Stillen bei HIV-Infektion der Mutter

The worldwide epidemic spread of HIV has caused a dilemma in natural infant feeding in the highly endemic areas. There is a risk of transmission of the virus through breast milk in case of an HIV-infection of the mother. In countries where the use of infant formula is safe and the child is not reliant on the immunoprotective properties of human milk it has been decided to recommend to HIV-infected mothers not to breastfeed their children. In those countries where most mothers have neither access to education nor to the option of a hygienic and nutrient oriented preparation of the formula, the risk of mortality of non-breastfed infants is so high that avoiding breastfeeding is more dangerous for the child than the risk of transmission of HIV by breastfeeding. Therefore, in—and for—these countries, appropriate infant feeding strategies have been developed. The availability of antiretroviral drugs and their application to pregnant and lactating mothers as well as to the newborn has reduced the risk of mother to child transmission dramatically.     

A study of feeding patterns in young infants

With the aim of studying the feeding patterns in infants under 6 months of age, 451 mothers attending the children's clinic in two university hospitals in the north of Tehran were interviewed. All babies had been born in hospital and > 98 per cent had been breastfed during the first few hours of birth. The rate of full breastfeeding at 6 months of age, with no introduction of the bottle, was 83 per cent; approximately 6.5 per cent of infants were fed on breast and bottle concomitantly, and in about 10.5 per cent breastfeeding had been discontinued before 6 months and the babies were fed on bottle only. About 60 per cent of mothers who stopped breastfeeding, did so during the first postnatal month and another 20 per cent during the 2nd and 3rd month after the babies' birth. The mother's age, education or parity, did not affect the rate of breastfeeding. Low birthweight, especially birthweight less than 2 kg, was a risk factor for early termination of breastfeeding. Caesarean delivery and hospitalization of the infant during the neonatal period was also associated with a higher rate of bottlefeeding compared with newborns who had been delivered normally, discharged early, and nursed at home. Although breastfeeding rates are high, the finding that the majority of mothers who give up breastfeeding do so in the early weeks, calls for better support to all mothers by committed health personnel during the period when breastfeeding is being established, and for extra assistance to women whose infants are hospitalized or have a low birthweight.     

Electric breast pump use increases maternal milk volume in African nurseries

Health experts worldwide recognize breastmilk as the superior infant food. Recommendations from the American Academy of Pediatrics and the World Health Organization (WHO) identify exclusive breastfeeding for the first half-year of life and continuation of breastfeeding into toddlerhood as offering maximum protection from illness, providing a substrate for immunological protection. Data from developed countries identify increasing morbidity and mortality rates for infants who have never received breastmilk in life and demonstrate that infants benefit from exclusive breastfeeding, especially, in areas of severe poverty. Preterm infants, most at risk for morbidity and mortality in developing countries, are identified as needing their own mother's milk for survival. Exclusive feeding of own mothers' milk (OMM) is associated with improved infant survival; however, inadequate maternal milk volume (MMV) often necessitates adding artificial feedings or exogenous substances to OMM. The objective of this study was to compare mean daily MMV for mothers of premature or sick infants in special care nurseries (SCN) using one of three methods of OMM expression: electric breast pump, non-electric pedal breast pump, and hand (manual) expression. We studied 65 mothers whose infants were cared for in two SCN in Africa (Kenya and Nigeria) and were unable to feed directly at the breast. In this randomized trial, mothers were randomly assigned to one of three milk expression groups at birth. MMV, the dependent variable, was measured for an average of 8.7 days. MMV for the electric and pedal pump and hand milk expression was 578 +/- 228 ml (n = 22), 463 +/- 302 ml (n = 24) and 323 +/- 199 ml (n = 19), respectively. Data were evaluated using a one-way ANOVA (p = 0.014). The Tukey revealed significant differences (p < 0.01) between electric breast pump expression and hand expression but not between the electric and pedal pump or the pedal pump and hand expression. Findings revealed greater MMV with electric breast pumps than hand-expression for mothers of infants in African nurseries. This data has important implications for international policy if exclusive OMM feeding is to be achieved for the vulnerable infant. Funded by West Virginia University Department of Research and Graduate Studies HSC Grant # 2U023U; Non-monetary donations of breast pumps and breast pump kits were made by Medela (Medela, Inc., McHenry, IL, USA).     

