Formula versus maternal breast milk for feeding preterm or low birth weight infants

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Abstract

Artificial formula can be manipulated to contain higher amounts of macro‐nutrients than maternal breast milk but breast milk confers important immuno‐nutritional advantages for preterm or low birth weight (LBW) infants. To determine the effect of feeding preterm or LBW infants with formula compared with maternal breast milk on growth and developmental outcomes. We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 9), and Ovid MEDLINE, Ovid Embase, Ovid Maternity & Infant Care Database, and CINAHL to October 2018. We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles. Randomised or quasi‐randomised controlled trials that compared feeding preterm or low birth weight infants with formula versus maternal breast milk. Two review authors planned independently to assess trial eligibility and risk of bias, and extract data. We planned to analyse treatment effects as described in the individual trials and report risk ratios and risk differences for dichotomous data, and mean differences for continuous data, with 95% confidence intervals. We planned to use a fixed‐effect model in meta‐analyses and to explore potential causes of heterogeneity in subgroup analyses. We planned to use the GRADE approach to assess the certainty of evidence. We did not identify any eligible trials. There are no trials of formula versus maternal breast milk for feeding preterm or low birth weight infants. Such trials are unlikely to be conducted because of the difficulty of allocating an alternative form of nutrition to an infant whose mother wishes to feed with her own breast milk. Maternal breast milk remains the default choice of enteral nutrition because observational studies, and meta‐analyses of trials comparing feeding with formula versus donor breast milk, suggest that feeding with breast milk has major immuno‐nutritional advantages for preterm or low birth weight infants. Formula versus maternal breast milk for feeding preterm or low birth weight infants Review question  Does feeding preterm or low birth weight infants with formula rather than maternal breast milk affect growth and development? Background  Artificial formulas can be manipulated to contain higher amounts of important nutrients such as protein than maternal breast milk but newborn infants often find formula difficult to digest. Artificial formulas, furthermore, do not contain the antibodies and other substances present in breast milk that protect the immature gut of preterm or low birth weight infants and reduce the risk of infection and severe bowel problems. If preterm infants are fed with formula rather than maternal breast milk (breast‐fed directly or mother's own expressed breast milk), this might increase the risk of these problems and adversely affect growth and development. Given these concerns, we planned to review the evidence from clinical trials that compared formula versus maternal breast milk for feeding preterm or low birth weight infants. Study characteristics  In searches up to October 2018, we did not find any eligible randomised controlled trials. Key results and conclusions  There are no trial data to answer this question. Since another Cochrane Review showed that feeding with formula compared to donor breast milk increases the risk of serious gut problems in preterm or low birth weight infants, it is unlikely that families and clinicians would consider it acceptable to allocate an infant to receive formula as an alternative to maternal breast milk when it is available.

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Most cited references 18

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Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

C Agostoni, G. Buonocore, VP Carnielli … (2010)

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infant's own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

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Human milk for the premature infant.

Mark Underwood (2013)

Premature infants are at risk for growth failure, developmental delays, necrotizing enterocolitis, and late-onset sepsis. Human milk from women delivering prematurely has more protein and higher levels of bioactive molecules. Human milk must be fortified for premature infants to achieve adequate growth. Mother's own milk improves growth and neurodevelopment, decreases the risk of necrotizing enterocolitis and late-onset sepsis, and should be the primary enteral diet for premature infants. Donor milk is a resource for premature infants whose mothers are unable to provide an adequate supply of milk. Challenges include the need for pasteurization, nutritional and biochemical deficiencies, and limited supply. Copyright © 2013 Elsevier Inc. All rights reserved.

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Growth and development of premature infants fed predominantly human milk, predominantly premature infant formula, or a combination of human milk and premature formula.

L O'Connor, Robert Hall, Joanne S Szabo … (2003)

In a recent meta-analysis, human milk feeding of low birth-weight (LBW) infants was associated with a 5.2 point improvement in IQ tests. However, in the studies in this meta-analysis, feeding regimens were used (unfortified human milk, term formula) that no longer represent recommended practice. To compare the growth, in-hospital feeding tolerance, morbidity, and development (cognitive, motor, visual, and language) of LBW infants fed different amounts of human milk until term chronologic age (CA) with those of LBW infants fed nutrient-enriched formulas from first enteral feeding. The data in this study were collected in a previous randomized controlled trial assessing the benefit of supplementing nutrient-enriched formulas for LBW infants with arachidonic acid and docosahexaenoic acid. Infants (n = 463, birth weight, 750-1,800 g) were enrolled from nurseries located in Chile, the United Kingdom, and the United States. If human milk was fed before hospital discharge, it was fortified (3,050-3,300 kJ/L, 22-24 kcal/oz). As infants were weaned from human milk, they were fed nutrient-enriched formula with or without arachidonic and docosahexaenoic acids (3,300 kJ/L before term, 3,050 kJ/L thereafter) until 12 months CA. Formula fed infants were given nutrient-enriched formula with or without added arachidonic and docosahexaenoic acids (3,300 kJ/L to term, 3,050 kJ/L thereafter) until 12 months CA. For the purposes of this evaluation, infants were categorized into four mutually exclusive feeding groups: 1) predominantly human milk fed until term CA (PHM-T, n = 43); 2) >/= 50% energy from human milk before hospital discharge (>/= 50% HM, n = 98); 3) /= 50% HM infants at term CA. There was a positive association between duration of human milk feeding and the Bayley Mental Index at 12 months CA (P = 0.032 full and P = 0.073 reduced, statistical models) after controlling for the confounding variables of home environment and maternal intelligence. Infants with chronic lung disease fed >/= 50% HM until term CA (n = 22) had a mean Bayley Motor Index about 11 points higher at 12 months CA compared with infants PFF-T (n = 24, P = 0.033 full model). Our data suggest that, despite a slower early growth rate, human milk fed LBW infants have development at least comparable to that of infants fed nutrient-enriched formula. Exploratory analysis suggests that some subgroups of human milk fed LBW infants may have enhanced development, although this needs to be confirmed in future studies.