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BREAST MILK VS FORMULA IN PRE-TERM INFANTS 1

Effects of Breast Milk Compared to Formula on Pre-Term Infants


Kayle Augustine, Jenna Henshaw, Chandace Regano, Emily Wyant
03/22/2017
NURS 3947: Nursing Research
Dr. Valerie O’Dell
BREAST MILK VS FORMULA IN PRE-TERM INFANTS 2

Abstract
When talking about breast milk many women know of the benefits it can have for

themselves as well as for their infant. Many, however, don’t realize the time and commitment

that goes along with breastfeeding or the options like donor breast milk for women who

aren’t producing enough or cannot breastfeed their infant. The purpose of this research was

to look at the benefits of breastfeeding in preterm infants in terms of hospital stay, the effects

that breastmilk has on brain development, how breastfeeding may affect the child’s future

eating habits and the benefits of donor milk if a mother cannot breastfeed herself. All these

areas are important regarding pre-term infants, who are at a higher risk of mortality than

infants at full term.


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Effects of Breast Milk and Pre-Term Infants


There has been much research done on the effects of breast milk vs bottle milk in

infants and how it effects their growth and development. However there is minimal research

being done on the benefits that mothers own milk can have on preterm and low birth weight

infants. We found out that mothers who express their own milk for enteral nutrition in their

preterm infant helps reduce the amount of days they are hospitalized, and infants were able to

regain their birth weight quicker. The use of donor milk, we discovered can be just as

beneficial as mothers own milk. However, it is recommended that if mom can use her own

milk to do so. Brain development was found to be bigger in preterm infants who were fed

breast milk vs those who were on formula and breastmilk had a positive effect on children’s

future eating habits where they were more willing to eat diverse and healthy foods.

Literature Review
Introduction
To gather information and studies regarding preterm infant and breastfeeding benefits, six

sources were gathered by OhioLINK and the Electronic Journal Center (EJC). Hospital stays

and brain development for pre-term infants will be discussed as well as donor milk

possibilities and the affects of the infants future eating habits.


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Length of Hospitalization, Breast Milk vs. Formula

Everyone knows what great benefits come from breastfeeding an infant, not only for the

newborn but for mom as well. However, are there other benefits when it comes to breastfeeding

preterm and low birth weight infants? Things that were looked at in this study included; weight

on discharge, NEC, sepsis, how long it took to regain birthweight, length of stay, how many days

from birth they were able to start enteral nutrition. Using a multidisciplinary team consisting of

a lactation consultant, neonatal dietician, a midwife, and neonatal medical staff, they developed a

program. “The study was designed as a time series study comprising two cohorts, one before

and one after the implementation of a new multimodal programme for breastmilk expression.”

(Healy D. B.) This program provided information packets to women that included advice on

when to begin expression and how often to express post delivery. As well as details on different

methods of expression, on maintenance of milk supply, collection, storage and transportation,

and a guide to sterilize equipment used.

This study predicted the average length of time to regain birthweight (14 days) would be

shortened by 2 days with the implementation of their program. There were 43 infants in the pre-

intervention group and 39 in the post-intervention group. In both groups there was an average of

94% of mothers who had expressed milk to be given to their infants on one or more times during

the study. There was no significant difference between the two groups except for number of

multiples. In this study, the post-intervention group began enteral feedings slightly early and had

achieved full enteral feeds earlier then the pre-intervention group, however these findings were

insignificant. In the post-intervention group 30 babies as compared to 28 in the pre-intervention

group received breastmilk as their first enteral feed.

“Birthweight was regained significantly earlier in the postintervention cohort (10.4 days `
BREAST MILK VS FORMULA IN PRE-TERM INFANTS 5

4.3, pre-intervention 12.5 days ` 4.3, p < 0.05), and the duration of hospital stay was also

significantly shorter in the postintervention group (51.9 days ` 19.7, pre-intervention =

61.9 days ` 23.4, p <0.05).” (Healy D.B.)

There was no significant difference between groups when it came to the number of them

on oxygen therapy. However it was noted that at 36 weeks that oxygen therapy delayed the start

of enteral feedings which caused a delay in regaining the birthweight, resulting in a longer

hospital stay. During this study it was noted that females grew at a higher velocity then males

and that the growth velocity was significantly higher in the post-intervention group at an average

of 18.64 g/kg/day. The pre-intervention group grew about 16.56 g/kg/day, these results were not

considered significant.

