Exclusive Human Milk Diet Research Articles

Use of exclusive human milk diet in a neonate with single ventricle physiology supported on a ventricular assist device as a bridge to heart transplantation: case report.

Malnutrition is common among paediatric heart failure patients, with nutritional rehabilitation critical for survival and optimal health outcomes. Ventricular assist devices have been associated with improved growth, though additional nutritional support may be needed. Here, we report the use of human milk-based fortifiers to avoid severe malnutrition in a neonate supported on a ventricular assist device until transplantation.

A budget impact analysis of exclusive human milk diet in very low birth weight infants in United Arab Emirates

Introduction Very low birth weight (VLBW) infants have the highest rate of neonatal intensive care unit (NICU) admissions owing to the higher comorbidities associated with premature birth and long hospital stays. VLBW infants fed a bovine (BOV)-based diet have higher mortality rates, necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and other comorbidities than those fed 100% human milk-based products. This study aims to evaluate the budgetary impact of adopting an exclusive human milk diet (EHMD) instead of a BOV-based diet in VLBW infants from Al-Ain Hospital, Sheikh Shakhbout Medical City, and Dubai Health Authority (DHA) in the United Arab Emirates (UAE). Methods We use a decision tree model to estimate the budget impact of adopting EHMD versus the current local practice (BOV) over five years. Patients enter the tree model and have a probability of transitioning to one of the following mutually exclusive health states: NEC, which may be treated medically or surgically; LOS, NEC, and LOS; or neither NEC nor LOS. Depending on the feeding strategy, infants in the aforementioned health states are likely to develop any of the following complications: retinopathy of prematurity, bronchopulmonary dysplasia, or short bowel syndrome. The model accounts for the costs associated with diet, management of health states and complications, and the follow-up period. Results Al-Ain Hospital saved United Arab Emirates Dirham (AED) 3.3 million ($1.4million) in the first year of the EHMD feeding arm and AED 16.6 million ($7.1million) over the course of five years. In comparison to Sheikh Shabout Medical City and DHA, AED 36.7 million ($15.8million) and AED 24 million ($10.3million) were saved over five years, respectively, with AED 7.3 million ($3.1million) and 4.8 million ($2million) saved in the first year. The estimated pooled results across the three institutions were AED 5.1 million ($2.2million) and AED 25.7 million ($11million) savings in the first year and over five years, respectively. Conclusion Implementing the EHMD feeding scheme in VLBWs that has significant clinical benefits has resulted in substantial budget savings from the payer’s perspective in the UAE owing to fewer comorbidities associated with premature birth and shorter hospital stays. It is highly recommended for the Emirati health care settings to evaluate the real-world neonatal complication rates.

Is an Exclusive Human Milk Diet at the Time of Neonatal Intensive Care Unit Discharge Adequate to Maintain Growth and Neurodevelopment among Very Preterm Infants?

Background: An exclusive human milk (EHM) diet has numerous benefits. Formula supplementation may be recommended for former preterm infants at the time of neonatal intensive care unit (NICU) discharge to meet perceived metabolic demands and caloric goals. Recommendations addressing postdischarge nutrition for very preterm infants (VPTIs) are controversial, as the benefits of human milk supplementation regarding long-term growth, neurodevelopment, and chronic conditions are mixed. Objective: To compare growth and neurodevelopment of former VPTI fed an EHM diet to a supplemented/formula diet at NICU discharge. Materials and Methods: A retrospective cohort study of VPTI was followed at the Regional Neonatal Follow-up Program. Patients were categorized by diet at NICU discharge: EHM diet; mixed diet (EHM and formula); and exclusive formula diet. Growth percentile ranks at the first neonatal follow-up visit and 3 years of age were compared by diet type at NICU discharge. Neurodevelopmental outcomes as measured by the Bayley Scales of Infant Development 3rd Edition at 3 years of age were also compared. Results: Among 835 VPTIs, weight percentiles at the first neonatal follow-up visit were similar between the three NICU discharge diet types. One hundred fifty-eight subjects received neurodevelopmental evaluations at 3 years of age; anthropometrics and neurodevelopment were similar irrespective of diet at NICU discharge. Conclusion: An EHM diet at NICU discharge is appropriate to support growth in infancy as well as growth and neurodevelopment through 3 years of age. Thus, this raises the question of whether routine nutritional supplementation is necessary for VPTIs at NICU discharge.

