Elsevier

The Journal of Pediatrics

Volume 180, January 2017, Pages 15-21
The Journal of Pediatrics

Medical progress
Donor Human Milk Update: Evidence, Mechanisms, and Priorities for Research and Practice

https://doi.org/10.1016/j.jpeds.2016.09.027Get rights and content

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MOM and DHM: Compositional and Bioactive Differences that Impact Outcome

Previous comparisons addressing the composition and bioactivity of MOM and DHM have focused almost exclusively on the effects of pasteurization, with mixed findings for some components.13, 15, 16 However, factors other than pasteurization impact DHM in clinically significant ways, including maturity of the mammary gland (preterm MOM vs term DHM), stage of lactation for which DHM replaces MOM (eg, mature DHM replacing MOM colostrum and transitional milk), and freeze-thaw cycles that are inherent

DHM and Morbidities

There is empirical evidence for the efficacy of DHM in reducing the risk, incidence, and severity of NEC when DHM replaces formula.12, 13, 58, 59, 60 This consistent finding in randomized and nonrandomized studies is clinically and economically significant regardless of the lack of impact on other acquired morbidities. However, most DHM studies included some MOM feedings within a larger human milk metric, with no information about the relative proportions of MOM and DHM received before the

Combining MOM and DHM into the Same Human Milk Feeding Group for Research and Quality Improvement

Most randomized studies comparing the effects of DHM and formula have included infants receiving some MOM in both groups because of the inability to assign feeding type ethically.7, 14, 59, 72 However, other studies have used the terminology, human milk-fed or breast milk-fed, to include both MOM and DHM feedings without any information detailing the relative proportions or the exposure periods for the 2 milks. Human milk-fed has been used to describe characteristics of study samples73 and as

Impact of DHM Availability on Provision of MOM

One systematic review and 1 report of a large database of 22 California NICUs have suggested that the introduction of DHM programs does not reduce rates of provision of MOM for VLBW infants.60, 79 However, the measures used to evaluate the impact of DHM ranged from “any breastfeeding at NICU discharge,” which was inconsistently defined among the studies, to actual measures of MOM dose for specific exposure periods pre- and postimplementation of a DHM program.60, 79 Esquerra-Zwiers et al80

Acceptability of DHM by NICU Families and Staff

Several studies have examined the acceptability of DHM by NICU families and staff in developing82, 83, 84 and developed85 countries. Concerns remain about the safety and quality of DHM in developing countries, especially those in which the prevalence of HIV is high.82, 84 Brownell et al85 examined 5-year trends in nonconsent for DHM in a large US urban medical center, reporting that non-White race and increasing infant gestational age predicted refusal for DHM consent, although total refusals

The Economics of MOM and DHM and Prioritization of Resources

DHM reduces the costs associated with NEC when substituted for formula,90 but is significantly more costly than acquiring MOM,91 which reduces multiple other morbidities and their associated costs in VLBW infants.6, 8, 36 These comparisons raise the question as to how investments in human milk feeding should be targeted. Investing in DHM is often easier than addressing barriers to the provision of MOM in the NICU, but most lactation barriers in this population are modifiable when evidence-based

Summary

Increasingly, the terminology human milk feeding is used to include both MOM and DHM for VLBW infants, implying that the multiple beneficial outcomes attributed only to MOM can be generalized to DHM. In particular, there is lack of fit between preterm MOM and DHM during the early critical postbirth window when nutritional and immunomodulatory programming and select organ growth via MOM components are thought to occur. Although DHM has been associated with reductions in NEC, MOM is more

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      Furthermore, as others have shown,41,42 we observed greater weight gain in infants fed with high MOM proportions, suggesting a growth-promoting effect of MOM compared with DHM, perhaps mediated through the microbiome. Further research is needed to explore this hypothesis, but it is consistent with the known impact of DHM processing (pasteurization and freezing) on the maternal cells, microbes, and bioactive proteins (including lipase and adipokines) found in fresh MOM,19–21,43 and the unique composition of MOM in early lactation compared with mature milk typically provided to donor milk banks.18,43,44 Somewhat unexpectedly, we observed that infants with high MOM intake had enrichment of one unclassified member of Enterobacteriaceae, a family comprising many (but not exclusively) inflammatory species.

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    Funded by the National Institutes of Health (NR010009). The authors declare no conflicts of interest.

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