Human milk bank in a district general hospital.

A human milk bank was organised in the special care baby unit of a district general hospital. The staff of the unit and members of a voluntary organisation helped to contact donors and arrange collection of milk samples. Over two years 2093 samples of expressed breast milk were collected from 187 donors and examined bacteriologically. Of these samples, 1171 (56%) grew no bacteria. If the organism count exceeded 2.5 X 10(6)/1 but was less than 1 X 10(9)/1 samples were subjected to mild heat treatment. If the count exceeded 1 X 10(9)/1 the milk was not fed to babies. Sixty-five babies received milk from the bank during the second year. Although these infants were vulnerable, mortality and morbidity were not adversely affected by the banked milk they received. The cost of establishing and running a human milk bank need not be high. Extensive resources such as extra staff and laboratory and transport facilities were not needed. Enthusiastic co-operation and good will between hospital staff, voluntary helpers, and donors contributed greatly to the success of the scheme.     

Does opening a milk bank in a neonatal unit change infant feeding practices? A before and after study

Background

Donor human milk banks are much more than simple centers for collection, storage, processing, and distribution of donor human milk, as they cover other aspects and represent a real opportunity to promote and support breastfeeding. The aim of our study is to assess the impact that opening a human milk bank has had on the proportion of infants receiving exclusive breast milk at discharge and other aspects related to feeding children with birth weight < or = 1500 g or < 32 weeks gestation admitted to the neonatal unit.

Methods

The study included babies of < or = 1500 g or < 32 weeks gestation. Fifty infants born from February to July in 2006, before the opening of the human milk bank, and 54 born from February to July in 2008, after its opening, met inclusive criteria. We collected data about days of hospital stay, hours of life when feeding was started, hours of life when full enteral feeding was attained, the type of milk received during admission, and the type of feeding on discharge.

Results

Children born in 2008 commenced feeding 16 hours earlier than those born in 2006 (p = 0.00). The proportion of infants receiving exclusive breast milk at discharge was 54% in 2006 and 56% in 2008 (p = 0.87). The number of days they received their mother's own milk during the first 28 days of life was 24.2 days in 2006, compared to 23.7 days in 2008 (p = 0.70). In 2006, 60% of infants received infant formula at least once in the first 28 days of life, compared to 37% in 2008 (p = 0.01).

Conclusions

The opening of a donor human milk bank in a neonatal unit did not reduce the proportion of infants exclusively fed with breast milk at discharge, but did reduce the proportion of infants that received infant formula during the first four weeks of life. Also, having donor human milk available enables commencement of enteral feeding earlier.     

Latent anaphylactic sensitisation of infants of low birth weight to cows' milk proteins.

Latent systemic anaphylactic sensitisation to cows'' milk was assessed in 61 preterm infants who were randomly assigned to receive either a special formula for preterm infants based on cows'' milk or banked breast milk or one or other of these as a supplement to maternal milk. A single sample of venous blood was taken near to the time of discharge from the neonatal intensive care unit, and the histamine release by blood basophils in response to in vitro challenge with cows'' milk and anti-IgE was measured. Compared with the blood from infants fed on human milk, that from infants fed on preterm formula showed a significant increase in histamine release to challenge with cows'' milk, the response being greater in blood from infants of lower birth weight and gestational age. A smaller but significant increase in blood histamine release with anti-IgE challenge was observed in the group fed on preterm formula. Infants of low birth weight fed on preterm formula based on cows'' milk may develop latent systemic sensitisation more rapidly than infants born at term. The clinical importance of this requires further investigation.     

Feeding Overstrength Cows' Milk to Babies

The dangers of overstrength milk feeds have been emphasized in several reports during the last two years. They may even be a factor in unexpected death in infants. Samples of prepared dried milk feeds were obtained from 302 mothers who brought their 5- to 8-week-old infants to a special follow-up clinic. Determination of the sodium content of the milk indicated that 57% of the feeds were significantly overstrength. There is an urgent need to improve mothers'' knowledge of the importance of preparing dried cows'' milk infant feeds correctly.     

Effect of antigen load on development of milk antibodies in infants allergic to milk.

