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The Importance of Human Milk in Preterm Infants
Almerinda Barroso Pereira
Hospital de Braga
The Importance of Human Milk in Preterm Infants
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Premature infants have great nutritional needs to achieve
optimal growth in the neonatal period.
– Infants born at the beginning of the third trimester of pregnancy often
are growth-restricted because of decreased intrauterine nutrient
deposition.
– Medical conditions: hypotension, hypoxia, acidosis, infection, surgery,
increase metabolic energy requirements and nutrient needs .
– Additional impediments to growth are physiologic immaturity of the
gastrointestinal tract including decreased gastrointestinal motility and
reduced intestinal enzyme activity.
The Importance of Human Milk in Preterm Infants
• Nutritional support helps to correct growth
restriction at birth and to achieve an appropriate
rate of weight gain.
• Enteral nutrition must be provided to premature
infants with human milk as the preferred feeding
for all infants.
Pediatrics. 2012;129(3):e827
ADVANTAGES OF HUMAN MILK
• Improved gastrointestinal function, digestion, absorption of nutrients.
• Promotes more rapid attainment of full enteral feeds.
• Improved host defence with reduced rates of infection.
• Enhanced maternal psychological well-being and maternal-infant bonding.
• Shorter duration of hospitalization in premature infants.
• Improved cognitive and visual development.
• Breastfeeding is associated with long-term benefits , infant and mother.
www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf (October 2008)
Human Milk
• Clinical Direct Benefits:
– Improvement in Gastrointestinal Function
– Host Defence - Anti-microbial Components
• Long – Term Benefits:
– Reduction of Acute Illnesses
– Decreased Risk of Chronic Diseases
– Improved Neurodevelopment Outcome
Human Milk and Gastrointestinal Function
 Components of human milk stimulate gastrointestinal growth
and motility, which enhance the maturity of the gastrointestinal
tract:
– Cortisol, somatomedin-C, insulin-like growth factors, insulin, and thyroid
hormone may affect intestinal growth and mucosal function.
– Growth factors (nerve growth factor) may play a role in the innervation
of the intestinal tract .
– Gastrointestinal mediators (neurotensin and motilin) may affect
gastrointestinal motility.
– Free amino acids may be trophic for intestinal growth (taurine) and may
stimulate enterocyte growth (glutamine).
Clin Perinatol. 1999;26(2):335.
Human Milk and Gastrointestinal Function
• Components of human milk are protective and decrease the
risk of infections:
• Growth factors (epidermal growth factor) affect development
of the intestinal tract and may be protective against invasive
disease.
– Human milk is associated with neonatal intestinal colonization
by the beneficial microbes of the Bifidobacteria and Lactobacilli
species rather than potential enteropathogenic bacteria.
– Anti-inflammatory agents, Enzymes, Immunoglobulins IgA and
IgG, protective agents..
Am J Physiol Gastrointest Liver Physiol. 2005;288(4):G755.
Acta Paediatr. 2004;93(11):1496.
Arch Dis Child Fetal Neonatal Ed. 2011;96(3):F160
Compared to formula, human milk has been shown to:
• Increase the rate of gastric emptying.
• Increase the intestinal lactase activity in premature
infants.
• Decrease the risk of NEC in premature infants.
Human Milk Improved Host Defense - Reduced Rates Infection
• Presence of maternal antibodies ([IgG] [sIgA]) in breast milk
provided by the enteromammary immune system.
• Mothers exposed to their own infants by skin-to-skin contact
may also make specific antibodies to nosocomial pathogens.
• Human milk feeding may result in fecal flora comprised of less
pathogenic microorganisms than nursery-acquired pathogens.
Human Milk Anti-microbial Components
• Human milk contains a variety of heterogeneous
agents that possess antimicrobial activity:
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Protein: lactoferrin, lysozyme, serum immunoglobulin A.
Lipid: free fatty acids and monoglycerides, lipase.
Carbohydrate: oligosaccharides .
White blood cells: neutrophils and macrophages,
lymphocytes in human milk may contribute to cytokine
production (T-cells) or Ig A production (B-cells).
JAMA. 2009;302(13):1421
Pediatr Res. 2006;59(3):377.
Human Milk - Reduce Acute Illnesses
• A study of former premature infants demonstrated that infants
who received human milk had fewer days of upper respiratory
symptoms compared to those who were formula-fed during the
first seven months of life (17.6 vs 38 days).
• The incidence of sepsis is reduced in premature infants receiving
human milk.
J Perinatol. 2002;22(5):354.
Human Milk - Decrease Risk of Chronic Diseases
Adult Cardiovascular Disease
• In a randomized trial, adolescents born preterm who
received human milk compared to those who received
formula had a lower serum C-reactive protein (CRP) and a
lower ratio of low density lipoprotein (LDL) to high density
lipoprotein (HDL) cholesterol, indicative of a lower risk for
cardio vascular disease.
Lancet. 2004;363(9421):1571.
Neurodevelopment Outcome
• Improved long-term cognitive development in premature infants
has been reported with the receipt of human milk during
hospitalization, including extremely low birth weight (ELBW)
infants.
• Breastfeeding is associated with improved cognitive development,
particularly in children born preterm.
• The benefit of breastfeeding upon cognitive function is modulated
by variations of a gene involved in the control of fatty acid
metabolism. (FADSE2 gene)
Pediatrics. 2007;120(4):e953.
Proc Natl Acad Sci U S A. 2007;104(47):18860
J Pediatr. 2012;160(1):25...
Visual function
• Several studies have indicated that human milk-fed term and
premature infants have improved visual function compared
to formula-fed infants.
• This benefit has been attributed to docosahexaenoic acid
(DHA), which is a component of phospholipids found in
brain, retina, and red cell membranes.
• The severity and incidence of retinopathy of prematurity are
decreased among breastfed compared to formula fed
infants.
• This association may relate to the substantial antioxidant
capacity of human milk compared with formula.
Pediatr Int. 2007;49(6):894.
J Pediatr. 2008;152(3):356.
Hearing function
• Infants fed breast milk have faster brainstem
maturation, compared with infants fed formula,
based on the rate of maturation of brainstem
auditory-evoked responses in preterm infants .
• This effect may be attributable to the constituent
composition of breast milk, compared with
synthetic formulas.
Pediatrics. 2000;106(2 Pt 1):318
Stress Reduction
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There appears to be an analgesic effect of breastfeeding, which may be
due to the enhanced maternal-infant bonding.
•
Breastfed infants experience less stress during painful procedures than
formula fed infants.
•
The lactation hormones, oxytocin and prolactin, are important
components of the stress axis and have a positive impact on social
behaviors, including maternal-infant bonding.
•
Another possible explanation for the analgesic effect of breastfeeding is
a higher cortisol level in breast-fed compared to formula-fed infants.
•
Improved bonding may reduce infant stress.
BMJ. 2003;326(7379):13.
J Pediatr. 2009;154(3):452
• Human Milk is strongly supported because of its
acknowledged direct benefits to nutrition, gastrointestinal
function, host defense, and psychological well-being.
• There is increasing evidence that human milk has long-term
benefits beyond the period of breastfeeding. These include
continued protection against acute illnesses, and reported
reduction of specific chronic diseases.
• Human Milk also may have improved neurodevelopmental
outcome compared to those who were formula-fed.
Human Milk is the Best in Preterm Infants