Evaluation of growth and feeding tolerance in infants with single-ventricle physiology receiving retrospective standard of care feeding regimens compared with protocolised formula or exclusive human milk feeding regimens.

Determine whether weight gain velocity (g/day) 30 days after initiating feeds following cardiac surgery and other clinical outcomes improve in infants with single-ventricle physiology fed an exclusive human milk (EHM) diet with early fortification compared to non-protocolised "standard of care." This retrospective cohort study compares term infants with single-ventricle physiology who underwent neonatal surgical palliation. The retrospective control group (RCG) was fed according to non-protocolised standard of care at a single centre and was compared with infants in a previous protocolised multi-site randomised controlled trial assigned to either an EHM group or a control group (TCG). The primary outcome measure is weight gain velocity. Secondary outcomes include change in weight z-score, and incidence of feeding intolerance and necrotising enterocolitis. We evaluated 45 surgically palliated neonates with single-ventricle physiology compared to the prior trial patients (EHM = 55, TCG = 52). Baseline demographics were similar between groups, except the RCG had fewer patients with hypoplastic left heart syndrome (51% vs. 77% vs. 84%, p = 0.0009). The RCG grew similarly to the TCG (7.5 g/day vs. 8.2 g/day), and both groups had significantly lower growth than the EHM group (12 g/day). Necrotising enterocolitis/suspected necrotising enterocolitis were similar in the RCG versus TCG but significantly higher in the RCG compared to the EHM group (20.5% vs. 3.6%, p = 0.033). Incidences of other morbidities were similar. Neonates with single-ventricle physiology have improved short-term growth and decreased risk of necrotising enterocolitis or suspected necrotising enterocolitis when receiving an EHM diet after surgical palliation compared to non-protocolised feeding with bovine formula.

Exclusive Human Milk Diets and the Reduction of Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) is common in preterm infants, especially infants less than 32weeks gestation. Mortality from NEC is 7% and occurs in 1 out of 1000 preterm infants. Studies have shown the efficacy of an exclusive milk from mother diet in decreasing rates of NEC and associated mortality. To evaluate the effectiveness of an existing exclusive human milk diet (EHMD) protocol on the incidence of NEC in extremely premature infants. EHMD, for the purposes of this project is defined as breast milk of mother, with or without human milk-based fortifier. A single-center retrospective quasi-experimental study. The sample included 201 infants born less than 32weeks gestation, weighing less than 1250 grams, small for gestational age (SGA) and with low Apgar scores. Outcomes measured included incidences of NEC, mortality, and co-morbidities in infants pre- and postinitiation of an EHMD protocol. Just 4.8% of the EHMD group had a NEC diagnosis compared to 10.5% of the bovine-based (BOV) group. There was a 1% mortality rate of the EHMD group as compared to 6% in the BOV group. The EHMD group had a statistically significant greater weight gain during hospitalization as compared to infants fed BOV ( P =<.05). Neonatal intensive care units should consider EHMDs for use in this infant population. Future research is needed to support dissemination of the use of EHMD as standard of practice.

The impact of exclusive human milk diet on short-term growth of very preterm infants.

The impact of exclusive human milk diet (EHMD) on postnatal growth remains controversial. This study aims to investigate the association between EHMD and short-term growth. This multicenter retrospective study aims to compare growth between the EHMD and non-EHMD groups among infants <32 weeks of gestation. Primary outcomes include weight, length, and head circumference growth trajectories between birth and 34 weeks postmenstrual age. Sensitivity and subgroup analyses were performed. An EHMD was independently associated with poorer length growth, especially in infants born at ≥28 weeks' gestation or those exposed to hypertensive disorders of pregnancy. While initiating fortification at <26 kcal/oz on an EHMD showed inferior growth, initiating fortification at ≥26 kcal/oz was associated with improved weight growth, and similar length and head circumference growth when compared to the non-EHMD group. An EHMD with initial fortification at ≥26 kcal/oz may be implemented to avoid bovine milk exposure while sustaining comparable growth.

Association of Fortification with Human Milk versus Bovine Milk-Based Fortifiers on Short-Term Outcomes in Preterm Infants-A Meta-Analysis.

