Human Milk for the Premature Infant

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Key points

  • Fortified mother's own milk is the optimal diet for the premature infant to maximize growth, development, and protection against necrotizing enterocolitis and infection.

  • Fortified pasteurized human donor milk is recommended by the American Academy of Pediatrics Section on Breastfeeding as the preferred alternative for premature infants whose mothers are unable to provide a sufficient volume of their own milk.

  • Pasteurized donor human milk does not provide the same nutrient or biologically active

Amniotic fluid, “premature” human milk, and “term” human milk

Amniotic fluid contains amino acids, proteins, vitamins, minerals, hormones, and growth factors. Although the concentration of these nutrients is much lower than that found in human milk, the large volumes of amniotic fluid swallowed in utero (up to 1 liter a day late in gestation, considerably more than the newborn consumes after birth) have a significant impact on growth and maturation of both the fetus and the fetal intestine.2 Animal studies and limited human observations suggest that

Benefits of human milk for premature infants

The most recent policy statement from the Section on Breastfeeding of the American Academy of Pediatrics represents a significant shift from previous statements in its recommendation that all preterm infants should receive human milk, with pasteurized donor milk rather than premature infant formula the preferred alternative if a mother is unable to provide an adequate volume.18 The current recommendation is based on an impressive array of benefits that human milk provides to this highly

Challenges of providing human milk to premature infants

Providing human milk to very premature infants presents a variety of challenges. To maximize milk supply, new mothers should begin frequent pumping shortly after delivery. Mothers whose babies are in the neonatal intensive care unit (NICU) should be encouraged to begin pumping within 6 to 12 hours of delivery and to pump 8 to 12 times per day, ensuring that they empty the breast each time. These interventions significantly increase the likelihood that a premature infant will receive his

Pasteurized donor human milk for premature infants

There are significant challenges in providing donor human milk for all premature infants whose mothers are unable to provide an adequate supply of their own milk: Nutrition, safety, supply, and immune protection. First, most donor human milk is provided by women who have delivered at term and have weaned their own infant but continue to pump and donate their milk in later lactation. As noted in Fig. 1, this milk from mothers of term infants, several months after delivery, is low in protein,

An “all-human” diet for premature infants

The development of a human milk fortifier formulated by concentrating pasteurized donor human milk and then adding vitamins and minerals has created the possibility of providing an “all-human diet” to premature infants. Various caloric densities of this fortifier allow for individual adjustment based on growth or blood urea nitrogen. A small study demonstrated a decrease in both moderate and severe NEC in small premature infants (birth weight <1250 g) receiving the “all-human diet.”77

Improving breastfeeding rates for premature infants

Premature labor and delivery are highly stressful to parents. Education regarding the importance and value of breastfeeding should begin during pregnancy and be reemphasized when premature delivery seems likely. As noted, pumping with an electric pump should be initiated within 6 to 12 hours of delivery and continued 8 to 12 times per 24 hours until the milk supply is well established.45 Reassurance and encouragement are valuable, because new mothers are often worried and discouraged by the

Withholding mother's own milk from premature infants

In most instances, provision of mother's own milk is optimal. The few circumstances in which mother's own milk should not be provided are discussed in Chapter 15. Although it is certainly plausible that premature infants with their immature immune systems are more vulnerable to infection, in most cases data regarding differences between premature and term infants in susceptibility to milk-associated infections are lacking. This section focuses on contraindications specific to premature infants.

Summary

Fortified human milk has tremendous benefits in improving the growth and short- and long-term outcomes for the premature infant. Mother's own milk has clear advantages to donor human milk both owing to its composition and the lack of necessity for pasteurization. Increased efforts to establish and maintain milk supply in women delivering preterm are likely to have greater benefits than providing pasteurized donor human milk. Improved pasteurization protocols and carefully performed trials of

Acknowledgments

The author wishes to thank Sarah Lueders, UC Davis Children's Hospital NICU dietitian, for assistance in compiling Table 1.

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    Funding sources: Eunice K. Shriver National Institute of Child Health and Human Development Grant HD059127. The author has received nutritional products from Prolacta Bioscience for clinical trials.

    Disclosure: The authors have nothing to disclose.

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