Recommendations to promote breast milk feeding and enhance nutritional care for preterm infants in the Asia-Pacific region: highlights from a roundtable discussion of key opinion leaders

@#Introduction: Preterm infants are vulnerable to nutritional deficiencies, thus optimal nutrition is crucial in promoting growth among these infants. However, socio-cultural complexities and limited resources in the Asia-Pacific demands a judicious approach in implementing nutritional care that is pragmatic to align with current evidence-based recommendations. Methods: A roundtable meeting was held in Jakarta in 2017 for key opinion leaders in neonatology from the Asia- Pacific to discuss issues when delivering nutritional care in this region and the unique circumstances encountered. Results: Priority areas discussed include: (i) breast milk feeding, (ii) donor milk bank/sharing, (iii) human milk fortification, and (iv) nutrient-enriched breast milk substitutes. Socio-cultural practices impeding breastfeeding, insufficient maternity leave, the religious issue of milk kinship, and limited availability of specialty nutritional care products were among the most challenging factors. Conclusion: The group proposed recommendations to enhance breastfeeding uptake, accessibility to a complete portfolio of specialty nutritional care products, and encouraging more active collaborations to engage policy makers in addressing these contemporary issues.

Clinical study on different breast milk enhancement strategies in premature infants / 中国新生儿科杂志

Objective To study the effect of different breast milk enhancement strategies and the incidence of complications in premature infants.Method Premature infants whose gestational age less than 34 weeks and birth weight less than 2 000 g were prospectively enrolled from January 2017 to February 2018 at the Department of Neonatology of Huangshi Maternal and Child Health-Care Hospital.According to the odd even number at the end of the hospitalization admission number,participants were assigned into 50～＜70 ml/(kg· d) group and 70～＜90 ml/(kg· d) group,When the children reached the corresponding amount of breast-feeding to be given breast milk fortifier.The demographic information,incidence of complications,rate of weight gain,percentage of extrauterine growth retardation (EUGR) and decrease of Z score at discharge were compared between groups.Result A total of 140 cases were included,with gestational age (31.4±1.9) weeks and birth weight (1 402±213) grams.Among the participants,67 infants were assigned to 50～＜70 ml/(kg·d) group,and 73 infants were assigned to 70～＜90 ml/(kg·d) group.There was no statistical difference between two groups in gender,gestational age,birth weight,length,head circumference,rates of asphyxia,ratio of intrauterine growth retardation,Z score of weight at birth,age at which breast milk fortifiers were added,full enteral feeding time,duration of parenteral nutrition,average length of hospital stay and the time of restoration of birth weight (P＞0.05).The proportion of feeding intolerance in 50～ ＜70 ml/(kg· d) group was higher than that in 70～＜90 ml/(kg· d) group (11.9％ vs.4.1％),the difference was statistical significant (P=0.013).There was no statistical difference in other complications between the two groups (P＞ 0.05).The body weight increase rate of premature infants in 50～＜70 ml/ (kg· d) group was higher than that in 70～＜90 ml/(kg· d) group,and decrease of Z score at discharge in 50～＜70 ml/(kg· d) group was lower than that of 70～＜90 ml/(kg· d),the difference was significant (P＜0.05).Conclusion Adding breast milk fortifier earlier——when the breast feeding amount of 50～＜70 ml/(kg· d)——is more beneficial to the growth and development of premature infants,it also reduces the incidence of EUGR on discharge.However,during the feeding process,it was necessary to be aware of the complications.

Research progress of enteral nutrition in very low birth weight infants / 中华实用儿科临床杂志

The nervous system of very low birth weight infants is particularly sensitive to malnutrition.The growth and neural development of very low birth weight infants will be limited by various nutritional deficiencies.Early enteral nutrition is beneficial for the growth and neural development of very low birth weight infants.However,there is still a controversy about the timing of starting enteral nutrition,the amount of milk to be fed,the rate of adding milk and whether strengthening breast milk or adding probiotics.This article reviews the problems and controversy of enteral nutrition in very low birth weight infants.