呵护早产儿从母乳喂养开始

母乳喂养是降低新生儿死亡率的重要干预手段之一,对早产儿尤其如此。早产母乳中的成分与足月母乳不同,其营养价值和生物学功能更适合早产儿的需求。在NICU积极推进母乳喂养能降低早产相关疾病的发生率,改善神经行为发育,降低成年慢性非传染性疾病的发病风险。对低出生体质量早产儿,强化母乳喂养是最佳的喂养方式,能优化蛋白质摄入,促进早产儿体格增长和骨骼矿化。应当以积极的支持策略来保证早产儿母乳喂养的顺利实施。     

Udział mleka kobiecego w żywieniu noworodków urodzonych przedwcześnie

Aim

The objective of this study was to assess methods of feeding preterm neonates during hospitalization and at NICU discharge.

Material and methods

It was a questionnaire-based observational study on the use of human breast milk in nutrition of preterm infants. The questionnaires were distributed among mothers of preterm neonates on the last day of hospitalization.The material was divided into two groups: children born before 33 weeks of gestation (group 1) and children born between 33 and 37 weeks of gestation (group 2).

Results

During hospitalization, 85% received maternal breast milk – 24% were given breast milk only and 61% were additionally fed with neonatal formula for preterm babies, whereas 15% infants received only the formula. At the day of discharge data on feeding ways were: 59% children received exclusive breast-feeding, 12% mixed-feeding (maternal breast milk combined with formula in a 50:50 ratio), 9% mixed-feeding with formula constituting over 50% of the total supply, and 20% were not breastfed at all. In group 2, during hospitalization, 84% were breastfed and the remaining 16% received formula. At the day of discharge the ratio was in favor of maternal breast milk: 95% of the infants received it. Additional analysis of ways of administering breast milk and formula were made. The results revealed that 19 mothers were breastfeeding, 4 used expressed breast milk, and 28 combined both methods. Additionally 29% children received formula: in 8 of them, i.e. a half of the studied cases, it constituted less than half of daily milk supply, while the remaining subjects received maternal breast milk and formula in a 1:1 ratio.     

Type of milk feeding during acute diarrhoea and the risk of persistent diarrhoea: a case control study

The role of feeding breast milk, unmodified bovine milk or adapted infant formula during acute diarrhoea in protecting against or causing persistence of the episodes was investigated in a population-based case control study in an urban area of north India. After adjustment for confounding variables, exclusive breast-feeding was associated with an odds ratio of 0.06 (95% CI 0.002-2.1), a 16.5 times lower odds in favour of developing persistence of an episode. Infants fed unmodified bovine milk in addition to breast milk had an odds of 2.5 times (95% CI 1.0-9.9) in favour of developing persistence of acute diarrhoea ( p = 0.04). In infants receiving unmodified bovine milk and no breast milk, this odds ratio was 11.1 (95% CI 1.0-228.8) ( p = 0.05). This study indicates that promoting exclusive breastfeeding may reduce the persistence of diarrhoea over and above its effect in decreasing the incidence of acute diarrhoea. In urban areas of the developing countries where working mothers often use milk supplementation beyond the age of three months, our findings suggest that use of adapted spray dried formula may be safer than unmodified bovine milk with respect to the risk of developing persistent diarrhoea.     

Breast milk feeding in very low birthweight infants

ABSTRACT. The infant feeding practices of 77 very low birthweight (VLBW) survivors with birthweights under 1500 g were studied. 58 (75%) infants received fresh expressed breast milk (EBM) from their own mothers, of whom 42 were successfully breastfed at a medium postconceptual age of 36 weeks. Overall incidence of breastfeeding in the VLBW population was 44% at 3 months and 23% at 6 months. The postnatal ages at which breastfeeding stopped ranged from 2 months to 28 months (median 4 months). No significant differences in perinatal factors were found between the breast milk and milk formula groups. There were significantly more mothers in the breast milk group who were given advice and encouragement during their pregnancy on breastfeeding and who had planned in the antenatal period to breastfeed their infants. The most common reasons given for deciding against providing breast milk were related to extreme prematurity of the infant. Nursery weight gain of infants fed breast milk and milk formula were similar. Necrotizing enterocolitis occurred significantly less frequently in the breast milk group. The study suggested that the special attention and positve encouragement given to parents of VLBW infants had contributed to the successful establishment and continuation of a feeding regime utilizing fresh breast milk from the infant's own mother, which we believe has immunological, psychological and nutritional benefits in this high-risk infant population.     

