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Recommendations Summary

VLBW: Mother's Milk Supplementation (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: Mothers' Milk Supplementation

    When quantity of mothers’ milk is insufficient, health care practitioners should supplement VLBW (less than or equal to 1, 500g) preterm infants with donor milk during the time that the infant is at high risk for necrotizing enterocolitis (NEC). VLBW preterm infants fed mother's own milk supplemented with donor milk had a lower risk of NEC compared to those fed mother's own milk supplemented with formula.

    Rating: Fair

    • Risks/Harms of Implementing This Recommendation

      VLBW preterm infants supplemented with donor milk vs. formula may have a higher risk of cognitive neuroimpairment, according to post-hoc exploratory analysis of data from an RCT conducted by O’Connor and colleagues (O'Connor et al 2016). However, meta-analysis of this and other studies did not show a significant difference in neurodevelopment (Quigley et al 2018).

      VLBW preterm infants supplemented with donor milk vs. formula may have lower short-term growth rates in weight, length, and head circumference, according to Cochrane analysis (Quigley et al 2018).

    • Conditions of Application

      This recommendation is limited to scenarios in which mother’s milk for VLBW preterm infants is limited, and donor milk is available to supplement. 

    • Potential Costs Associated with Application

      Some studies have shown no difference in total cost between donor milk and formula. However, cost comparison likely differs by institution, region, country, cost of donor milk, rate of NEC, and the cost of NEC for a specific institution (FDA 2018, Trang et al 2018, Fengler et al 2019)

      Implementation Considerations

      Practitioners should use a multidisciplinary approach when implementing donor human milk programs in Neonatal Intensive Care Units.  Implementation teams should consider development of policies and protocols, and a process for tracking human milk.  Furthermore, practitioners should work with the multidisciplinary team to develop an institutional protocol regarding the time period when VLBW preterm infants are at highest risk for NEC and need for donor milk supplementation.  

      The Food and Drug Administration (FDA) recommend against feeding infants donor milk obtained directly from individuals or the Internet.  Donor milk should only be obtained from a source that has screened its milk donors and taken other precautions to ensure safety such as the Human Milk Banking Association of North America (Buckle and Taylor 2017).

    • Recommendation Narrative

      Many studies, and international health organizations agree that mother's milk is associated with improved infant health outcomes (WHO 2015, Eidelman 2012). However,  VLBW preterm infants that receive mother’s milk will potentially require supplementation. Increased awareness of the benefits of human milk has led to increased use of donor milk. The Human Milk Banking Association of North America reported a 12 percent increase in distribution of donor human milk from 2017 to 2018 (Human Milk Banking Association of North America, 2020).  A systematic review was conducted to compare supplementation of mother’s milk-fed VLBW preterm infants with donor milk vs. formula. A decreased risk of NEC was found in infants receiving 58% to 89% intake from mother’s own milk supplemented with human milk vs. formula. No difference was found in the remaining evaluated outcomes: Mortality, retinopathy of prematurity, sepsis, bronchopulmonary disease, growth, or body composition. One randomized controlled trial with low risk of bias was identified in the systematic review that compared impact of formula supplementation vs. donor supplementation on neurodevelopment when the mother’s milk supply was not sufficient. No difference was found on Bayley Development scores after 18 months, however, this did result in a higher risk of cognitive neuroimpairment.

    • Recommendation Strength Rationale

      • High certainty evidence for mortality, necrotizing enterocolitis, retinopaty of prematurity, sepsis, weight gain, lenght gain, head circumference.
      • Moderate certainty evidence for bronchopulmonary disease.
      • Low/weak certainty evidence for body composition, neurodevelopment, gastrointestinal health, bone mineral content.

    • Minority Opinions

      Consensus reached.