Effect of adding time of human milk fortifier on growth and incidence of complications of very low birth weight premature infants / 中华实用儿科临床杂志

Objective To investigate the effects of human milk fortifier(HMF)addition at different time points on the growth,development and the incidence of complications in very low birth weight(VLBW)infants.Methods A total of 93 VLBW infants admitted into Neonatal Intensive Care Unit of Tianjin Central Hospital of Obste-trics and Gynecology from January to September 2015 with more than 80％of total milk intake during hospitalization,excluding those who had severe asphyxia or abandoned treatment and died,were collected.The included cases were divided into 2 groups by using completely randomized grouping method,early fortification group(n=48)and delayed fortification group(n=45)adding HMF with the enteral intake of 50 mL/(kg·d)and 100 mL/(kg·d),respectively.The outcomes included growth development and the incidence of complications during hospitalization.Then,t test and chi-square test of independent samples were used for statistical analysis.Results There was significant difference in the weight growth rate between the 2 groups,and the growth rate of early fortification group and delayed fortification group were(15.4±2.4)g/(kg·d)and(13.6±2.3)g/(kg·d),respectively(t=3.043,P=0.004).There was no significant difference in height growth rate,head circumference growth rate,weight at 34 weeks postmenstrual age,time of recovering birth weight and parenteral nutrition,hospitalization duration,body weight,body length,head circumference at discharge and the incidence of extrauterine growth retardation between the 2 groups(all P>0.05).There was no statistical difference in incidence of feeding intolerance,necrotizing enterocolitis,nosocomial infection,retinopathy of prematurity,bronchopulmonary dysplasia between the 2 groups(all P>0.05).Conclusions HMF with enteral intake of 50 mL/(kg·d)contributes to weight gain rate in VLBW infants during hospitalization,but not to the increase in the incidence of complications.

Effect of Fortification and Additives on Breast Milk Osmolality.

This study evaluated the effect of fortification and commonly used additives on the osmolality of human milk. Osmolality after fortification with milk powder and human milk fortifier increased from 303 mOsmol/kg to 397 and 373 mOsmol/kg, respectively. The maximal increase in osmolality was seen with the addition of calcium gluconate.

Exploration on fortification of breast feeding in preterm infants / 中国实用护理杂志

Breast milk, whether the ratio of nutritional ingredients or immunological characteristics, were the most suitable for physiological needs of preterm infants. However, breast milk composition was in dynamic change, causing imbalance of energy, which could not make the premature infant to achieve the desired growth state. Human milk fortifier, retaining advantages of the breast milk, promoted growth of premature infants further. This review primarily focused on two ways of adding human milk fortifiers, standardization fortification and targeted fortification. The former was widely used in neonatal intensive care unit, while the latter was more able to explore the growth of premature infant potentially, and to achieve a more ideal ectopic growth rate. With the development of breast milk bank, storage and component extraction technology brought about donor human milk-based human milk fortifier, which provided new directions of very low birth weight infants and very preterm infants breastfeeding. The progress of human milk fortification of premature infants was closely related to expansion of multi-disciplinary centers, and only the harmonious development of multi-center maked things much more rational and systematic.

Serum phenylalanine in preterm newborns fed different diets of human milk, / Fenilalanina plasmática em recém-nascidos pré-termo alimentados com diferentes dietas de leite humano,

Objective: To evaluate phenylalanine plasma profile in preterm newborns fed different human milk diets. Methods: Twenty-four very-low weight preterm newborns were distributed randomly in three groups with different feeding types: Group I: banked human milk plus 5% commercial fortifier with bovine protein, Group II: banked human milk plus evaporated fortifier derived from modified human milk, Group III: banked human milk plus lyophilized fortifier derived from modified human milk. The newborns received the group diet when full diet was attained at 15 ± 2 days. Plasma amino acid analysis was performedon the first and last day of feeding. Comparison among groups was performed by statistical tests: one way ANOVA with Tukey's post-test using SPSS software, version 20.0 (IBM Corp, NY, USA), considering a significance level of 5%. Results: Phenylalanine levels in the first and second analysis were, respectively, in Group I: 11.9 ± 1.22 and 29.72 ± 0.73; in Group II: 11.72 ± 1.04 and 13.44 ± 0.61; and in Group III: 11.3 ± 1.18 and 15.42 ± 0.83 μmol/L. Conclusion: The observed results demonstrated that human milk with fortifiers derived from human milk acted as a good substratum for preterm infant feeding both in the evaporated or the lyophilized form, without significant increases in plasma phenylalanine levels in comparison to human milk with commercial fortifier. .