The phenomenon that large amounts of antigen, such as are absorbed during the neonatal period, suppress the IgE response while low-dose exposure enhances it was investigated by analysing the antibody responses of infants allergic to milk according to their degree of exposure to cows''-milk protein. IgG, IgA, and IgM milk-specific antibodies in these infants and in age-matched controls were measured by enzyme-linked immunosorbent assay. Milk-specific IgE and total IgE were also measured. Children allergic to milk who were breast fed and had had minimal exposure to cows'' milk had decreased titres of IgG, IgA, and IgM milk antibodies compared with infants allergic to milk who, before diagnosis, had been fed substantial volumes of cows'' milk. Conversely, the infants with minimal exposure to cows'' milk showed vastly increased total and milk-specific IgE antibodies compared with the milk-fed infants. These results support recent experimental evidence that appreciable amounts of allergen suppress rather than stimulate IgE production. These data may have important implications for dietary regimens in at-risk infants. The results also lend support for the role of IgE in immediate-type allergic reactions and suggest that various non-IgE immune mechanisms play a part in the aetiology of intolerance to cows''-milk protein in some children.     

Significance of Milk pH in Newborn Infants

Bottle-fed infants do not gain weight as rapidly as breast-fed babies during the first week of life. This weight lag can be corrected by the addition of a small amount of alkali (sodium bicarbonate or trometamol) to the feeds. The alkali corrects the acidity of cow''s milk which now assumes some of the properties of human breast milk. It has a bacteriostatic effect on specific Escherichia coli in vitro, and in infants it produces a stool with a preponderance of lactobacilli over E. coli organisms. When alkali is removed from the milk there is a decrease in the weight of an infant and the stools contain excessive numbers of E. coli bacteria.A pH-corrected milk appears to be more physiological than unaltered cow''s milk and may provide some protection against gastroenteritis in early life. Its bacteriostatic effect on specific E. coli may be of practical significance in feed preparations where terminal sterilization and refrigeration are not available. The study was conducted during the week after birth, and no conclusions are derived for older infants. The long-term effects of trometamol are unknown. No recommendation can be given for the addition of sodium bicarbonate to milks containing a higher content of sodium.     

Multiprofessional training for breastfeeding management in primary care in the UK

Upon hospital discharge it is not unusual for mothers of preterm infants to continue to meet all or most of their infants' nutritional needs through bottle feedings of expressed breast milk (EBM) because of infants' physiological immaturity and maternal concerns with an inadequacy of milk supply. Although for some mothers the challenge of transitioning the infant to feeding at the breast may be beyond their ability and resources, for others it appears to be based on a conscious choice. Mothers are often unaware of the advantages of breastfeeding at the breast. The purpose of this article is to examine some of the factors that may contribute to the inability and resistance of mothers to transition their preterm infants, and to report on the potential short and long-term advantages associated with feeding at the breast as opposed to feeding bottles of EBM.     

Metabolic acidosis and infant feeding.

Most cows'' milk based formulae for infant feeding present a greater acid load to the infant than breast milk. To determine the effect of this difference the acid base state of 180 healthy term infants was measured on the sixth day of life and related to the type of feed. Those infants fed on cows'' milk formula (SMA) had a mean pH of 7-34 +/- 0-05 and a base deficit of 8-8 +/- 3-1, while those fed on breast milk had a mean pH of 7-38 +/- 0-05 and a base deficit of 5-6 +/- 3-1. The difference between the two groups of infants was significant for both these measurements. Metabolic acidosis was defined as a base deficit greater than 10 mmol/l. Seventy-four per cent of the 34 infants who were acidotic at six days were bottle-fed. There was a significant correlation between the pH of the feed and the degree of acidosis in the infant as measured by the base deficit. The findings suggest that when breast milk is not available a pH-adjusted milk formula would be desirable for preventing and treating neonatal metabolic acidosis.     

Egg and cows' milk hypersensitivity in exclusively breast fed infants with eczema,and detection of egg protein in breast milk.

Forty nine eczematous infants who were still solely and exclusively breast fed and who had never received anything but breast milk were studied for evidence of sensitisation to foods. Thirty four similar infants without eczema formed a control group. The eczematous infants were divided into three groups according to clinical criteria: (1) definite atopic eczema; (2) possible atopic eczema; (3) atopic eczema unlikely. Twenty three infants showed cutaneous hypersensitivity to foods, usually egg and cows'' milk. Seven of 14 infants in group 1 and nine of 20 in group 2 were sensitised compared with four of 15 in group 3 and three of 34 controls (p less than 0.01). Ovalbumin was detected in breast milk from 14 of 19 mothers tested after ingestion of egg, the concentrations being the same for mothers feeding eczematous and normal infants. Breast fed babies developing eczema may be sensitised by foods eaten by their mothers.     

Effect of maternal dietary exclusion on breast fed infants with eczema: two controlled studies.