This meta-analysis assessed short-term outcomes after using human milk-derived fortifiers (HMFs) compared with bovine milk fortifiers (BMFs) in preterm infants fed an exclusive human milk (HM) diet, either mother's own milk (MOM) or donor human milk (DHM). We searched PubMed, Embase, Google Scholar, CENTRAL and CINHAL between January 2015 and August 2023 for studies reporting outcomes in infants with ≤28 weeks gestation and/or birthweight ≤ 1500 g on an exclusive human milk diet fortified with HMF versus BMF. The primary outcomes were death and NEC (stage ≥ 2). Four studies with a total of 681 infants were included. Mortality was significantly lower in infants fed with an HM-HMFs diet (four studies, 681 infants; RR = 0.50, 95% CI = 0.26-0.94; p = 0.03; I2 = 0%), NEC was similar between the two groups (four studies, 681 infants; RR = 0.48, 95% CI = 0.20-1.17; p = 0.11; I2= 39%). BPD was higher in the HM-BMFs group (four studies, 663 infants; RR = 0.83, 95% CI = 0.69-1.000; p = 0.05, I2 = 0%), although not statistically significant. No differences were found for sepsis (RR = 0.97, 95% CI = 0.66-1.42; p = 0.96; I2 = 26%) or combined ROP (four studies, 671 infants; RR = 0.64, 95% CI = 0.53-1.07; p = 0.28; I2 = 69%). An HM-HMFs diet could possibly be associated with decreased mortality with no association with NEC, BPD, sepsis, or ROP. This meta-analysis was limited by the small number of studies included. However, the results should not be refuted for this reason as they provide an impetus for subsequent clinical trials to assess the observed associations.

Human milk cream alters intestinal microbiome of preterm infants: a prospective cohort study.

In very low birth weight (VLBW) infants, human milk cream added to standard human milk fortification is used to improve growth. This study aimed to evaluate the impact of cream supplement on the intestinal microbiome of VLBW infants. Whole genome shotgun sequencing was performed on stool (n = 57) collected from a cohort of 23 infants weighing 500-1250 grams (control = 12, cream = 11). Both groups received an exclusive human milk diet (mother's own milk, donor human milk, and donor human milk-derived fortifier) with the cream group receiving an additional 2 kcal/oz cream at 100 mL/kg/day of fortified feeds and then 4 kcal/oz if poor growth. While there were no significant differences in alpha diversity, infants receiving cream significantly differed from infants in the control group in beta diversity. Cream group samples had significantly higher prevalence of Proteobacteria and significantly lower Firmicutes compared to control group. Klebsiella species dominated the microbiota of cream-exposed infants, along with bacterial pathways involved in lipid metabolism and metabolism of cofactors and amino acids. Cream supplementation significantly altered composition of the intestinal microbiome of VLBW infants to favor increased prevalence of Proteobacteria and functional gene content associated with these bacteria. We report changes to the intestinal microbiome associated with administration of human milk cream; a novel supplement used to improve growth rates of preterm very low birth weight infants. Since little is known about the impact of cream on intestinal microbiota composition of very low birth weight infants, our study provides valuable insight on the effects of diet on the microbiome of this population. Dietary supplements administered to preterm infants in neonatal intensive care units have the potential to influence the intestinal microbiome composition which may affect overall health status of the infant.

Fatty acid concentrations in preterm infants fed the exclusive human milk diet: a prospective cohort study.

Quantify blood fatty acids and growth outcomes in preterm infants fed the exclusive human milk diet. A prospective cohort study of 30 infants 24-34 weeks gestation and ≤1250 g fed the exclusive human milk diet. Blood fatty acids were quantified at two time points. Comparisons were made using two-sample t-tests and Wilcoxon rank sum. Donor human milk-fed (n = 12) compared to mother's own milk-fed infants (n = 18) from birth to after 28 days of life, had an increased interval change of linoleic to docosahexaenoic acid ratio (5.5 vs. -1.1 mole percent ratio, p = 0.034). Docosahexaenoic and eicosapentaenoic acid interval changes were similar between groups. The arachidonic acid change was similar between groups (-2.3 vs. -0.9 mole percent, p = 0.37), however, both experienced a negative change across time. At 36 weeks postmenstrual age, growth velocities were similar for groups. An exclusive human milk diet maintains birth docosahexaenoic and eicosapentaenoic acid concentrations. However, the postnatal deficit in arachidonic acid was not prevented.