Quantifying breast milk intake by term and preterm infants for input into paediatric physiologically based pharmacokinetic models

Despite the many benefits of breast milk, mothers taking medication are often uncertain about the risks of drug exposure to their infants and decide not to breastfeed. Physiologically based pharmacokinetic models can contribute to drug‐in‐milk safety assessments by predicting the infant exposure and subsequently, risk for toxic effects that would result from continuous breastfeeding. This review aimed to quantify breast milk intake feeding parameters in term and preterm infants using literature data for input into paediatric physiologically based pharmacokinetic models designed for drug‐in‐milk risk assessment. Ovid MEDLINE and Embase were searched up to July 2, 2019. Key study reference lists and grey literature were reviewed. Title, abstract and full text were screened in nonduplicate. Daily weight‐normalized human milk intake (WHMI) and feeding frequency by age were extracted. The review process retrieved 52 studies. A nonlinear regression equation was constructed to describe the WHMI of exclusively breastfed term infants from birth to 1 year of age. In all cases, preterm infants fed with similar feeding parameters to term infants on a weight‐normalized basis. Maximum WHMI was 152.6 ml/kg/day at 19.7 days, and weighted mean feeding frequency was 7.7 feeds/day. Existing methods for approximating breast milk intake were refined by using a comprehensive set of literature data to describe WHMI and feeding frequency. Milk feeding parameters were quantified for preterm infants, a vulnerable population at risk for high drug exposure and toxic effects. A high‐risk period of exposure at 2–4 weeks of age was identified and can inform future drug‐in‐milk risk assessments.     

Late metabolic acidosis and poor weight gain in moderately pre-term babies fed with a casein-predominant formula: a continuing need for caution

When our neonatal unit opened in 1984 our formula feeding policy for moderately preterm babies was for casein-predominant rather than "humanized" whey-predominant milk formulae to be given. However, an early cluster of cases of late persistent metabolic acidosis prompted an investigation into the acid-base status and weight gain in preterm infants. This study of 70 healthy, moderately preterm (32-35 weeks) Chinese babies has convincingly shown that a casein-predominant low protein formula is associated with significant metabolic acidosis, persisting sometimes for as long as 8 weeks, and poor weight gain when compared with infants fed on either a humanized or a special low-birthweight formula. This is an important message for the many neonatal units in developing countries where the cost of humanized formulae might initially seem prohibitive, encouraging instead casein-predominant formulae when breast milk is not available. Any additional expense incurred in using humanized formulae will be compensated for by the shortened time spent in hospital.     

Low breastfeeding continuation to 6 months for very preterm infants: A European multiregional cohort study

Breastfeeding confers multiple benefits for the health and development of very preterm infants, but there is scarce information on the duration of breastfeeding after discharge from the neonatal intensive care unit (NICU). We used data from the Effective Perinatal Intensive Care in Europe population‐based cohort of births below 32 weeks of gestation in 11 European countries in 2011–2012 to investigate breastfeeding continuation until 6 months. Clinical and sociodemographic characteristics were collected from obstetric and neonatal medical records as well as parental questionnaires at 2 years of corrected age. Among 3,217 ever‐breastfed infants, 34% were breastfeeding at 6 months of age (range across countries from 25% to 56%); younger and less educated mothers were more likely to stop before 6 months (adjusted relative risk [aRR] <25 years: 0.68, 95% CI [0.53, 0.88], vs. 25–34 years; lower secondary: 0.58, 95% CI [0.45, 0.76] vs. postgraduate education). Multiple birth, bronchopulmonary dysplasia (BPD), and several neonatal transfers reduced the probability of continuation but not low gestational age, fetal growth restriction, congenital anomalies, or severe neonatal morbidities. Among infants breastfeeding at discharge, mixed versus exclusive breast milk feeding at discharge was associated with stopping before 6 months: aRR = 0.60, 95% CI [0.48, 0.74]. Low breastfeeding continuation rates in this high‐risk population call for more support to breastfeeding mothers during and after the neonatal hospitalization, especially for families with low socio‐economic status, multiples, and infants with BPD. Promotion of exclusive breastfeeding in the NICU may constitute a lever for improving breastfeeding continuation after discharge.     

