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.
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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
Conditional-
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).
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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.
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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).
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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.
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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.
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Minority Opinions
Consensus reached.
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Risks/Harms of Implementing This Recommendation
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Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula intake on mortality?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on late onset sepsis, NEC and ROP?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on weight?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on length?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on head circumference?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on feeding tolerance?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on bone mineral content?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on protein utilization?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of greater than or equal to 75% donor milk intake vs. exclusive formula on development?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on mortality?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on nectorizing enterocolitis?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on retinopathy of prematurity?
In VLBW preterm infants (less than or equal to 1,500g at birth) what is the effect of supplementation of mothers' milk with donor milk versus formula on sepsis?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on bronchopulmonary disease?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on weight gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on length gain?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on head circumference?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on body composition?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on neurodevelopment?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on gastrointestinal health?
In VLBW preterm infants (less than or equal to 1,500g at birth), what is the effect of supplementation of mothers' milk with donor milk vs. formula on bone mineral content?-
References
Cristofalo E, Schanler R, Blanco C, Sullivan S, Trawoeger R, Kiechl-Kohlendorfer U, Dudell G, Rechtman D, Lee M, Lucas A, Abrams S. Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. The Journal of Pediatrics 2013; 163:1592-1595.e1
Lapillonne A, Glorieux F, Salle B, Braillon P, Chambon M, Rigo J, Putet G, Senterre J. Mineral balance and whole body bone mineral content in very low-birth-weight infants. Acta Paediatrica (Oslo, Norway : 1992). Supplement 1994; 405:117-22
Roberts S, Lucas A. The effects of two extremes of dietary intake on protein accretion in preterm infants. Early Human Development 1985; 12:301-7
Tyson J, Lasky R, Mize C, Richards C, Blair-Smith N, Whyte R, Beer A. Growth, metabolic response, and development in very-low-birth-weight infants fed banked human milk or enriched formula. I. Neonatal findings. The Journal of Pediatrics 1983; 103:95-104 -
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
- Buckle A, Taylor C. Cost and Cost-Effectiveness of Donor Human Milk to Prevent Necrotizing Enterocolitis: Systematic Review. Breastfeed Med. 2017;12(9):528-536.
- Eidelman AI. Breastfeeding and the use of human milk: an analysis of the American Academy of Pediatrics 2012 Breastfeeding Policy Statement. Breastfeed Med. 2012;7(5):323-324.
- Fengler J, Heckmann M, Lange A, Kramer A, Flessa S. Cost analysis showed that feeding preterm infants with donor human milk was significantly more expensive than mother's milk or formula. Acta Paediatr. 2019.
- Human Milk Banking Association of North America. News and Events. https://www.hmbana.org/news/donor-human-milk-distribution-2018.html. Published 2020. Accessed March 9, 2020.
- O'Connor DL, Gibbins S, Kiss A, et al. Effect of Supplemental Donor Human Milk Compared With Preterm Formula on Neurodevelopment of Very Low-Birth-Weight Infants at 18 Months: A Randomized Clinical Trial. JAMA. 2016;316(18):1897-1905.
- Quigley M, Embleton ND, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2018;6:CD002971.
- Trang S, Zupancic JAF, Unger S, et al. Cost-Effectiveness of Supplemental Donor Milk Versus Formula for Very Low Birth Weight Infants. Pediatrics. 2018;141(3).
- U.S. Food and Drug Administration. Use of Donor Milk. Pediatrics Web site. https://www.fda.gov/science-research/pediatrics/use-donor-human-milk. Published 2018. Accessed.
- World Health Organization. WHO recommendations on interventions to improve preterm birth outcomes. In. Geneva, Switzerland: World Health Organization, ; 2015.
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References