Outcomes in very preterm infants receiving an exclusive human milk diet, or their own mother's milk supplemented with preterm formula

BackgroundAn infant's Own Mother's Milk (OMM) is the mainstay of very preterm nutrition. When a supplement is required, preterm formula and pasteurised human donor milk (pHDM), are options. Which is optimal is unknown. Aims and outcome measuresComparison of “survival to 34 weeks postmenstrual age (PMA) without surgery for necrotising enterocolitis (NEC)” and other outcomes, in infants receiving OMM supplemented with pHDM without bovine macronutrient fortification (exclusive human milk diet), and infants receiving OMM supplemented with preterm formula. DesignCohort analysis of observational data from the National Neonatal Research Database; data-adaptive Super Learner approach with Targeted Maximum Likelihood Estimation to calculate Adjusted Risk Differences (ARD) between the groups. ParticipantsInfants born below 32 weeks gestation admitted to neonatal units in England and Wales between 01 and 06-2017 and 31-05-2022. ResultsCompared to the formula supplemented group (n = 7133), infants receiving an exclusive human milk diet (n = 1007), had lower survival to 34 weeks PMA without NEC surgery (ARD -9.8 %, 95%CI -11.4 to −8.2), higher all-cause (10.7 %, 9.1 to 12.2) and NEC-related mortality (1.0 %, 0.4 to 1.5), and lower rates of treated retinopathy of prematurity (−2.8 %, −3.4 to −2.3) and bronchopulmonary dysplasia (−12.1 %, −14.0 to −10.1). ConclusionsThe lower survival to 34 weeks PMA without NEC surgery in infants receiving an exclusive human milk diet is unexpected. We adjusted for factors that influence outcomes but cannot exclude the possibility of confounding, hence our data justify a randomised controlled trial to identify optimal supplementary feeds for very preterm infants.

Implementing an exclusive human milk diet for preterm infants: real-world experience in diverse NICUs

BackgroundHuman milk–based human milk fortifier (HMB-HMF) makes it possible to provide an exclusive human milk diet (EHMD) to very low birth weight (VLBW) infants in neonatal intensive care units (NICUs). Before the introduction of HMB-HMF in 2006, NICUs relied on bovine milk–based human milk fortifiers (BMB-HMFs) when mother's own milk (MOM) or pasteurized donor human milk (PDHM) could not provide adequate nutrition. Despite evidence supporting the clinical benefits of an EHMD (such as reducing the frequency of morbidities), barriers prevent its widespread adoption, including limited health economics and outcomes data, cost concerns, and lack of standardized feeding guidelines.MethodsNine experts from seven institutions gathered for a virtual roundtable discussion in October 2020 to discuss the benefits and challenges to implementing an EHMD program in the NICU environment. Each center provided a review of the process of starting their program and also presented data on various neonatal and financial metrics associated with the program. Data gathered were either from their own Vermont Oxford Network outcomes or an institutional clinical database. As each center utilizes their EHMD program in slightly different populations and over different time periods, data presented was center-specific. After all presentations, the experts discussed issues within the field of neonatology that need to be addressed with regards to the utilization of an EHMD in the NICU population.ResultsImplementation of an EHMD program faces many barriers, no matter the NICU size, patient population or geographic location. Successful implementation requires a team approach (including finance and IT support) with a NICU champion. Having pre-specified target populations as well as data tracking is also helpful. Real-world experiences of NICUs with established EHMD programs show reductions in comorbidities, regardless of the institution’s size or level of care. EHMD programs also proved to be cost effective. For the NICUs that had necrotizing enterocolitis (NEC) data available, EHMD programs resulted in either a decrease or change in total (medical + surgical) NEC rate and reductions in surgical NEC. Institutions that provided cost and complications data all reported a substantial cost avoidance after EHMD implementation, ranging between $515,113 and $3,369,515 annually per institution.ConclusionsThe data provided support the initiation of EHMD programs in NICUs for very preterm infants, but there are still methodologic issues to be addressed so that guidelines can be created and all NICUs, regardless of size, can provide standardized care that benefits VLBW infants.

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.

