JPediatr(RioJ).2016;92(2):111---112
www.jped.com.br
EDITORIAL
Should
human
milk
for
premature
children
be
fortified
after
discharge
to
improve
neurodevelopmental
outcomes?
夽
,
夽夽
O
leite
materno
deve
ser
fortificado
para
crianc
¸as
prematuras
após
terem
alta
para
melhorar
os
resultados
de
neurodesenvolvimento?
Myriam
Peralta-Carcelen
a,∗,
Harriet
H.
Cloud
baUniversityofAlabamaatBirmingham(UAB),Birmingham,UnitedStates
bDepartmentofNutritionandSciences,UniversityofAlabamaatBirmingham(UAB),Birmingham,UnitedStates
Pretermchildrenareathigherriskforneurodevelopmental problems.1Exclusivebreastfeedingforallchildren,
includ-ing term infants, has been recommended for the health benefitsaswellasoverallwellbeing.2Inaddition,improved
developmentaloutcomeshavebeenreportedinterm chil-dren whoareexclusively breastfed.3 In pretermchildren,
the advantages of human milk have been well estab-lished for protection against necrotizing enterocolitis and sepsis, and trophic effects.4 However, it has been
recog-nized that, in preterm children, human milk alone may notsupportoptimalgrowthbecauseofinsufficientnutrient content.5 Preterm infants are born at a periodof
signifi-cant organ development and areat risk for deficiency of essentialnutrientsandtrophicfactorsthatpromotegrowth and brain development, such as long-chain polyunsatu-ratedfattyacidsandpossiblyothers.6Withoutfortification,
pretermchildren mayhave growthretardation,which has beenassociatedwithimpairedneurodevelopment.7
There-fore, it has been recommended that all preterm infants
夽 Please cite this article as: Peralta-Carcelen M, Cloud HH.
Shouldhumanmilkfor premature childrenbe fortifiedafter dis-chargeto improveneurodevelopmental outcomes?JPediatr(Rio J).2016;92:111---2.
夽夽
SeepaperbydaCunhaetal.inpages136---42.
∗Correspondingauthor.
E-mail:mperalta@peds.uab.edu(M.Peralta-Carcelen).
with birth weight <1800g should receive fortified human milk,to add supplemental nutrient fortification, focusing onproteins and minerals, and vitamins in particular dur-ingtheneonatalintensivecareunitstaytoassureadequate growth.8 This fortification has been provided with
differ-ent commercially available components, and the quality ofavailable products varies. Some unitsuse a more stan-dardizedapproachedwhileothersuseamoreindividualized approach.9
Improved neurodevelopmentaloutcome and theuse of humanmilkinpretermchildrenhasbeenreportedinlarge, mostlyobservationalretrospectivestudies10;amorerecent
reviewdidnotconcludethattherewasimproved neurode-velopmentaloutcomewiththeuseofhumanmilkinpreterm childrenintheirmeta-analyses.11 However,inthatreview,
studiesincludeddidnothavemuchinformationonfortifier use.Astudy12reportedaparadoxbetweenpreterminfants
fedwithhumanmilkthat grew lessduringhospitalization comparedtoformulafedinfants,buthadbetter neurode-velopmentinthefirstfewyearsoflife;however,thegroup thatwas breastfedhad higher birth weight,although the authorscontrolledforgrowthrestrictionandsocioeconomic status.
Use of fortified human milk during the NICU stay has demonstratedimprovementingrowthinpreterminfants12;
however,studiesonlongtermneurodevelopmentaloutcome arenotconclusive.Areviewlookedspecificallyforeffectsof humanmilkfortificationafterdischargeondevelopment13
http://dx.doi.org/10.1016/j.jped.2016.01.001
112 Peralta-CarcelenM,CloudHH.
and did not find differences in neurodevelopmental out-come.
There are several human milkfortifiers that had been promoted foruse withhuman milkin prematureinfants5;
inaddition,somehospitalsusepowderedpretermformula inordertoprovidemineralsandotherneedednutrientsfor pretermchildren. The costof commerciallyavailable for-tifiersishigh,inadditiontoproblemswithaddingpossible contaminationor excessiveuseof fortifiersandeffectson long-termhealth.