This study did have a few limitations, they did not regulate if the staff followed the

program or supported moms in breastfeeding. As well as this being such a small sample size,

though it produced promising results the researcher even states that “Ideally, a multicentre study

would be required to achieve a large and homogenous sample of the population...” (Healy D.B.).

Overall this study proved that there are in fact positive outcomes for preterm infants when they

are breastfed, which included; shorter time to regain birthweight and a significantly reduced stay

at the hospital. These being very important because they reduce financial, familial, and parental

stress on the new mom. Proving that giving mom access to appropriate information, encouraging

her, giving her the resources she needs, and supporting her, influence the outcome of continuing

with breastfeeding and health of the newborn.

Brain Development and Growth with Breastfeeding

The less time the infant has in utero, the more at risk is the baby for mortality. This is

why nutrition for the pre-term infant is important. Missing the last few weeks of pregnancy
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can have a real effect on cognitive function for newborns (Hallowell & Spatz, 2012). Infants

born between 34 and 36 6/7 weeks of gestation (late-pre-term infants) are still three times

more likely to die from even most common causes like congenital malformations, sudden

infant death syndrome and even just low birth weight (Hallowell & Spatz, 2012). Term

infants (between 37 and 42 weeks) may have up to 8 more weeks to develop in utero; that is

almost 2 months of valuable development time! This period of time includes oral feeding

behaviors of the brain for surviving in extrauterine life and is an often cause of re-

hospitalization (Hallowell & Spatz, 2012). Brain ultrasounds done on preterm and full-term

infants have showed that there is 35% difference in brain development; the preterm infant

only has 65% of its full brain development (Hallowell & Spatz, 2012). According to studies,

the last trimester is when the brain doubles in volume. With a 70% increase in subcortical

grey matter, this is more than half just done in the last few weeks of pregnancy (Herba, Roza,

Govaert & Hofman, 2013).

The primary structures of brain development (arachidonic acid and docosahexaenoic

acid, also known as DHA) are not available in formulas, but can be obtained in breastmilk.

This is vital protection for the infant but is usually provided by the placenta in the most

abundance in the last trimester of pregnancy, where most newborns might not get to keep up

with brain development (Hallowell & Spatz, 2012).

Sucking development is also an issue for pre-term infants. Feeding can be very difficult

for preterm infants due to some being born before or during the gestational time they should

be developing their suck, swallow and breath coordination to live and breath on their own.

Preterm compared to full term infants can have a poor sucking patterns that may be slower

and not as long, so large volumes of milk or formula is lower (Gewolb & Vice, 2006 as cited
BREAST MILK VS FORMULA IN PRE-TERM INFANTS 7

in Hallowell & Spatz, 2012). Again, these pre-term infants are most likely to be re-

hospitalized.

The generation R study is a study that gives good scientific evidence that breastmilk does

have a positive affect on brain development and growth. The Generation R Study was

directed by the Erasmus University Medical Center Rotterdam with the Faculty of Social

Sciences of the Erasmus University Rotterdam, the Municipal Health Service Rotterdam

area, the Rotterdam Homecare Foundation and the Stichting Trombosedienst &

Artsenlaboratorium Rijnmond (STAR), with results that support breast milk to be better for

cognitive development (Herba, Roza, Govaert & Hofman, 2013). In this study done in 2013,

they found that 30 breastfed only infants had more mature neural development and

myelination compared to the 23 formula-fed infants (Herba, Roza, Govaert & Hofman,

2013). Out of 680 women, 318 infants were breastfed only, 81 infants only bottle-fed with

formula and 281 infants with a mix of breastmilk and formula. Ultrasounds were done on all

infants who were currently around 7 weeks (some ultrasounds thrown out due to poor

quality) looking at the gangliothalmic ovoid in 774 infants the ventricular volume in 759

infants and the corpus callosum in 781 infants (Herba, Roza, Govaert & Hofman, 2013).

Results were quite different regarding the gangliothalamic ovoid diameter and ventricular

volume, where that both appeared to be bigger in babies that were breastfed only compared

to formula, though there was not much of a difference in babies who were both breastfed and

formula fed. Though there was not a significant different regarding the corpus callosum, this

studies shows that breastmilk does affect the infant’s brain different than formula does.
BREAST MILK VS FORMULA IN PRE-TERM INFANTS 8

Future Eating Habits

Although there has been research performed previously regarding the positive impact,

such as with an increased diversity in diet, that breast milk has on children who had been

born full term, a study conducted at Nationwide Children’s Hospital suggested that the same

can be found with preterm infants. As stated by Husk et al. (2016 p. 130), “Preterm birth can

limit early feeding options while simultaneously increasing risk for negative health outcomes

that could benefit from dietary-based preventative measures.” Thus, a well balanced eating

pattern is vital in possibly combating the disadvantage at which premature infants are placed.