Thirty seven breast fed infants with eczema were studied to see whether changes in their mothers'' diets affected their skin condition. Nineteen mothers and babies took part in a double blind crossover trial of exclusion of egg and cows'' milk, and 18 took part in open exclusion of 11 foods followed by double blind challenge to those mothers whose infants seemed to respond. Babies were examined at the beginning and end of each dietary period, and the extent and severity of the rash were given a numerical score. The eczema improved in six infants when their mothers avoided egg and cows'' milk and worsened again when these were reintroduced. Two infants suffered gastrointestinal reactions after maternal ingestion of egg and cows'' milk, one developing colitis. Maternal dietary exclusion seems to benefit some breast fed babies with eczema.     

Simultaneous quantification of sialyloligosaccharides from human milk by capillary electrophoresis

The acidic oligosaccharides of human milk are predominantly sialyloligosaccharides. Pathogens that bind sialic acid-containing glycans on their host mucosal surfaces may be inhibited by human milk sialyloligosaccharides, but testing this hypothesis requires their reliable quantification in milk. Sialyloligosaccharides have been quantified by anion exchange high-performance liquid chromatography (HPLC), reverse- or normal-phase HPLC, and capillary electrophoresis (CE) of fluorescent derivatives; in milk, these oligosaccharides have been analyzed by high pH anion exchange chromatography with pulsed amperometric detection and, in our laboratory, by CE with detection at 205nm. The novel method described here uses a running buffer of aqueous 200mM NaH2PO4 (pH 7.05) containing 100mM sodium dodecyl sulfate (SDS) mixed with 45% (v/v) methanol to baseline resolve 5 oligosaccharides and separate all 12. This allows automated simultaneous quantification of the 12 major sialyloligosaccharides of human milk in a single 35-min run. This method revealed differences in sialyloligosaccharide concentrations between less and more mature milk from the same donors. Individual donors also varied in expression of sialyloligosaccharides in their milk. Thus, the facile quantification of sialyloligosaccharides by this method is suitable for measuring variation in expression of specific sialyloligosaccharides in milk and their relationship to decreased risk of specific diseases in infants.     

Heterogeneity of Multimedia Exposures to Neurotoxic Elements (Al,As, Cd,Pb, Mn,and Hg) in Breastfed Infants from Porto Velho,Brazil

Infant exposure to neurotoxic elements is a public health issue that needs monitoring with regard to breast milk composition. We studied six neurotoxic elements in breast milk samples at different stages of lactation in mothers from Porto Velho, Brazil. We used a flow-injection mercury system (FIMS) to determine total Hg concentrations and an inductively coupled plasma optical emission spectrometer (ICP-OES) to determine the concentrations of Al, As, Cd, Pb, and Mn in 106 donors of a human milk bank. Association rules analyses were applied to determine the pattern of binary and ternary mixtures of the measured exposants. The metal concentration was mostly below the limit of detection (LOD) for Cd (99%), Pb (84%), and Hg (72%), and it was above the LOD for As (53%), Mn (60%), and Al (82%), respectively. Median concentrations (dry weight) of Al, As, Hg, Mn, and Pb were 1.81 μg/g, 13.8 ng/g, 7.1 ng/g, 51.1 ng/g, and 0.43 μg/g, respectively. Al is singly the most frequent element to which infants are exposed. Occurring binary combination (> LOD) was 56% for Al-Mn, 41% for Al-As, 22% for Al-Hg, and 13% for Al-Pb. In 100% of neonates, exposure to Al-ethylmercury (EtHg) occurred through immunization with thimerosal-containing vaccines (TCV). Association rules analysis revealed that Al was present in all of the multilevel combinations and hierarchical levels and that it showed a strong link with other neurotoxic elements (especially with Mn, As, and Hg). (a) Nursing infants are exposed to combinations of neurotoxicants by different routes, dosages, and at different stages of development; (b) In breastfed infants, the binary exposures to Al and total Hg can occur through breast milk and additionally through TCV (EtHg and Al); (c) The measured neurotoxic elements were found at low frequencies in breast milk and at concentrations that pose no public health concerns for milk banking.     

