XIII International Conference on Kangaroo Mother Care - Different opinions, experiences and related KMC issues: Good practices, stabilisation concept, nutrition and basic respiratory support.

AIM: This study aimed to summarise the views and experiences of the participants in the workshop of the XIII International Conference on Kangaroo Mother Care (KMC). METHODS: The results of the discussions held during the workshop of the XIII International Conference on KMC were summarised. There were 152 participants from 47 countries. Four main KMC topics were discussed: good practices, immediate implementation, nutrition and basic ventilation. RESULTS: Several agreements were reached, namely that professional societies and governments should develop official recommendations to promote KMC as standard care for preterm and low birth weight infants and that parents should be involved as active caregivers in neonatal care units. Moreover, the criteria for referring community-born infants to KMC require standardisation. Important inequalities in resource availability among high-, middle- and low-income countries were recognised for all topics. Specific needs were identified for parenteral nutrition and fortifiers, nasal continuous positive airway pressure (nCPAP) and oxygen blenders, which are rarely available in low- and middle-income countries. Immediate implementation of KMC was discussed as a new concept. Its benefits were recognised, but its application has some variability. CONCLUSION: Adequate preterm care requires a basic neonatal package, including KMC, nCPAP, immediate management protocols and adequate nutrition and feeding strategies. The differences in resources among high-, middle- and low-income countries highlight the wide disparities in neonatal care according to the place of birth.

Validation of a screening questionnaire for a human milk bank to determine the presence of illegal drugs, nicotine, and caffeine.

OBJECTIVES: To validate the health and lifestyle questionnaire answered by donors to a human milk bank with respect to the presence of illegal drugs, nicotine, and caffeine levels in donor milk. STUDY DESIGN: A total of 400 human milk samples from 63 donors were analyzed by liquid chromatography tandem mass spectrometry for the presence of 14 illegal drugs, nicotine, and caffeine. Demographics and clinical and lifestyle data (illegal drugs, tobacco, and caffeinated beverage use) were collected from the required screening questionnaire of a human milk bank. The relationship between the 2 evaluation techniques was determined. RESULTS: Illegal drugs were not found in donor milk. Nicotine (46.1 ng/mL) and cotinine (138.6 ng/mL) were quantified in one milk sample from a donor who did not report tobacco use in the questionnaire (1.6% false negative). Caffeine was detected in 45.3% (181/400) of the total milk samples, with a mean concentration of 496 ± 778 ng/mL. The sensitivity and specificity of the questionnaire to detect caffeine in donor milk was 46% and 77%, respectively. CONCLUSIONS: The lifestyle questionnaire is reliable for the assessment of illicit drug use by donors to a human milk bank, but there are certain limitations regarding the identification of second-hand smoke exposure and the disclosure of consumption of caffeinated beverages. Data such as smoking habits of partners, type and volume of beverage or food containing caffeine, method of preparation, and time of day of consumption should be collected by the questionnaire.

Clinical Impact of Supplementation with Pasteurized Donor Human Milk by High-Temperature Short-Time Method versus Holder Method in Extremely Low Birth Weight Infants: A Multicentre Randomized Controlled Trial.

Nosocomial infections are a frequent and serious problem in extremely low birth weight (ELBW) infants. Donor human milk (DHM) is the best alternative for feeding these babies when mother's own milk (MOM) is not available. Recently, a patented prototype of a High-Temperature Short-Time (HTST) pasteurizer adapted to a human milk bank setting showed a lesser impact on immunologic components. We designed a multicentre randomized controlled trial that investigates whether, in ELBW infants with an insufficient MOM supply, the administration of HTST pasteurized DHM reduces the incidence of confirmed catheter-associated sepsis compared to DHM pasteurized with the Holder method. From birth until 34 weeks postmenstrual age, patients included in the study received DHM, as a supplement, pasteurized by the Holder or HTST method. A total of 213 patients were randomized; 79 (HTST group) and 81 (Holder group) were included in the analysis. We found no difference in the frequency of nosocomial sepsis between the patients of the two methods-41.8% (33/79) of HTST group patients versus 45.7% (37/81) of Holder group patients, relative risk 0.91 (0.64-1.3), p = 0.62. In conclusion, when MOM is not available, supplementing during admission with DHM pasteurized by the HTST versus Holder method might not have an impact on the incidence of catheter-associated sepsis.