Within the study, there were 133 children aged 10-16 months who had been born prior to 35

weeks’ gestation and 56 children aged 18-39 months old who were delivered at less than 29

weeks’ gestation; all of whom were no longer breastfeeding and could orally intake food

(Husk et al. 2016 p. 131). In order to find the correlation between breast milk and eating

habits, the researchers needed to investigate the details of the mothers’ breastfeeding history

along with the children’s diets using a questionnaire. “Dietary variety was assessed via 3

measures: (1) proportion items consumed at least once per month, (2) servings of a given

item consumed relative to total monthly food servings, (3) daily probability of consuming a

given item” (Husk et al. 2016 p. 130). All of these combined allowed them to evaluate how

wide the range was in diet for both the children who had been breastfed at least once and

those who had been fed that way only. According to the results:

“Longer durations of exclusive breastfeeding were associated with increased dietary

variety in the meat and fish, vegetable, and grain and starch categories. For meat and fish,

the percentage of consumed items (DV) increased by 1.6% (CI 0.2, 3.0) and dietary
BREAST MILK VS FORMULA IN PRE-TERM INFANTS 9

entropy (PRE) increased by 1.2% (CI: 0.2, 2.2) for each extra month of exclusive

feeding after adjustment” (Husk et al. 2016 p. 133).

Dietary entropy translates into the probability of consuming a given food item on any

given day (Husk et al. 2016 p. 133), so in other words, children who solely consumed breast

milk as infants had a higher chance of having meat and fish as part of their meal as well as

having an overall more positively diverse diet that included vegetables and grains. Not only

was this shift observed, but also a decrease in sweets within the children’s regimen as Husk

et al. states, “To our knowledge, the association between breastfeeding and reduced sweets

consumption that we observed here has not been reported previously, though Perrine et al.

(2014) did find a similar association between breastfeeding and reduced consumption of

sugar-sweetened beverages” (2016 p. 134) This association already having been established

allows for additional support for it in this study in addition to strengthening the claim to a

positive relationship between breastfeeding and dietary variety. Furthermore, the study

continued to establish that the frequency of receiving mother’s milk was an important aspect

to the overall picture. “Each month of exclusive breastfeeding was associated with a shift in

consumption patterns of less than half a food item, suggesting that (if causal) breastfeeding

would need to occur over a number of months to accumulate a notable impact on dietary

variety” (Husk et al. 2016 p. 134). For the impact to be truly effective, the duration of

breastfeeding needs to be over time and not just isolated incidences. As for the reasoning

behind why breastmilk has an effect on the food preferences of the child following infancy,

according to Husk et al.:

“...breast milk flavor varies with maternal diet during lactation (Mennella & Beauchamp,

1999), and breastfeeding can impact reactions to these same flavors after weaning
BREAST MILK VS FORMULA IN PRE-TERM INFANTS
10

(Mennella et al., 2001). By contrast, formula has a constant unchanging flavor profile that

does not vary over time (unless the composition of the formula is altered). As a result,

breastfeeding exposes children to a wider variety of flavors than formula, which may in

turn, promote greater acceptance of those same flavors later on” (2016 p. 134).

In other words, what the mother consumes possibly directly impacts the way the milk

tastes to the infant, and in that sense, influences what he/she is accustomed to and will prefer

in later years. Moreover, the study explains another rationale that the “parents who choose to

breastfeed are also more likely to provide a more varied and healthy diet to their children or

are more successful in getting their child to eat varied foods” (Husk et al. 135). In

conclusion, the study does indicate yet another reason to include breastmilk in the diet of

premature infants. For the benefit of their future dietary habits which will impact their overall

health and wellness, it would be best for parents to be aware of this information and to

implement it into the life of their child

Human Donor Milk

Many studies have been performed to show that newborns should receive their

own mother’s milk. According to Cristofalo et al. (2013), “Because not all mothers of

premature infants produce sufficient milk to meet their infant’s needs and some have

medical contraindications, pasteurized donor human milk has emerged as an alternative

for mother’s own milk.” In this study, infants were fed human donor milk or preterm

formula through parenteral nutrition. The extremely preterm infants had to weigh 500-

1250 grams, and the mothers had to have no intention of breast-feeding. “ Infants were

not enrolled if they had major congenital malformations, were transferred to a study site
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11

after 48 hours, had a high likelihood of transfer to a non-study institution during the study

period, or were participants in another study affecting nutritional management”

(Cristofalo et al. 2013, p. 1593).