RETROLENTAL FIBROPLASIA—Blindness in Infants of Low Weight at Birth

Retrolental fibroplasia is today the principal cause of blindness in children of preschool age, exceeding all other causes combined. The disease occurs in infants of low weight at birth, commonly those born prematurely. The incidence of the disease is rising at an alarming rate. Vitamin E deficiency, corticotropin (ACTH) deficiency, the use of cow''s milk in place of mother''s milk, and improper oxygenation have been suggested as etiologic factors but the cause remains a mystery. Often the incidence is high in institutions in which maximal care is given premature infants.Clinically, the disease advances through an “active” phase during which regression is possible, and a “subsiding” or “cicatricial” phase which terminates with the formation of a disorganized opaque mass behind the lens. The earliest manifestations are noted in the fundi. Hemorrhages, neovascularization, transudation commencing in the periphery, and retinal separation contribute to the formation of the characteristic retrolental membrane. The diagnosis may be made when the retrolental membrane is observed in the eye of an infant whose weight at birth was low. Differential diagnosis is required occasionally.Thus far, no form of therapy has prevented or reversed the pathologic changes successfully. Use of vitamin E, corticotropin and mother''s milk has not influenced the incidence of the disease. Avoidance of premature delivery if possible is indicated.     

Collecting and banking human milk: to heat or not to heat?

Data on human breast milk and its handling when fed to babies who cannot be breast-fed were reviewed to determine whether the method of processing and storage affected the properties of the milk. Breast milk is normally contaminated by potential pathogens, which seem to produce no ill effects, but it also contains antimicrobial properties which protect against infection. The evidence suggests that pasteurisation not only eliminates pathogenic bacteria but also damages bacteriostatic mechanisms, so making the milk more susceptible to later contamination. Pasteurisation also affects the nutritional properties of milk. Freezing has little effect on milk proteins, while a study on the effect of refrigeration showed that there was little bacterial growth at temperatures below 8 degrees C. Several years'' experience of feeding donated raw milk to newborn infants has confirmed that it produces no ill effects. These findings suggest that pasteurisation of donated breastmilk is unnecessary, and it is not recommended, while the decision whether or not to freeze the milk may be made on practical grounds. Raw breast milk can be safely stored at 4-6 degrees C for 72 hours.     

Continuous Intragastric Milk Feeds in Infants of Low Birth Weight

In a feeding trial 66 infants of low birth weight received continuous intragastric milk feeds from the fourth hour of life, starting with 60 ml/kg/24 hr and reaching a maximum of 300 ml/kg/24 hr on the ninth day. Each infant received only full-strength milk, which was either expressed human breast milk or SMA-S26 (a proprietary low-protein adapted cows'' milk) or half-cream Regal milk (partly-skimmed evaporated cows'' milk). For various reasons 10 babies had to be withdrawn, and the final assessment was made on the 56 who completed the trial successfully.Persistent vomiting was a problem in only four infants. In two of them the trial was continued after gastric lavage and in the other two vomiting stopped when the volume was reduced. Despite a careful search no evidence was found of aspiration of feeds in any infant. Continuous intragastric milk infusion was shown to be a safe method of feeding infants of low birth weight and SMA-S26 was almost as well tolerated as human milk. Because of the high-protein content of half-cream cows'' milk preparations and the resultant high plasma amino-acid levels when they are given in these large volumes they should be avoided for this type of feeding although they produce better weight gains in the first week of life.     

Case-control study of risk of dehydrating diarrhoea in infants in vulnerable period after full weaning.

OBJECTIVES: To investigate risk factors for dehydrating diarrhoea in infants, with special interest in the weaning period. DESIGN: Case-control study. SETTING: Metropolitan area of Porto Alegre, Brazil. SUBJECTS: Cases were 192 children aged 0-23 months hospitalised with acute diarrhoea and moderate to severe dehydration. Controls were 192 children matched for age and neighbourhood who did not have diarrhoea in the previous week. MAIN OUTCOME MEASURES: Associations between dehydrating diarrhoea and child''s age, type of milk consumed, time since breast feeding stopped, and breast feeding status. RESULTS: In infants aged < 12 months the risk of dehydrating diarrhoea was significantly higher in the first 9 months of life (P < 0.001), and in those aged 12-23 months the risk was again greater in younger children (12-17 months) (P = 0.03). The type of milk consumed before start of diarrhoea episode was strongly associated with dehydration independent of socioeconomic, environmental, maternal reproductive, demographic, and health services factors. Compared with infants exclusively breast fed, bottle fed infants were at higher risk (odds ratio (95% confidence interval) for cow''s milk 6.0 (1.8 to 19.8), for formula milk 6.9 (1.4 to 33.3)). Compared with those still breast feeding, children who stopped in the previous two months were more likely to develop dehydrating diarrhoea (odds ratio 8.4 (2.4 to 29.6)). This risk decreased with time since breast feeding stopped. CONCLUSION: These results confirm the protective effect of breast feeding and suggest there is a vulnerable period soon after breast feeding is stopped, which may be of relevance for developing preventive strategies.     

