Cathie Hilditch

Aims: To describe the prevalence of use of breastmilk and explore demographic characteristics and clinical outcomes associated with breastmilk provision in infants born <29 weeks' gestational age in Australia, New Zealand and Singapore.Methods: This is a secondary analysis of data from a randomised controlled trial, which enrolled 1273 infants in 13 neonatal units across Australia, New Zealand and Singapore from 2012 to 2015. Infants were classified as formula‐fed, donor milk‐fed or mother's milk‐fed at their first enteral feed and separately, at hospital discharge.Results: The percentage of infants receiving mother's own milk differed between centres both at first feed (79% to 100%), and at hospital discharge (47.1% to 71.6%). Aboriginal, Torres Strait Islander and Southeast Asian heritage, drug use and smoking were associated with lower rates of fully breastmilk feeding at hospital discharge. There was no significant difference in growth outcomes, length of stay and feeding tolerance between feeding groups.Conclusions: Achieving high breastmilk feeding rates at hospital discharge for all preterm infants born <29 weeks' gestational age at hospital discharge is possible; however, targeted support for mothers who are Indigenous, Southeast Asian and/or using recreational drugs and/or smoking and/or experiencing social disadvantage may be needed. A better understanding and shared knowledge of practice variations within neonatal units with high breastfeeding rates could improve breastmilk access and equity for preterm infants.Australian New Zealand Clinical Trials Registry: ACTRN12612000503820.

Introduction: This overview aims to systematically review evidence regarding effects of interventions undertaken in neonatal units to increase breastfeeding in preterm infants. Methods: We followed Cochrane methodology. Systematic reviews published to October 31, 2022, reporting meta-analysis of effects from original studies on breastfeeding rates in preterm infants of neonatal unit interventions designed to increase breastfeeding were included. Results: Avoidance of bottles during breastfeed establishment (comparator breastfeeds with bottle-feeds) demonstrated clear evidence of benefit for any breastfeeding at discharge and exclusive breastfeeding 3 months post-discharge, and possible evidence of benefit for exclusive breastfeeding at discharge, and any breastfeeding post-discharge. Kangaroo mother care (KMC) (comparator usual care) demonstrated clear evidence of benefit for any and exclusive breastfeeding at discharge and possible benefit for any breastfeeding post-discharge. Quality improvement (QI) bundle(s) to enable breastfeeds (comparator conventional care) showed possible evidence of benefit for any breastfeeding at discharge. Cup feeding (comparator other supplemental enteral feeding forms) demonstrated possible evidence of benefit for exclusive breastfeeding at discharge and any breastfeeding 3 months after. Early onset KMC (commenced <24 h post-birth), oral stimulation, and oropharyngeal colostrum administration, showed no evidence of benefit. No meta-analyses reported pooled effects for gestational age or birthweight subgroups. Conclusion: There is ample evidence to support investment in KMC, avoidance of bottles during breastfeed establishment, cup feeding, and QI bundles targeted at better supporting breastfeeding in neonatal units to increase prevalence of breastfeeding in preterm infants and promote equal access to breastmilk. Stratifying effects by relevant subgroups is a research priority.

3-Hydroxy-3-Methylglutaryl-CoA Lyase (HMGCL) deficiency can be a very severe disorder that typically presents with acute metabolic decompensation with features of hypoketotic hypoglycemia, hyperammonemia, and metabolic acidosis. A retrospective chart and literature review of Australian patients over their lifespan, incorporating acute and long-term dietary management, was performed. Data from 10 patients contributed to this study. The index case of this disorder was lost to follow-up, but there is 100% survival in the remainder of the cases despite several having experienced life-threatening episodes. In the acute setting, five of nine patients have used 900 mg/kg/day of sodium D,L 3-hydroxybutyrate in combination with intravenous dextrose-containing fluids (delivering glucose above estimated basal utilization requirements). All patients have been on long-term protein restriction, and those diagnosed more recently have had additional fat restriction. Most patients take L-carnitine. Three children and none of the adults take nocturnal uncooked cornstarch. Of the cohort, there were two patients that presented atypically—one with fulminant liver failure and the other with isolated developmental delay. Dietary management in patients with HMGCL deficiency is well tolerated, and rapid institution of acute supportive metabolic treatment is imperative to optimizing survival and improve outcomes in this disorder.