Effect of Holder pasteurization and frozen storage on macronutrients and energy content of breast milk.

OBJECTIVES: The aim of this study was to explore the effect of Holder pasteurization and frozen storage at -20°C after pasteurization on fat, total nitrogen, lactose, and energy content of breast milk. Both procedures are routinely practiced in human milk banks. METHODS: A total of 34 samples of frozen breast milk, donated by 28 women, were collected. Once thawed, an aliquot of each sample was analyzed before pasteurization; the remaining milk was pasteurized (Holder method) and split into 8 aliquots. One aliquot was analyzed after pasteurization and the remainder frozen at -20°C and analyzed 30, 60, 90, 120, and 180 days later. For every aliquot, fat, total nitrogen, lactose, and energy content were determined using the device human Milk Analyzer. RESULTS: We observed a significant reduction in fat (3.5%; -0.17 (-0.29; -0.04) g/dL) and energy content (2.8%; -2.03 (-3.60; -0.46) g/dL) after pasteurization. A significant decrease over time was observed for fat, lactose and energy content. No significant changes were observed for nitrogen content. Mean differences between day 0 postpasteurization and day 180 were -0.13 (-0.21; -0.06) g/dL for fat, -0.08 (-0.13; -0.03) g/dL for lactose, and -1.55 (-2.38; -0.71) kcal/dL for energy content. The relative decreases were 2.8%, 1.7%, and 2.2%, respectively. Overall (postpasteurization + frozen storage), a 6.2% and 5% decrease were observed for fat and energy, respectively. CONCLUSIONS: Holder pasteurization decreased fat and energy content of human milk. Frozen storage at -20°C of pasteurized milk significantly reduced fat, lactose, and energy content of human milk.

Human Milk Composition and Nutritional Status of Omnivore Human Milk Donors Compared with Vegetarian/Vegan Lactating Mothers.

Women of childbearing age in Western societies are increasingly adopting vegetarian diets. These women are sometimes rejected as milk donors, but little about the composition of their milk is known. The present study aimed to compare the intake, nutritional status, and nutritional composition of human milk from omnivore human milk donors (Donors) and vegetarian/vegan lactating mothers (Veg). Milk, blood, and urine samples from 92 Donors and 20 Veg were used to determine their fatty acid profiles, as well as vitamins and minerals. In a representative sample of both groups, we also determined the lipid class profile as a distribution of neutral and polar lipids, the molecular species of triacylglycerols, and the relative composition of phospholipids in their milk. A dietary assessment was conducted with a five-day dietary record (while considering the intake of supplements). We highlight the following results, expressed as the mean (SE), for the Veg vs. Donors: (1) Their docosahexaenoic acid (DHA) intake was 0.11 (0.03) vs. 0.38 (0.03) g/day; the plasma DHA was 0.37 (0.07) vs. 0.83 (0.06)%; and the milk DHA was 0.15 (0.04) vs. 0.33 (0.02)%. (2) Their milk B12 levels were 545.69 (20.49) vs. 482.89 (4.11) pM; 85% of the Veg reported taking B12 supplements (mean dose: 312.1 mcg/day); and the Veg group showed no differences with Donors in terms of total daily intake or plasma B12. (3) Their milk phosphatidylcholine levels were 26.88 (0.67) vs. 30.55 (1.10)%. (4) Their milk iodine levels were 126.42 (13.37) vs. 159.22 (5.13) mcg/L. In conclusion, the Vegs' milk was shown to be different from the Donors' milk, mainly due to its low DHA content, which is concerning. However, raising awareness and ensuring proper supplementation could bridge this gap, as has already been achieved for cobalamin.

