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Recommendations Summary

VLBW: Mother's Milk (2020)

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.

  • Recommendation(s)

    VLBW: Mother's Milk

    Health care practitioners should provide fortified mother's milk, when available, to VLBW (less than or equal to 1, 500g) preterm infants. Mother's own milk intake is associated with lower odds of retinopathy of prematurity when compared to exclusive formula,  and there is evidence of a negative dose-response relationship with sepsis and a positive dose-response relationship with Bailey development scores.

    Rating: Fair

    • Risks/Harms of Implementing This Recommendation

      No undesirable effects were found which could be due to limited evidence. 

    • Conditions of Application

      This recommendation is limited to scenarios in which mother's own milk is available. In addition, this review compared formula to mother's milk that was fortified.

    • Potential Costs Associated with Application

      The costs of supporting mother’s provision of their own milk to their infants, will be balanced against the costs of pasteurized donor human milk or formula. The balance between these costs is not clear and has not been addressed systematically in the literature.

    • Recommendation Narrative

      Many studies, as well as international health organizations, agree that mother's milk is associated with improved infant health outcomes. Two systematic reviews were conducted to evaluate available evidence for mothers’ milk intake for VLBW preterm infants in developed nations. 

      The first systematic review evaluated a minimum of 75% intake from m mother's milk in comparison to exclusive formula and association with identified outcomes among VLBW preterm infants. All systematic reviews outcomes had Grade III evidence (limited or weak) and were based on observational non-randomized studies. No significant differences were found between groups for mortality, necrotizing enterocolitis (NEC), sepsis, bronchopulmonary dysplasia, anthropometrics (weight, length, head circumference, fat free mass, or skinfold measurements), protein utilization, or visual acuity. No studies were identified that evaluated association with gastrointestinal health or bone mineral content. Infants fed mother's milk, however, were associated with lower incidence of retinopathy of prematurity (ROP), in comparison to those fed formula.   

      The second systematic review evaluated dose-response of higher vs. lower mother's milk and association with identified health outcomes among VLBW preterm infants. Remaining intake was supplemented with formula in the study populations. The majority of reviews for identified outcomes also resulted in Grade III evidence (limited or weak) and were based on observational non-randomized studies. One study was identified that evaluated mortality,  however, it was within a composite score that combined mortality,  NEC, and sepsis. Infants who received more than 50% of intake from mother's milk the first and second five days of life had a decreased hazard of the composite of mortality, NEC, and sepsis by 60 days, and a weaker effect was seen for mother's milk intake of 50% or less vs. none. No significant differences between groups were found for total infection, ROP, NEC (outside composite score), or anthropometrics, all Grade III evidence. A negative dose-response association was found for sepsis [Grade II evidence (fair)], and positive dose-response association was found for Bailey development scores (Grade III evidence).

      The benefits associated with mothers’ milk intake may be attributed to confounding factors or social determinants of health. Three specific associated benefits for mothers’ milk were found (decreased ROP and sepsis, and increased Bailey scores), however, these findings were from studies where mothers’ milk was fortified, and each study had risks of bias. Practitioners must exercise caution when making recommendations for mother's milk, in order to prevent promotion of mother's milk as the only option, increased pressure on mothers, or internet milk sharing. Ultimately, healthcare practitioners need to support parents to create healthy environments.

    • Recommendation Strength Rationale

      Mothers' Milk vs. Formula

      • Limited/weak certainty evidence (Grade III) for mortality, necrotizing enterocolitis, sepsis, bronchopulmonary disease, retinopathy of prematurity, weight gain, fat free mass, head circumference, protein utilization, skinfold measurment, visual acuity, lenght gain, and BUN.

      Mother's Milk Dose Response.

      • Moderate certainty evidence (Grade II) for sepsis.
      • Limited/Weak certainty evidence (Grade III) for mortality, total infections, retinopathy of prematurity, sepsis, necrotizing enterocolitis, bronchopulmonary dysplagia, anthropometrics, neurodevelopment, gastrointestional function.

    • Minority Opinions

      Consensus reached.