The present article from da Cunha et al.14 reports on
arandomizedclinical trialofaformulapowder(NESTLÉ®,
Vevey, Switzerland) human milk vs. human milk with no supplementationoninfantsborn weighinglessthan1500g afterbeingdischargedfromthenursery.Thisstudyhas mul-tiple strengths, such as using a valid randomized design and blinding developmental evaluators to the interven-tiongroup.However,there areseveralvariables thatwill be difficult to control for. Preterm infants represent a heterogeneouspopulation whomayrequirecarefully indi-vidualized nutritional care. In addition, there is large variation between the content of breast milk from one mothertoanother.Although thiswasarandomizedstudy, humanmilk contentwasnotanalyzed; therefore, a great variabilityacrossthedifferentmothersincludedinthestudy ispossible.Ifhigher-qualityfortifiersandmaternalvitamin and mineral supplementation were used,the results may havebeenstatisticallysignificantbetweengroups.
Althoughnotdescribedinthestudy,wecanassumethat infants were fed directly at the breast, and only supple-mented children receivedexpressed breast milk by other means.
This study addresses an important question regarding whetherfortificationofhumanmilkshouldberecommended post-dischargeforpreterminfantsforthetheoretical advan-tages of higher protein and nutrient content to improve neurodevelopmental outcomes. This becomesparticularly important for infants born at extreme prematurity with longerhospitalization,whomayhaveasignificant accumu-lateddeficitinnutrientspriortodischarge.Itispossiblethat withnewerguidelinesoffortificationduringtheNICUstay, childrenmaynotbeasadisadvantageaswehadassumed previously.Severalinvestigationsareongoing,looking into the quality and duration of human milk fortification. In addition,fortificationafterdischargeisnotwithout difficul-ties,consideringthehighcostofmulticomponentfortifiers; perhapslimitedavailability;possiblecontaminationduring mixing,in particularin areaswithlimitedresources;and, perhaps, eventhe discouragementof breastfeeding when infantsareathome.
We are left withthe question of whether we need to fortify breast milk for preterm infants after discharge to improveneurodevelopmentaloutcomes;however,wecanbe
reassuredfromthisstudythatifthereisaclinicalindication forfortification,itmustnotinterferewithexclusive breast-feeding---thedesiredmethodoffeedingpreterminfants ---givenalltheadvantagesthatbreastfeedingprovides.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.StephensBE,VohrBR.Neurodevelopmentaloutcomeofthe pre-matureinfant.PediatrClinNorthAm.2009;56:631---46.
2.FewtrellMS,Morgan JB,DugganC,GunnlaugssonG,Hibberd PL,LucasA,etal.Optimaldurationofexclusivebreastfeeding: whatistheevidencetosupportcurrentrecommendations?Am JClinNutr.2007;85:635S---8S.
3.Gertosio C,Meazza C, PaganiS, Bozzola M. Breastfeeding: gamutofbenefits.MinervaPediatr.2015,May[Epubaheadof print].
4.JohnsonTJ,PatelAL,BiggerHR,EngstromJL,MeierPP.Cost savingsofhumanmilkasastrategytoreducetheincidence ofnecrotizingenterocolitisin verylow birthweight infants. Neonatology.2015;107:271---6.
5.ZieglerEE.Humanmilkandhumanmilkfortifiers.WorldRev NutrDiet.2014;110:215---27.
6.AndersonA, Swank P, WildinS,Landry S, SmithK. Modeling analysisofchangeinneurologicabnormalitiesinchildrenborn prematurely:anovelapproach.JChildNeurol.1999;14:502---8.
7.EhrenkranzRA.Nutrition,growthandclinicaloutcomes.World RevNutrDiet.2014;110:11---26.
8.Moro GE, Arslanoglu S, Bertino E, Corvaglia L, Montirosso R, Picaud JC, et al. XII. Human milk in feeding premature infants: consensus statement. J Pediatr Gastroenterol Nutr. 2015;61:S16---9.
9.Arslanoglu S. IV. Individualized fortification of human milk: adjustable fortification. J Pediatr Gastroenterol Nutr. 2015;61:S4---5.
10.VohrBR,PoindexterBB,Dusick AM,McKinleyLT, HigginsRD, LangerJC, etal. Persistentbeneficial effects ofbreastmilk ingestedin theneonatalintensive care unit onoutcomes of extremelylowbirthweightinfantsat30monthsofage. Pedi-atrics.2007;120:e953---9.
11.KooW, TankS,MartinS,ShiR.Humanmilkand neurodevel-opmentinchildrenwithverylowbirthweight: a systematic review.NutrJ.2014;13:94.
12.Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. CDS Rev. 2004;1:CD000343.
13.YoungL,EmbletonND,McCormickFM,McGuireW.Multinutrient fortificationofhumanbreastmilkforpreterminfantsfollowing hospitaldischarge.CDSRev.2013;2:CD004866.
