Breast milk: the best lovebiotic

Abstract

We read with interest the recent article by Cibulskis and Armbrecht 1 describing the association of metabolic acidosis in premature infants fed on breast milk fortified with liquid fortifier. As our neonatal unit has reached 100% breast milk exposure to extremely low birth weight (ELBW) and 90% for very low birth weight (VLBW) infants through a quality improvement project, 2 we are keen on the author's observations. However, we wish to share some reservations regarding the methodology adopted to arrive at the associations and conclusions:(1) There is considerable room for selection bias between the two groups being compared. Two consecutive patient populations were selected at different time periods by block allocation. 3 A number of potential confounders, that could have influenced the study results, were left to the treating clinician's discretion. Generally a good randomisation process achieves groups that are similar in baseline characteristics, and thereby minimises confounding and type-1 errors that could lead to misleading results. 4 (2) Sufficient information is not provided on the acid-base status of the infants prior to administration of the liquid human milk fortifier (HMF). We also have no visibility in the paper of some key co-morbidities or pharmaceutical agents that might have contributed to metabolic acidosis, for example, sepsis, significant patent ductus arteriosus or regular medications with acidic pH such as caffeine citrate. (3) No institutional feeding guidelines have been explained or given as an appendix in the paper, and no clear values proposed advising clinicians regarding at what level of base excess/pH the HMF should be discontinued. (4) There is no logistical regression done and as such no association could be precisely deduced between metabolic acidosis and use of the HMF. When one nominal variable (dependent) and one measurement variable (independent) are in question, we would like to know whether variation in the measurement variable causes the variation in nominal variable. We do recognise that the authors did not attempt a causation hypothesis; however, the overall methodology permits only a weak association at the best.In our unit we use traditional powdered HMF and have not observed metabolic acidosis attributable to or associated with any of our ELBW (30) or VLBW (55) infants whose acid base status was prospectively collected as an additional variable while collating the Vermont-Oxford Network (VON) data for 2013 and 2014. Table 1 compares the contents of the powdered HMF we use (product C) with those used in the study. The compositions of the HMF described in the paper and ours are similar. We used mother's own breast milk as well as donor human milk from the bank during the period of observation. We also have a very low necrotising enterocolitis (NEC) rate-no cases in 2013 (with an inhouse birth rate of 4265), that too has been achieved without additional probiotic use. We have no unit-level experience with the liquid HMF and are hence unable to compare our results with the...

Caffeine Treatment for Apnea of Prematurity and the Influence on Dose-Dependent Postnatal Weight Gain Observed Over 15 Years

“…For the ELBW infants, breast milk use steadily increased from 20% in 2005 to 90% in 2012 and through a quality improvement project reached 100% from 2014 to 2016. 21 Inclusion criteria were (1) ELBW and VLBW infants born in our hospital during the study period with birth weight of <1500 g and gestational age of 23–30 weeks, and (2) infants requiring treatment with oral CC for AOP. Exclusion criteria were (1) infants born with major congenital anomalies, (2) infants concurrently receiving other medicines that could influence weight gain such as diuretics, ibuprofen, indomethacin, or postnatal corticosteroids, (3) infants transferred in/out of the unit from/to other neonatal centers, (4) infants with blood culture-proven sepsis during the course of oral caffeine treatment, (5) grade 3/4 intraventricular hemorrhage (IVH), (6) infants on fluid restriction, (7) infants who have received middle of the dosage range of 7–8 mg/(kg·day) of CC from the treating team, (8) infants with necrotizing enterocolitis (NEC) with modified Bell's stage 2b and above, 25 and (9) infants while receiving intravenous caffeine.…”

“…While caffeine has respiratory benefits for preterm infants, it may have adverse molecular and cellular effects on the developing brain. 20 , 21 Half-life of caffeine varies widely among infants based on their liver function status, exposure to certain concurrent medications, and the level of hepatic enzymes needed for metabolism. Among healthy adults, caffeine's half-life is ∼4.9 hours and in pregnant women 9–11 hours.…”

Spiritual Aspects of Breastfeeding: A Narrative Review

“…There are three treatment modalities: medical, surgical, and immunotherapy. Treatment of warts is a therapeutic challenge for dermatologists because no particular therapy has been proven effective at achieving complete remission in each patient (16,18). Treatment options should be made individually according to the experience of the physician, patient preference, and the application of evidence-based medicine (19).…”

“…Therefore breastfeeding is a complex practice not only because of its physical and biological nature but also because of its roots within society's social, spiritual, and cultural construct (17). In recent studies, breast milk has been introduced as the best love biotic besides its other values (18). The literature in the spirituality interventions is limited but evidence has demonstrated spirituality as integrative energy to promote health (19).…”

Child Health Care in Ireland

“…Consultants in Obstetrics, Neonatology / Paediatrics and Anesthetics are in-house during regular hours and provide an on-call service during out of hours as well. Irish breastfeeding rate remains low among the developed countries despite programs such as baby friendly health initiatives (BFHI), however more recently exposure of premature infants to breast milk has significantly improved in neonatal units (54). While the resources invested in the maternity services in Ireland is modest by OECD standards, Ireland continues to have a low perinatal mortality and maternal mortality rate.…”