The biological specificity and superiority of human milk. Scientific basis, guarantees and safety controls

Scientific knowledge has demonstrated that breastfeeding is the ideal method of feeding and nurturing infants and has recognised breastfeeding as primary in achieving optimal infant health, growth and development. Human milk is species-specific and offers a superior method of feeding. All other options differ markedly from it. Milk formulas are designed to mimic human milk as much as possible, but important compositional differences between human milk and formulas remain, and it is unlikely that this situation will change very soon, if ever. Thus, the breastfed infant remains the reference model against which all alternative feeding methods are measured, with regard to health, growth and development. Human milk has a dynamic nature and varies with time postpartum, but the variations of its composition with time of lactation match the changing needs of the growing infant. The role of the pediatrician is essential in promoting, protecting and supporting breastfeeding in the hospital, medical schools, individual practices and in the community. The purpose of this review is to describe and provide insight into the nutritional benefits, the contributions to host defence and the social and psychological benefits of maternal-infant bonding obtained by breastfeeding. This paper also summarises other substantial advantages obtained when infants are fed at the breast and describes the rare situations and medical reasons when human milk is not recommended, when alternative options should be considered, or when breastfeeding must be closely monitored. Early identification of those infants fed at the breast who have inadequate intakes is important, also to preserve breastfeeding.     

Breast feeding in neonatal alloimmune thrombocytopenia

Infants with neonatal alloimmune thrombocytopenia are at risk of severe intracranial haemorrhage. Placental transfer of maternal immunoglobulin G (IgG) directed against fetal platelet antigens is known to be the underlying mechanism. Since breast milk contains IgG it is theoretically possible that breast feeding of these infants could cause thrombocytopenia. The following case report shows that an infant with neonatal alloimmune thrombocytopenia may be safely breast fed, even when the breast milk contains the platelet specific antibody (HPA-1a).     

Care of the HIV-Exposed Child—To Breast Feed or Not?

Breast milk is the best form of nutrition for infants. However, it places infants born to HIV infected women at risk of acquiring HIV infection. Total avoidance of breastfeeding is the only way of completely avoiding HIV transmission through breast milk. However, this strategy has not proved to be viable in resource constrained nations. A high infection related mortality and morbidity, and a high prevalence of malnutrition have been observed in HIV exposed infants on replacement feeding. Exclusive breastfeeding for the first six months followed by rapid weaning has also not proved to be a good strategy, with a surge in infection related morbidity and malnutrition reported after weaning. Current evidence indicates that continued use of ARV prophylaxis to mother/infant starting during pregnancy and continued to cover the entire duration of breastfeeding offers the infant best chance of HIV free survival, combining the benefits of breast milk with safety induced by ARV prophylaxis.     

Immunological considerations on breast vs. formula feeding

The breast-fed baby is immunologically protected because the food is uncontaminated, because breast milk contains specific and unspecific constituents directed against microorganisms, toxins and food antigens, and because adverse immunological reactions against constituents of breast milk substitutes, as cow's milk proteins, are avoided. It is not known which of the mechanisms are the most important ones. Antiinfectious properties may also serve to protect the mammary gland. The documented lower morbidity of breast-fed compared to artificially fed infants in developing and developed countries is reviewed. Favourable immunological properties of human milk are sensitive to various ways of treatment, e.g. pasteurization. Exclusive breast feeding until several weeks or months of age appears to modify the relative risk of development of subsequent allergic disease, but the literature on this issue is not entirely conclusive. Breast feeding may also reduce the risk of developing other immunological disorders at later age, e.g. celiac disease and ulcerative colitis.     

