots of 128 DHM samples were obtained from the Rocky Mountain Children's Foundation Mother's Milk Bank (a member of the Human Milk Banking Association of North America, HMBANA). Macronutrients were measured via mid-infrared spectroscopy. Total IgA was measured via customized immunoassay in skim milk and insulin was measured via chemiluminescent immunoassay. Results: Mean post-pasteurization total IgA concentration was 0.23 ± 0.10 (range: 0.04-0.65) mg/mL a 17.9% decrease due to pasteurization (n = 126). Mean post-pasteurization DHM insulin concentration was 7.0 ± 4.6 (range: 3-40) μU/mL, a decrease of 13.6% due to pasteurization (n = 128). The average DHM pool postpartum milk age was not associated with total IgA or insulin concentrations, but pool donor number was associated with bioactive components. Pools with only one donor had lower total IgA and lower insulin concentrations than pools with at least 2 donors (p < 0.05). Increasing the number of donors in a pool decreased the variability in total IgA and insulin concentrations (p < 0.04). Conclusion: Increasing the number of donors included in DHM pools may help optimize bioactive components in DHM received by premature infants. These results help inform milk banking practices to decrease compositional variability in produced DHM pools.

Ensuring Exclusive Human Milk Diet for All Babies in COVID-19 Times

The coronavirus disease (COVID-19) pandemic has ramifications for the delivery of newborn nutrition and care services. World Health Organization recommends continuation of breastfeeding in these difficult times, with due precautions. If direct breastfeeding is not possible, milk expression should be explored. Pasteurized donor human milk from milk banks may be fed if mother's own milk is not available. To universalize access to human milk, the Indian government has proposed the establishment of comprehensive lactation management centers/milk banks, lactation management units, and lactation support units at all levels of the public health system. Due to COVID-19, these centers are encountering additional challenges cutting across interventions of rooming in, breastfeeding, milk expression, and provision of donor milk and kangaroo mother care. We discuss issues faced and alleviation measures taken by these centres in relation to provision of an exclusive human milk diet for infants during the pandemic.

Fat and Protein Variability in Donor Human Milk and Associations with Milk Banking Processes

Background: The impact of milk banking processes on macronutrient variability in donor human milk (DHM) is largely unknown. Objective: To gain a better understanding of fat and protein composition in DHM and assess potential relationships with modifiable milk bank processes. Methods: Samples of raw, pooled DHM were collected from 20 milk banks (n = 300) along with the following processing attributes: if macronutrient analysis was used to select donors for pooling (target pooling; yes/no), number of donors per pool, pooling container material (glass/plastic/other), and method for mixing during bottling (manual/mechanical). Fat and protein were assessed. Homoscedasticity was assessed and magnitude of the spread was quantified. Results: Fat ranged from 1.9 to 6.1 g/dL (n = 298) and protein ranged from 0.7 to 1.4 g/dL (n = 300). Variability in fat was significantly lower in samples that had been target pooled (p = 0.04), contained more donors per pool (p < 0.001), and had been mixed mechanically (p < 0.001). Variability in protein was significantly lower in samples that contained more donors per pool (p = 0.001). In a stratified analysis, increasing the number of donors per pool only reduced nutrient variability in samples that were not target pooled. Conclusion: For milk banks that do not target pool, using a greater number of donors in a pool may reduce fat and protein variability.

Cost analysis showed that feeding preterm infants with donor human milk was significantly more expensive than mother's milk or formula

AIM

This study analysed the comparative cost of feeding donor human milk to preterm infants compared to mother's own milk and formula.

METHODS

A document and process analysis and a time measurement study were carried out at the milk bank of the Level 1 Perinatal Center of the University Hospital of Greifswald, Germany, from April to June 2017. The cost analysis data were provided by the University's financial department.

RESULTS

The total cost per year was €92 085.02 for 300 litres of donor human milk: 27% of this was material costs, 51% was personnel costs, and 22% was other overheads. The average cost per litre was €306.95, and staff time was 492 minutes per litre. The total marginal cost for each additional litre of donor human milk, formula or unpasteurised mother´s milk was €82.88, €10.28 and €38.42, respectively. Pasteurising a litre of donor milk cost €3.51.

CONCLUSION

Providing preterm infants with donor milk was much more expensive than using formula or mother's own milk, but the cost of pasteurisation was minimal.

Feeding the preterm infant: an overview of the evidence

Feeding from own mother's milk is not always an option for preterm infants, and choosing between alternative means of feeding should be made in light of their effect on infants' health. In this work, we aimed to present evidence regarding feeding pre-term infants with human milk, either own mother's or donor milk (DM), and the potential effects on growth and other health related outcomes. Exclusive breastfeeding (BF) remains the optimal option, whereas feeding with DM as a sole diet or supplemental to maternal milk confers immunological advantages and fewer rates of necrotising enterocolitis against preterm formula feeding, yet the latter results in greater growth velocity. Literature gaps in the use of DM, practical suggestions for choosing suitable feeding means (i.e. continuous support of BF, adequate education regarding feeding preterm infants, including DM), and future perspectives on the potential effects of dietary manipulations of the maternal diet, are also discussed.