Associations of Dietary Intake and Nutrient Status with Micronutrient and Lipid Composition in Breast Milk of Donor Women.

The influence of the diet and nutritional status of milk donors on the nutritional composition of donor human milk (DHM) is unknown. The present study aimed to determine the nutritional profile of DHM and the associations between donors' dietary intake and nutritional status and the micronutrient and lipid composition in DHM. For this purpose, 113 donors completed a food frequency questionnaire, provided a five-day weighed dietary record, and collected milk for five consecutive days. Nutrient determinations in donors' erythrocytes, plasma, urine, and milk were performed. Multiple linear regressions were conducted for the evaluation of the associations. We highlight the following results: DHM docosahexaenoic acid (DHA) was positively associated with donors' plasma DHA content and donors' DHA intake (R2 0.45, p < 0.001). For every 1 g/day DHA intake, an increase of 0.38% in DHA content and 0.78% in total omega-3 content was observed in DHM (R2 0.29, p < 0.001). DHM saturated fatty acids were positively associated with erythrocyte dimethyl acetals, plasma stearic acid, trans fatty acids intake, and breastfeeding duration and negatively associated with erythrocyte margaroleic acid (R2 0.34, p < 0.01). DHM cholecalciferol was associated with plasma cholecalciferol levels and dairy intake (R2 0.57, p < 0.01). Other weaker associations were found for free thiamin, free riboflavin, pyridoxal, dehydroascorbic acid, and the lipid profile in DHM. In conclusion, the diet and nutritional status of donors influence the fatty acid profile and micronutrient content of DHM.

Comparative analyses of holder pasteurization vs. HTST pasteurization for donor milk: a cost-minimization study applicable to human milk banks.

BACKGROUND: High-temperature short-time (HTST) pasteurization (72-75 °C, 15 s) is an alternative treatment to traditional Holder pasteurization (HoP) (62ºC, 30 min) for donor milk. HTST pasteurization guarantees the milk's microbiological safety and retains more of its biologically and nutritionally active compounds, but the cost of implementing this technology for a human milk bank is unknown. METHODS: A cost-minimization study was carried out on the facilities of a regional human milk bank in a public hospital. Total production costs (fixed plus variables) were quantified using HTST pasteurization and HoP in three hypothetical scenarios: (1) costs of the first 10 L of pasteurized milk in a newly opened milk bank; (2) costs of the first 10 L of pasteurized milk in an active milk bank; and (3) costs using the maximum production capacity of both technologies in the first two years of operation. The following costs were analyzed: health care professionals, equipment and software, external services, and consumables. RESULTS: In scenario 1, the total production costs were € 228,097.00 for the HTST method versus € 154,064.00 for the HoP method. In scenario 2, these costs were similar (€ 6,594.00 for HTST pasteurization versus € 5,912.00 for HoP). The cost of healthcare professionals was reduced by more than half when pasteurization was carried out by the HTST method versus the Holder method (€ 84.00 and € 191.00, respectively). In scenario 3, the unit cost of milk pasteurized by the HTST method decreased from the first to the second year by 43.5%, while for the HoP method, it decreased by 30%. CONCLUSIONS: HTST pasteurization requires a high initial investment in equipment; however, it provides a significant minimization of production costs in the long term, pasteurizes large quantities of donor milk per working day and achieves a more efficient management of the time of the health care professionals in charge of the bank's operation compared to HoP.

Assessment of Iodine Concentration in Human Milk from Donors: Implications for Preterm Infants.