Effect of an Exclusive Human Milk Diet on the Gut Microbiome in Preterm Infants

The effect of using an exclusive human milk diet compared with one that uses bovine products in preterm infants is uncertain, but some studies demonstrate lower rates of key neonatal morbidities. A potential mediating pathway is the gut microbiome. To determine the effect of an exclusive human milk diet on gut bacterial richness, diversity, and proportions of specific taxa in preterm infants from enrollment to 34 weeks' postmenstrual age. In this randomized clinical trial conducted at 4 neonatal intensive care units in the United Kingdom from 2017 to 2020, microbiome analyses were blind to group. Infants less than 30 weeks' gestation who had only received own mother's milk were recruited before 72 hours of age. Statistical analysis was performed from July 2019 to September 2021. Exclusive human milk diet using pasteurized human milk for any shortfall in mother's own milk supply and human milk-derived fortifiers (intervention) compared with bovine formula and bovine-derived fortifier (control) until 34 weeks' postmenstrual age. Fortifier commenced less than 48 hours of tolerating 150 mL/kg per day. Gut microbiome profile including alpha and beta diversity, and presence of specific bacterial taxa. Of 126 preterm infants enrolled in the study, 63 were randomized to control (median [IQR] gestation: 27.0 weeks [26.0-28.1 weeks]; median [IQR] birthweight: 910 g [704-1054 g]; 32 [51%] male) and 63 were randomized to intervention (median [IQR] gestation: 27.1 weeks [25.7-28.1 weeks]; median [IQR] birthweight: 930 g [733-1095 g]; 38 [60%] male); 472 stool samples from 116 infants were analyzed. There were no differences in bacterial richness or Shannon diversity over time, or at 34 weeks between trial groups. The exclusive human milk diet group had reduced relative abundance of Lactobacillus after adjustment for confounders (coefficient estimate, 0.056; P = .03), but not after false discovery rate adjustment. There were no differences in time to full feeds, necrotizing enterocolitis, or other key neonatal morbidities. In this randomized clinical trial in preterm infants using human milk-derived formula and/or fortifier to enable an exclusive human milk diet, there were no effects on overall measures of gut bacterial diversity but there were effects on specific bacterial taxa previously associated with human milk receipt. These findings suggest that the clinical impact of human milk-derived products is not modulated via microbiomic mechanisms. ISRCTN trial registry identifier: ISRCTN16799022.

A Randomized Trial of an Exclusive Human Milk Diet in Neonates with Single Ventricle Physiology

To determine whether weight gain velocity (g/kg/day) 30days after the initiation of feeds after cardiac surgery and other clinical outcomes improve in infants with single ventricle physiology fed an exclusive human milk diet compared with a mixed human and bovine diet. In this multicenter, randomized, single blinded, controlled trial, term neonates 7days of age or younger with single ventricle physiology and anticipated cardiac surgical palliation within 30days of birth were enrolled at 10 US centers. Both groups received human milk if fed preoperatively. During the 30days after feeds were started postoperatively, infants in the intervention group received human milk fortified once enteral intake reached 60mL/kg/day with a human milk-based fortifier designed for term neonates. The control group received standard fortification with formula once enteral intake reached 100mL/kg/day. Perioperative feeding and parenteral nutrition study algorithms were followed. We enrolled 107 neonates (exclusive human milk=55, control=52). Baseline demographics and characteristics were similar between the groups. The median weight gain velocity at study completion was higher in exclusive human milk vs control group (12g/day [IQR, 5-18g/day] vs 8g/day [IQR, 0.4-14g/day], respectively; P=.03). Other growth measures were similar between groups. Necrotizing enterocolitis of all Bell stages was higher in the control group (15.4 % vs 3.6%, respectively; P=.04). The incidence of other major morbidities, surgical complications, length of hospital stay, and hospital mortality were similar between the groups. Neonates with single ventricle physiology have improved short-term growth and decreased risk of NEC when receiving an exclusive human milk diet after stage 1 surgical palliation. This trial is registered with ClinicalTrials.gov (www. gov, Trial ID: NCT02860702).

Effects of human milk on body composition and growth in very low birthweight infants.

To compare body composition and growth in very low birthweight infants according to their source of human milk: maternal expressed breast milk (MEBM) versus donor breast milk (DBM). We hypothesized that infants fed predominately MEBM would exhibit reduced body fat percentage compared to those fed predominately DBM. Premature infants weighing ≤1500 g on an exclusive human milk diet were enrolled in a single-center study between 2017 and 2021. Demographic data and anthropometric measurements were collected. All infants underwent body composition analysis via dual energy x-ray absorptiometry at 36 weeks corrected post menstrual age. A total of 60 infants were enrolled and 48 were included in the primary analysis. No differences were detected in percent body fat (14 vs. 12%, p = 0.7) or fat-free mass (2050 vs. 2130 g, p = 0.7). Both groups displayed similar growth and anthropometric measurements. Caloric and macronutrient intake between groups was similar. In the cohort of patients studied, no differences were observed in percent body fat based on primary human milk type intake in the first 28 postnatal days. Further investigation is required in a larger population of exclusive human milk fed preterm infants to determine if body composition differences exist based on an infant's primary human milk source. Premature infants are at risk for altered body composition at term corrected age, specifically increased body fat percentage, which may have implications for the future. To our knowledge this is the first study exploring body composition outcomes based on an infant's primary human milk source. Infants fed exclusive human milk (e.g., donor vs. maternal) displayed similar percent body fat and growth outcomes.