Each day the infants were weighed and had a weekly recumbent length and head

circumference while being fed the bovine milk-based preterm formula (BOV) or the

appropriately fortified human milk diet (HUM).

The primary outcome of the study was the duration of parenteral nutrition.

Secondary outcomes were growth, duration of hospital stay, days of mechanical

ventilation and oxygen therapy, and the incidence of late-onset sepsis, necrotizing

enterocolitis (NEC), and retinopathy of prematurity (Cristofalo et al. 2013, p. 1593).

With NEC, the intestinal tissue in the preterm infants becomes damaged and starts

to die. There were 53 infants that were in the study, and there were six cases of NEC.

Five of the Infants were fed BOV, while only one infant that developed the disease was

fed HUM. “Based on NEC surgery results, the number of infants needed to be fed an

exclusive human milk diet to prevent one case of surgical NEC in six infants” (Cristofalo

et al. 2013, p. 1594).

The rate of growth in the infants was less in the babies fed HUM compared to

BOV. This includes changes in recumbent length, head circumference, and weight. “We

did identify slightly slower growth rates in HUM vs BOV but believe that these small

differences can be prevented by further adjustments in fortifier content to support

improved rates of growth” (Cristofalo et al. 2013, p. 1593). Late-onset sepsis was another

portion that was studied on the infants. There were 19 infants, fed BOV, and 16 infants,
BREAST MILK VS FORMULA IN PRE-TERM INFANTS
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fed HUM, that developed this problem. “Late-onset sepsis was defined as clinical signs

and symptoms consistent with sepsis occurring greater than five days after birth in

association with the isolation of a causative organism from a blood culture” (Cristofalo et

al. 2013, p. 1593). This is not a huge difference in number but less newborns that were

fed HUM had developed sepsis. The duration of hospital stay, mechanical ventilation,

and oxygen therapy that was needed was less in infants receiving HUM compared to

BOV. However, the incidence of retinopathy of prematurity was higher in infants fed

HUM than with BOV.

The results of this study shows the importance for any infant, especially the

extremely premature newborns to receive human milk. According to Cristofalo et al.

2013, “indeed, the recent American Academy of Pediatrics policy statement on the use of

human milk states that premature infants should receive only human milk from their

mother and that, if it is not available, pasteurized donor human milk should be used.”

The importance to educate new mothers on the benefits of providing their own milk to

their infant is especially needed to help promote growth and development of each

newborn. There are some contraindications for breast feeding such as certain

medications, diseases, and use of illicit drugs, but these mothers should understand the

importance of the use of donor human milk for their children.

Conclusion

Looking at all these studies as a whole, breastfeeding and breastmilk definitely

makes an impact on different areas on an infant, especially pre-term newborns who are

already at risk for maldevelopment. Breastmilk positivity impacted the infants hospitals
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stay by shortening the length, extending the growth of their brain and development and

positivity impacted their future eating habits as a whole. Donor milk is also a great option

if a mother cannot produce milk or cannot breastfeed.


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References

Hallowell, S. G & Spatz, D. L (2012). The Relationship of Brain Development and


Breastfeeding in the Late-Preterm Infant. Journal of Pediatric Nursing (2012) 27, pages
154–162 Retrieved from
file:///C:/Users/Kayle/Documents/3.%20Junior%20Year/Spring%20Semester/Nursing%2
0Research/Brain%20Development.pdf

Healy, D. B., Brennan, A., O'donovan, R., Daly, V., Doolan, A., & Dempsey, E. M. (2016).
Structured promotion of breastmilk expression is associated with shortened
hospitalisation for very preterm infants. Acta Paediatrica, 105(6), 1-5. Retrieved from
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_ENTITY_ID:MAIN_FILE,37062341&cs=3iP8ZsnC0bnwCVdgjo97mvODr3NTA2ETL
P64McS9uCN4ymDMmjozGxlv9WsJZqKaqv5GfenF8p6dGziyUIAIcQ

Herba, C. M., Roza, S., Govaert, P., Hofman, A. Jaddoe, V., Verhulst F. C., & Tiemeier, H.
(2013). Breastfeeding and early brain development: the Generation R study. John Wiley
& Sons Ltd Maternal and Child Nutrition, 10, pp. Pages 332-349. Retrieved from
file:///C:/Users/Kayle/Documents/3.%20Junior%20Year/Spring%20Semester/Nursing%2
0Research/Brain%20Development%202.pdf