Aim: To assess effects of early versus delayed introduction of human milk fortification in preterm infants.Methods: We searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PubMed and CINAHL for randomised controlled trials evaluating start time for human milk fortification in preterm infants (March 2020). Two authors assessed trial eligibility and risk of bias, extracted data and assessed evidence certainty.Results: We identified 1307 publications and included three trials (378 infants). Meta‐analysis comparing fortification commencing at an enteral feed volume of ≤40 mL/kg/day versus ≥75 mL/kg/day, showed little to no difference in rates of necrotising enterocolitis (3 trials), sepsis (3 trials), feeding intolerance (2 trials) (low‐quality evidence) and infant growth (1 trial, very low‐quality evidence).Conclusions: Whether early introduction of fortification, at an enteral feed volume of ≤40 mL versus delayed at ≥75 mL/kg/day improves growth or influences adverse feeding outcomes is very uncertain.

Aim: To answer the clinical question ‘In infants about to be delivered and admitted to neonatal units, what clinical practice strategies, compared to standard care, have been shown to decrease incidence rates of intraventricular haemorrhage (IVH)?’Methods: MEDLINE via Ovid (1943 to 5 January 2018), Embase via Ovid (1974 to 5 January 2018) and the Cochrane Library (5 January 2018) were searched for relevant articles.Results: A total of 478 articles, after the removal of duplicates, were found and screened by title and Forty full‐text articles were subsequently reviewed, and 19 were included as relevant to the structured clinical question. An additional article was included based on expert advice.Conclusion: There are various levels of research evidence for clinical practice strategies to decrease the incidence rates of IVH. Higher‐quality evidence suggests that antenatal corticosteroids decrease the rates of IVH, and multiple evidence‐based intervention bundles implemented in the neonatal unit are associated with decreased rates of IVH.

Aim: This evidence‐based review aims to answer the following structured clinical question: In preterm infants <37 weeks' gestation (patient), does early fortification of breast milk (intervention) compared to late fortification (control) improve growth outcomes at the time of discharge or affect length of hospital stay (outcome)?Methods: MEDLINE, Embase, Maternity and Infant Care Database and Evidence‐Based Medicine Reviews were searched for articles published from 2000 onwards that were relevant to the structured clinical question. The National Institute for Health and Care Excellence, National Health and Medical Research Council, Agency for Healthcare Research and Quality, National Institute of Health and Turning Research into Practice databases were also searched, and reference lists of relevant articles were reviewed.Results: A total of 167 articles, after removal of duplicates, were found and screened by title and Five full‐text articles were ultimately included in the review.Conclusions: The results of this review suggest that early fortification is safe and well tolerated. However, earlier fortification has not been shown to have a significant impact on growth outcomes at time of discharge or length of stay. More research is required to determine if early fortification of breast milk may have benefits regarding longer‐term growth and neurodevelopmental outcomes.

Breast milk is the preferred form of nutrition for all infants and has been shown to reduce morbidity and improve health outcomes in preterm infants. However, mothers of preterm infants face many challenges initiating and sustaining breastfeeding within the neonatal unit. This scoping review examines evidence‐based practices which aim to improve breastfeeding rates in preterm infants at the time of hospital discharge. A literature review identified 17 articles which are included in this review. Supporting evidence was found for the implementation of kangaroo mother care and/or skin‐to‐skin care, peer counsellors, provision of oropharyngeal colostrum in early infancy and use of donor human milk banks. However, overall it is apparent that high quality research including systematic review and data synthesis in the form of meta‐analysis is required in this area to reach sound conclusions regarding recommendations of different interventions. This scoping review provides an important foundation for further research into this area.

To answer the clinical question ‘Among late preterm infants are there any interventions that improve the rates of breastfeeding and the use of breast milk compared with current practice?’. MEDLINE via Ovid, Embase via Ovid, the Maternity and Infant Care Database and the Cochrane Library were searched for relevant articles. Articles were excluded if they did not discuss specific interventions to improve breastfeeding, for example, if they only commented on factors such as age, race and education. Articles were also excluded if they were not specific to the late preterm infant population. A total of 516 articles were found and screened by title and abstract independently by two reviewers. The full text of 17 articles was independently reviewed. The reference lists of these full‐text articles were screened, and 14 abstracts were subsequently reviewed. The final analysis included three studies. There is limited high‐quality research evidence for interventions to improve breastfeeding in late preterm infants. In the absence of robust academic research, clinical practice should be guided by clinical expertise and involve a multidisciplinary team, including qualified lactation consultants. While it seems reasonable for hospitals to support interventions that improve breastfeeding in term infants, managing late preterm infants as healthy term infants without additional specialist support may result in high breastfeeding failure rates among late preterm infants.