Use of human milk and fortification in the NICU.

Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow's milk, however there are concerns regarding a possible association between the use of cow's milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or "blind fortification", adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.

Evolution of Preterm Infant Nutrition from Breastfeeding to an Exclusive Human Milk Diet: A Review.

The benefits of feeding human milk to human infants are well-established. Preterm infants, particularly those born with very low birthweight (VLBW; <1,500 g), are a uniquely vulnerable population at risk for serious, life-threatening complications as well as disruptions in normal growth and development that can affect their lives into adulthood. Feeding VLBW preterm infants an exclusive human milk diet (EHMD) from birth that consists of the mother's own milk or donor human milk plus a nutritional fortifier made exclusively from human milk has been associated with a reduction in morbidity and mortality and improved early growth and developmental metrics. Preliminary evidence suggests that the health benefits of adopting an EHMD (or avoiding cow milk products) early in life may last into adulthood. This review briefly summarizes the history of breastfeeding and describes the available evidence on the benefits of an EHMD among VLBW preterm infants as well as the importance of high-quality manufacturing standards for producing safe and effective human milk-based products.

Randomised controlled trial of human derived breast milk fortifier versus bovine milk fortifier on body composition in very preterm babies

BackgroundPreterm infants receiving a diet of exclusive human milk compared to predominantly preterm formula have lower weight and non-adipose tissue mass by term. Human milk fortification is recommended. However, it is not known if the protein source affects body composition. AimsTo compare the effect of an exclusive human milk based diet (intervention) with a diet containing cow milk products (control) on body composition. ParticipantsInfants born below 30 weeks gestation. Study designRandomised multicentre, open label, controlled trial. Infants preferentially received their own mother's milk. Infants were randomised to either an exclusive human milk diet (human milk formula to make up a shortfall in own mother's milk and human milk derived fortifier) or cow milk-based supplementation (preterm formula to make up a shortfall in own mother's milk and cow milk-based fortifier). Fortification began at an enteral intake of 150 ml/kg/day. Infants underwent whole-body magnetic resonance imaging at term. Primary outcomeBody composition (adipose tissue (ATM) and non-adipose tissue mass (N-ATM)) at term. ResultsWe randomly assigned 38 infants to intervention (n = 19) and control arms (n = 19). Primary outcomes were analysed in 15 infants in the intervention arm and 12 in the control arm. The estimates of the effect of the intervention following adjustment for length and sex, were non-significant (ATM (kg): 0.137, 95 % confidence interval (CI) -0.01, 0.29; N-ATM: −0.137; −0.01, 0.29). ConclusionsWe identified no clinically relevant differences in body composition in preterm babies <30 weeks gestation receiving a macronutrient-equivalent exclusive human milk diet compared with a diet containing cow milk products.

Effect of an exclusive human milk diet on feeding tolerance in preterm infants

To compare the time to full enteral feeds in preterm infants fed exclusive human milk (EHM) - mother's own milk (MOM) fortified with human milk-based fortifier (HMBF), to those who received partial human milk (PHM) - MOM fortified with bovine milk-based fortifier (BMBF), and exclusive formula. A single-center retrospective study of infants with birth weight <1250 g from 2013 to 2018. Data on feeding, growth and other short-term neonatal morbidities were collected. On regression analysis, time to full enteral feeds was significantly higher in PHM compared to EHM group (β-coefficient 4.14, 95% CI 0.00-8.29) and formula-fed group compared to EHM (β-coefficient 4.3, 95% CI 0.32-8.20). No significant differences in growth velocity, length of stay and other morbidities were found between the groups. Infants in EHM had better feeding tolerance and reached their enteral feed goals sooner compared to PHM and formula-fed groups.