Breast Milk Substitute: A Bacteriological Study

The increased susceptibility of infants fed on cows'' milk preparations has been attributed, at least in part, to differences in the nature of the large-bowel content—owing to the acidity of the faeces and their high content of Lactobacillus bifidus. In an attempt to mimic these features of the breastfed infant in one who is fed artificially, a breast milk substitute was devised which resembles breast milk in several important ways. When this material was fed to newborn infants the faeces developed the characteristics of those of the breast-fed child.     

Prevalence of anemia among James Bay Cree infants of northern Quebec

BACKGROUND: Anemia is common among First Nation infants in Canada, often as a result of iron deficiency, which places them at risk for psychomotor impairment. Prevalence data are unavailable, and the risk factors are unknown. This study assessed the prevalence of anemia and associated risk factors among 9-month-old Cree infants in northern Quebec. METHODS: Between January 1995 and October 1998, 6 of 9 Cree villages in the James Bay region adopted a screening protocol for anemia in 9-month-old infants. Cross-sectional data were obtained from medical charts. The data for babies of very low birth weight and those with fever or infection were excluded. Among the 386 babies whose hemoglobin concentration was known, the type of milk consumed at the time of screening was known for 354. Associations between hemoglobin concentration and mean cell volume at 9 months, and milk type and weight gain since birth were analysed. RESULTS: The mean hemoglobin concentration of the 386 infants was 114.1 (standard deviation [SD] 10.6) g/L. The prevalence of anemia was 31.9% (95% confidence interval [CI] 27.2%-36.7%) with a hemoglobin cutoff value of 110 g/L, 17.6% 95% CI 13.9%-21.7%) with a cutoff value of 105 g/L, and 7.8% (95% CI 5.3%-10.9%) with a cutoff value of 100 g/L. Babies exclusively fed formula at 9 months had a higher mean hemoglobin concentration (118.5 [SD 9.9] g/L) than those exclusively fed breast milk (109.9 [SD 10.0] g/L), cow''s milk (112.5 [SD 10.1] g/L) or more than one type of milk (112.0 [SD 10.8] g/L) (p < 0.05). Compared with formula, the odds ratio (OR) for anemia was 7.9 (95% CI 3.4-18.2) for breast milk, 5.0 (95% CI 2.0-12.7) for cow''s milk and 5.2 (95% CI 1.9-14.6) for mixed milks. Infants fed formula and those fed cow''s milk had significantly greater weight gains since birth, by 724 g and 624 g respectively, than breast-fed infants (p < 0.05). When milk type was controlled for, weight gain since birth was significantly associated with the presence of microcytic erythrocytes (OR comparing highest tertile of weight gain to lowest tertile 2.9, 95% CI 1.2-6.6). INTERPRETATION: Iron-deficiency anemia is highly prevalent among James Bay Cree infants. Measures to increase iron intake are required.     

Enrichment of soybean milk with calcium

Calcium in soymilk was increased to that of human milk by the addition of 0.2% calcium lactate. It was, however, impossible to raise the calcium content of soymilk to that of cow's milk. The maximum amount of calcium lactate that could be added to soymilk without coagulation of the milk protein was found to be 0.45% which resulted in about 75 mg of Ca/100 ml of soymilk. This amount was approximately 60% of the calcium in cow's milk. Sodium citrate had to be added in combination with calcium lactate to reinforce colloidal stability of the milk. The ratio of Ca to P in the milk containing added 0.45% calcium lactate was comparable to that of cow's milk and at the amount normally consumed daily by infants and children it seemed to meet the requirements of Ca and P.     

Body fat of British and Dutch infants.

The fatty acids in the body fat of 41 British and 37 Dutch infants between birth and 1 year were determined. At birth linoleic acid contributed 1-3% of the total fatty acids of the body fat in infants in both countries. By one month its proportion in the fat of the Dutch infants was about 25% and by four months 32-37%; in the fat of the British infants it was never more than 3%. In the Dutch infants this large increase in the linoleic acid percentage was accompanied by a fall in the percentage contribution of others, particularly the saturated acids myristic, palmitic, and stearic. Infants born preterm showed changes in their fat after birth similar to those in fullterm infants. The difference between the composition of the fat of the infants in the two countries is attributed to the nature of the fat in the milk they received. Until recently most British infants who are not breast-fed have been given milks based on cow''s milk with only minor modifications. For the past 10 years many Dutch infants have been given a milk in which all the cow''s milk fat has been replaced by maize oil. Dutch infants also had a lower concentration of cholesterol in their serum than British infants, which was not unexpected. The results show that the triglycerides in the adipose tissue are profoundly influenced by the nature of the fat in the diet.