Crying, fussing and colic behaviour in breast- and bottle-fed infants

Persistent infant crying and "colic" have been linked in some studies to feeding, but this association has not been tested in a planned longitudinal study comparing breast- with formula fed babies. We used validated maternal diaries of infant behaviours, kept for three days at both two and six weeks of infant age, in a comparative study of 97 breast- or formula fed babies. The total duration of overall crying rose significantly between 2 and 6 weeks in breast-fed infants and fell in those fed formula. At 6 weeks, breast-fed infants cried an average of almost 40 minutes more per day than formula fed infants; and 31% cried for more than three hours per day, compared with only 12% of the formula fed group. At six weeks, breast-fed infants also slept almost 80 minutes less per day than the formula fed babies. While six weeks is the established peak age for infant crying, those fed formula peaked much earlier and at 2 weeks intense crying/colic behaviour occurred in 43% of formula fed babies and just 16% of those fed by breast. These findings link the timing of the infant crying peak to the mode of feeding. Our data indicate that any regimen designed to reduce crying should commence in the neonatal period in formula fed infants.     

Development of a biochemical marker to detect current breast milk intake

The WHO recommends exclusive breastfeeding for 6 months, but despite interventions, breastfeeding rates remain stubbornly low. Financial voucher incentives have shown promise but require a biomarker for validation of intake. This study aimed to develop a simple biochemical assay of infant urine that would tell if an infant was receiving any breast milk to validate maternal report. Urine samples were collected and snap frozen from 34 infants attending with minor illness or feeding problems, of whom 12 infants were exclusively breastfed, nine exclusively formula fed, and 11 mixed breast/formula fed. High‐performance anion exchange chromatography was used to identify discriminating patterns of monosaccharide composition of unconjugated glycans in a sequence of three experiments. The absolute concentration of all human milk oligosaccharides measured blind could detect “any breastfeeding” only with a sensitivity of 48% and specificity of 78%. Unblinded examination of N‐acetylglucosamine (GlcNAc) measured as GlcNH₂ after hydrolysis of GlcNAc improved sensitivity to 75% at the expense of a specificity of 28%. Estimation of the relative abundance of GlcNH2 (GlcNH2[%]) or the ratio of GlcNH2 to endogenous mannose (Man) improved accuracy. In a further blind experiment, the GlcNH2/Man ratio with a cut‐off of 1.5 correctly identified all those receiving “any breast milk,” while excluding exclusively formula fed infants. The GlcNH2/Man ratio in infant urine is a promising test to provide biochemical confirmation of any breastfeeding for trials of breastfeeding promotion.     

Predictional need for supplementing breastfeeding in preterm infants under Kangaroo Mother Care

It has been estimated that 95% of low-birthweight infants are born in developing countries. Nevertheless, most of the globally available resources are invested in developed countries, both for sophisticated, expensive technological care and for research focused on solving problems in scenarios in which access to expensive resources is available. Very little research on scientifically sound, economically accessible interventions reaches internationally recognized scientific journals. For instance, one accepted scientific dogma is that all premature infants must receive breast-milk fortifiers. Thus, healthcare workers consider that not offering fortification or supplementation to all preterm infants under 2000 g is unethical, as it denies them the proven benefits of this intervention. This approach oversimplifies the problem by assuming that infants under 2000 g are a homogeneous population, with similar needs and risks. The largest proportion of preterm survivors in developing countries comprises infants weighing > 1200 g, and their nutritional needs differ from those weighing < 1200 g, who represent a significantly smaller proportion. In developing countries, fortification of breast milk is seldom a feasible option. Even supplementing breast milk with formula implies an expense that cannot always be covered. In addition, many preterm infants (particularly those weighing > 1200 g) can grow properly on exclusive breastfeeding. In our experience, about 45% of infants under ambulatory Kangaroo Mother Care (KMC) thrive properly. The choice between giving and withholding supplementation for all preterm infants is not an ethical issue, because there is no choice. This was the justification for conducting the study reported here, which attempts to answer the question of how to identify, as early as possible, those premature infants who survive the early neonatal period and have no obvious risk factors for inadequate growth other than prematurity, but who are less likely to thrive with exclusive breastfeeding. Conclusion: The answer to this question will allow us to use our meagre resources in the most reasonable way, as supplementing breast milk involves not only the direct cost of the formula but also that of training the mothers in techniques for feeding their infants without compromising breastfeeding or increasing the risk of infectious diseases.     