Objetivo: Avaliar o perfil plasmático do aminoácido fenilalanina em recém-nascidos pré-termo alimentados com diferentes dietas de leite humano. Métodos: Foram estudados 24 recém-nascidos pré-termo de muito baixo peso, distribuídos em três grupos com diferentes dietas: Grupo I: leite humano de banco com 5% de aditivo comercial para leite humano com proteína de origem bovina (LHB-AC); Grupo II: leite humano de banco com aditivo de leite humano modificado evaporado (LHB-E); e Grupo III: leite humano de banco com aditivo de leite humano modificado liofilizado (LHB-L). Os recém-nascidos receberam a dieta definida para o grupo quando alcançaram dieta plena por 15 ± 2 dias. A análise do aminoácido plasmático foi feita no primeiro e último dias da dieta. A comparação entre os grupos foi realizada por meio do teste ANOVA de uma via, seguido pelo pós-teste de Tukey, utilizando-se o software SPSS (IBM Corp, NY, EUA), versão 20.0, e considerando um nível de significância de 5%. Resultados: As concentrações plasmáticas do aminoácido fenilalanina na primeira e segunda análises foram, respectivamente, no Grupo I (LHB-AC) 11,9±1,22 e 29,72±0,73; no Grupo II (LHB-E) 11,72±1,04 e 13,44±0,61; e no Grupo III 11,3±1,18 e 15,42±0,83 umol/L. Conclusão: Os resultados encontrados demonstram que o leite humano com aditivos do próprio leite humano comportou-se como um bom substrato para alimentação do recém-nascido pré-termo, tanto na forma evaporada como liofilizada, sem levar a aumentos significativos na concentração plasmática de fenilalanina em comparação ao leite humano com aditivo comercial. .

Nutrition management strategy of very low and extremely low birth weight infants / 中华实用儿科临床杂志

Extrauterine growth restriction is a major clinical problem for very low and extremely low birth weight infants.They need the rapid accumulation of protein and energy after born;otherwise it will lead to an increase in nutritional deficiencies,malnutrition and neurological problems.The ideal nutritional strategies is to provide parenteral nutrition after birth,amino acids and lipids are initially provided at a minimum of 2.0 g/(kg · d) and 1.0 g/(kg — d),which advance to 3.5-4.0 g/(kg · d) and 3.0 g/(kg · d),keep the appropriate protein/energy ratio.The appropriate vitamin,minerals and elements should be provided.Enteral feeding should be initiated immediately about 24 h after birth,minimal feeding [10-20 mL/(kg · d)] should last 3-5 days.Human milk should gradually increase to 75-120 mL/(kg · d) and add human milk fortifier.Parenteral nutrition is stopped when human milk fed to 120 mL/(kg · d).

Efeitos do aditivo do leite materno com ferro sobre as propriedades bacteriostáticas do leite materno / Effects of human milk fortifier with iron on the bacteriostatic properties of breast milk

OBJETIVO: Comparar o crescimento bacteriano em colostro puro e colostro com aditivo do leite materno contendo ferro. MÉTODOS: Foram comparadas 78 amostras de colostro puro ou colostro com adição de aditivo do leite materno contendo ferro para avaliar o crescimento de Escherichia coli, Staphylococcus aureus e Pseudomonas aeruginosa. Para a análise qualitativa, discos de papel-filtro foram imersos em amostras de cada grupo e incubados por 48 horas com 10¹ Unidades Formadoras de Colônias/mL de cada cepa. Para a avaliação quantitativa, 1 mL de cada cepa contendo 10(7) Unidades Formadoras de Colônias/mL foi homogeneizado com 1 mL, tanto de colostro puro quanto de colostro com aditivo do leite materno, espalhado em placa de Petri e incubado a 37ºC. O número de Unidades Formadoras de Colônias foi contado 24 horas depois. RESULTADOS: A análise qualitativa não mostrou nenhuma diferença no crescimento bacteriano. Na avaliação quantitativa, o crescimento de Escherichia coli (EC) no grupo C foi de 29,4±9,7 x 10(6) CFU/mL, enquanto no grupo FM85 foi de 31,2±10,8 x 10(6) CFU/mL. A diferença entre o crescimento médio foi de 1,9±4,9 x 10(6) CFU/mL (p = 0,001). Não houve diferenças no crescimento de Staphylococcus aureus e Pseudomonas aeruginosa. CONCLUSÃO: A adição de ferro a essa concentração reduz a ação bacteriostática do leite materno contra Escherichia coli.