Preterm infants are particularly vulnerable to developing iodine deficiency. Donor human milk (DHM) is the preferred feeding option if the mother's own milk (MOM) is not available, but information on DHM iodine concentration (DHMIC) is lacking. Hence, we aimed to assess DHMIC to further evaluate the adequacy of iodine provision in preterm infants. Finally, associations that might influence DHMIC were studied. In 113 donors, we measured iodine intake by evaluating dietary records for five consecutive days with the DIAL® Software. From the second day of dietary record, donors provided human milk samples (at least one per day) for four consecutive days. Daily human milk samples were analyzed for DHMIC. A DHMIC ≥ 200 µg/L was considered an adequate iodine content for preterm infants. DHMIC and urine iodine concentration (UIC) were determined using ICP-MS. In our study, 83.2% of donors had a full-term infant. Breastfeeding time range was 1.5−49.4 months. During the dietary record, 55.8% took iodine-containing supplements, providing 40−200 µg/day of iodine. The medians (p25, p75) UIC and DHMIC were 112.4 (75.8, 160.1) and 148.5 (97.6, 206.1) µg/L, respectively. In this iodine-sufficient population, 70% had a DHMIC of <200 µg/L. Donors' intake of iodine-containing supplements was associated with higher DHMIC.

Maternal and Neonatal Prognostic Factors for Cardiorespiratory Events in Healthy Term Neonates During Early Skin-to-Skin Contact.

Background: During early skin-to-skin contact (ESSC), alterations in peripheral oxygen saturation (SpO2) and heart rate (HR) have been frequently observed. Objectives: This study aimed to determine the incidence of cardiorespiratory events (CREs) during ESSC in healthy term newborns (HTNs) and estimate the association of maternal and neonatal prognostic factors with the risk of CREs. Methods: A pooled analysis of the cohort from a clinical trial involving healthy mother-child dyads during ESSC was performed. Pulse oximetry was employed to continuously monitor SpO2 and HR within 2 h after birth. The individual and combined prognostic relevance of the demographic and clinical characteristics of dyads for the occurrence of a CRE (SpO2 <91% or HR <111 or >180 bpm) was analyzed through logistic regression models. Results: Of the 254 children assessed, 169 [66.5%; 95% confidence interval (95% CI), 60.5-72.5%] had at least one CRE. The characteristics that increased the risk of CRE were maternal age ≥35 years (odds ratio, 2.21; 95% CI, 1.19-4.09), primiparity (1.96; 1.03-3.72), gestational body mass index (BMI) >25 kg/m2 (1.92; 1.05-3.53), and birth time between 09:00 p.m. and 08:59 a.m. (2.47; 1.02-5.97). Conclusion: CREs were more frequent in HTNs born during nighttime and in HTNs born to first-time mothers, mothers ≥35 years, and mothers with a gestational BMI >25 kg/m2. These predictor variables can be determined during childbirth. Identification of neonates at higher risk of developing CREs would allow for closer surveillance during ESSC.

Mother's Bed Incline and Desaturation Episodes in Healthy Term Newborns during Early Skin-to-Skin Contact: A Multicenter Randomized Controlled Trial.

INTRODUCTION: Early skin-to-skin contact (ESSC) is associated with rare, sudden, unexpected postnatal collapse episodes. Placing the newborn in ESSC closer to an upright position may reduce the risk of airway obstruction and improve respiratory mechanics. This study assessed whether a greater inclination of the mother's bed during ESSC would reduce the proportion of healthy term newborns (HTNs) who experienced episodes of pulse oximeter saturation (SpO2) <91%. METHODS: We conducted a multicenter randomized controlled trial comparing the effect of the mother's bed incline, 45° versus 15°, on desaturation in HTNs during ESSC. Before delivery on 1,271 dyads, randomization was conducted, and stringent criteria to select healthy mothers and term newborns were monitored until after birth. Preductal SpO2 was continuously monitored between 10 min and 2 h after birth. The primary outcome was the occurrence of at least one episode of SpO2 <91%. RESULTS: 254 (20%) mother-infant dyads were eligible for analysis (45°, n = 126; 15°, n = 128). Overall, 57% (95% confidence interval [CI]: 51%-63%) of newborns showed episodes of SpO2 <91%. The proportion of infants with SpO2 <91% episodes was 52% in 45° and 62% in 15° (relative risk: 0.80; 95% CI: 0.6-1.07). CONCLUSIONS: We did not show that a high mother bed inclination during ESSC led to significantly fewer HTNs who experienced episodes of SpO2 <91%. Desaturation episodes from 10 min to 2 h after birth occurred in more than half of HTNs.