Breast feeding and infant growth.

Various studies demonstrate that the lactation potential of relatively undernourished mothers in developing countries equals that of women in developed countries. It can also sustain optimal growth as well as that of women in developed countries. Studies at the National Institute of Nutrition in Hyderabad, India, show that the average poor woman secrets 500 to 800 ml of breast milk/day for the first 6 months and that little difference in breast milk intakes at 3 months exists between these women and those from developed countries. Even though breast milk of women in developing countries has a lower fat content than that of women in developed countries, the protein levels correspond. Further, caloric content of breast milk from undernourished and well nourished women is basically similar. Moreover, food supplementation for undernourished women does not greatly improve the macronutrient or quantity composition of breast milk. On the other hand, breast milk of undernourished mothers has lower levels of fat-soluble and water-soluble vitamins than that of well nourished women, revealing their vitamin deficiencies. Studies show that undernourished women in India can successfully begin breast feeding and breast feed for up to 24 months. Breast fed infants of undernourished mothers in India grow just as well as those of well nourished mothers during the first 6 months of life. The evidence in India indicates that, ideally, supplementary feeding should not begin before 6 months, and definitely, not before 4 months, to reduce the risk of infection (especially diarrheal disease) and delay the return to fertility. Industrialization and urbanization in India results in more and more women, especially those in urban slums, not having the option to exclusively breast feed their infants. This change adversely affects infant heath; so pediatricians, administrators, and policymakers must come up with initiatives to counter these effects.     

Trends in breastfeeding: it is not only at the breast anymore

The past characterisations of breastfeeding as being only at the breast of the mother may no longer be applicable in the United States as mothers now frequently express their milk. We conducted a retrospective cohort study with women who visited the Cincinnati Children's Breastfeeding Medicine Clinic to understand breast milk feeding behaviours of healthy mothers and infants, which included questions specifically about breast milk expression. All 40 mothers in the cohort expressed their milk and all 40 infants were fed expressed milk. One infant was fed another mother's milk for 30 days. Two‐thirds (13/40) of infants received their mother's expressed milk at least a week after it was first expressed and 25% (10/40) of infants continued to be fed expressed breast milk after mothers had stopped expressing milk. There were 14 sequences of breast milk production by the mothers and 16 sequences of consumption by the infants. Early in the post‐partum period, mothers started expressing milk even though their infants were consuming all of the breast milk that they needed at the breast. As a result of breast milk expression by all mothers in this cohort, we observed highly variable patterns of maternal breast milk production and infant breast milk consumption, which were not necessarily synchronous within a dyad. It is now time to develop appropriate ways to characterise the production and consumption of breast milk more accurately and investigate whether these behaviours have consequences for the health of mothers and infants.     

Infant milk feeding practices in the Netherlands and associated factors

AIM: The aim of the study was to describe infant feeding practices and associated factors, and to explore mothers' main reasons for starting and stopping breastfeeding. METHODS: We performed a national inquiry into milk feeding practices among 9133 Dutch infants aged < 7 mo by means of a questionnaire. RESULTS: 78% of mothers initiated breastfeeding. At 1 and 4 mo, respectively, 51 and 25% of infants were fed primarily on human milk; after 6 mo, only 15% of mothers still provided human milk as the only source of milk feeding. During the whole 6-mo period, another 11 to 18% was fed on both breast and formula milk. Women initiating breastfeeding were more likely to be higher educated, have a higher-educated partner, be non-smokers, have a full-time job, and be primiparous. In addition, breastfeeding initiation rate was higher for women born outside the Netherlands. Longer duration of breastfeeding was mostly found amongst higher-educated, non-smoking women. The odds for continuation of breastfeeding after 4 mo increased when mothers' working hours did not exceed 16 h/wk. Infant delivery at home was associated with a higher initiation rate as well as longer duration of breastfeeding compared to hospital delivery. Infants born after 38 wk of gestation, with a birthweight of 3500 g had higher odds to be breastfed for a longer period. CONCLUSION: Only a minority of Dutch infants is breastfed for 6 mo. Maternal and infant characteristics are important predictors of breastfeeding initiation and duration.