OBJECTIVE: To compare bacterial growth in pure colostrum versus colostrum with human milk fortifier (HMF) containing iron. METHODS: The growth of Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa in 78 samples of pure colostrum or colostrum with added iron-containing HMF was compared. For qualitative analysis, filter paper discs were immersed in samples from each group and incubated for 48 hours with 10¹ colony forming units (CFUs)/mL of each strain. For quantitative assessment, 1 mL of each strain containing 10(7) CFUs/mL was homogenized with 1 mL of either colostrum or colostrum with human milk fortifier, seeded into a Petri dish, and incubated at 37ºC. Twenty-four hours later, the number of CFUs was counted. RESULTS: The qualitative analysis showed no difference in bacterial growth. In the quantitative evaluation, E. coli growth in the control group was 29.4±9.7 x 10(6) CFU/ mL, while in the HMF group it was 31.2±10.8 x 10(6) CFU/mL. The difference between the average growth was 1.9±4.9 x 10(6) CFU/mL (p = 0.001). There were no differences in S. aureus and P. aeruginosa growth. CONCLUSION: Addition of iron at this concentration reduces breast milk bacteriostatic action against E. coli.

Growth and clinical efficacy of fortified human milk and premature formula on very low birth weight infants / 소아과

PURPOSE: A prospective, controlled trial was conducted to evaluate growth, efficacy, safety and nutritional status for very low birth weight infants fed with human milk fortified with Maeil human milk fortifier (Maeil HMF(R); Maeil Dairies Co., Ltd.). METHODS: We enrolled 45 premature infants with a birth weight <1,500 g and gestational age <33 weeks, who were born at Dong-A University Hospital from October, 2006 through December, 2007. They were divided into 2 groups: infants in one group were fed with human milk fortified with HMF(R), and the second were fed with preterm formula. Growth, biochemical indices, feeding tolerance, and other adverse events in each group were assessed serially and compared relatively. Follow-up data were also collected after discharge at 1, 3, and 6 months corrected age. RESULTS: Characteristics of the 2 groups including average gestational age, birth weight, sex, respiratory distress syndrome, patent ductus arteriosus, and other adverse events (sepsis, retinopathy of prematurity, and intraventricular hemorrhage) showed no significant difference. Average feeding start day (8.00+/-3.27 d vs. 8.86+/-5.37 d) (P=0.99) and the number of days required to reach full feeding after start feeding (41.78+/-20.47 d vs 36.86+/-20.63 d) (P=0.55) were not significantly different in the group fed human milk fortified with HMF(R) when compared with the group that was fed preterm formula. The duration of total parenteral nutrition and the incidence of feeding intolerance also showed no differences between the 2 groups. Although infants fed with human milk fortified with HMF(R) showed faster weight gain than those fed with preterm formula at the end stage of the admission period, other growth indices of the two groups showed no significant difference. No significant correlations were found between the 2 groups with regard to weight gain velocity, height gain velocity, head circumference velocity, and post- discharge follow up growth indices. CONCLUSION: Premature infants fed human milk fortified with HMF(R) showed no significant difference compared with those fed preterm formula in growth, biochemical indices, and adverse events. Using human milk fortifier can be an alternative choice for very low birth weight infants, who need high levels nutritional support even after discharge from NICU.

Effects of Maeil Human Milk Fortifier on Growth and Bone Mineralization in Preterm Infants

PURPOSE: A prospective, controlled trial was conducted to evaluate growth, bone mineralization, and nutritional status receiving preterm human milk supplemented with a newly formulated Maeil human milk fortifier. METHODS: Twenty five fortified human milk-fed and preterm formula-fed infants with a birth weight < 1, 800 g and gestational age <35 weeks, who were born at Ajou University Hospital from March, 2003 through August, 2004 were studied. Growth, biochemical indices of bone mineralization, feeding tolerance, morbidity and wrist X-ray were assessed serially. Total body bone mineral density was measured by dual energy X-ray absorptiometry at 2 and 5months of age. RESULTS: There were no differences in growth, including weight, height and head circumference, between two groups. Serum Ca, P, ALP and other biochemical indices were similar. Although low grade rickets (grade I and II) were occasionally found on wrist X-ray, the rate of occurrence and severity were similar. The bone mineral densities of both group showed no difference. CONCLUSION: The fortified human milk-fed infants and preterm formula-fed infants showed no difference in growth, and bone mineralization. This newly formulated Maeil human milk fortifier can be safely used in preterm infants.