What is the impact of mother's bed incline on episodes of decreased oxygen saturation in healthy newborns in skin-to-skin contact after delivery: Study protocol for a randomized controlled trial.

BACKGROUND: Early mother-child skin-to-skin contact (SSC) in the first 2 h postpartum is highly beneficial for both mother and child. However, cases have been reported of newborns who have experienced apparently life-threatening events (ALTEs) or sudden death during this procedure. The causes of these events are unknown. Newborn's prone position could influence the onset of these events but there is very little evidence to support any recommendation. We hypothesize that newborns' breathing obstruction episodes increase as mothers lie more horizontally. The main objective of this study is to compare the occurrence of desaturation and bradycardia episodes as a function of mother's bed incline. The study is designed as a randomized, controlled, assessor blind, multicenter, superiority trial with two parallel groups and 1:1 allocation ratio. METHODS: The study participants will be full-term healthy mother-newborn dyads from ten hospitals in Spain. Participants will be randomly assigned to one of two study arms defined by mother's bed inclination (45° or 15°). The planned sample size is 5866. Centralized permuted blocks randomization and assessor blinding will be implemented. The newborns will be monitored remotely with pulse oximetry, from 10 min to 2 h after delivery. We established SO2 and heart rate (HR) limit alarms, as well as an action protocol in the event of alarm activation. The primary outcome is the number of healthy newborns who undergo episodes of SO2 ≤ 90%. Secondary outcomes are the mean SO2 level, the number of newborns who experience episodes of SO2 ≤ 85%, the time to SSC discontinuation due to abnormal SO2 or HR, and episodes of HR < 111 beats per minute (bpm) or > 180 bpm. Subgroups and pooled analysis will be performed to identify if breast-feeding and mother and child positions favor the occurrence of desaturation or bradycardia episodes. DISCUSSION: A simple intervention such as modifying mother's bed angle of inclination while in SSC with her child during the first 2 h postpartum could favor newborn's hemodynamic and respiratory stabilization and thus contribute to reducing the onset of ALTEs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02585492 . Registered on 22nd October 2015. PROTOCOL VERSION: 2 (30th June 2015).

[Recommendations for the creation and operation of maternal milk banks in Spain]. / Recomendaciones para la creación y el funcionamiento de los bancos de leche materna en España.

It is widely agreed that the best source of nutrition for the newborn is the milk of their own mothers. In those cases where it is not available, especially in very premature and/or very low birth weight infants, as well as other sick newborns, the preferred choice before formula is the human milk provided by selected donors. This indication is supported by the highest international bodies dedicated to the health of the child population, including the World Health Organisation as well as the main national and international scientific societies in the field of Paediatrics. Milk banks are health institutions responsible for the collection, processing and distribution of donated human milk. Currently, there are 14 human milk banks operating in Spain, grouped in the Spanish Association of Human Milk Banks, created in September 2008. In order to homogenise the criteria and to unify the working methods of the different milk banks, the Spanish Association of Human Milk Banks has developed standards to harmonise the protocols, and to serve as a guide for the start-up of new milk banks in the Spanish territory. These standards, set out in the present article, range from the donor selection and the evaluation process to the collection, processing, storage, and distribution of donor human milk.

An Adoptive Mother Who Became a Human Milk Donor.

Inducing lactation in the absence of pregnancy (nonpuerperal lactation) is not always successful and, in many cases, only partial breastfeeding is achieved. Different protocols have been described, but scientific evidence and research are lacking in this area. The authors describe the case of a woman with a history of a miscarriage, for whom the lactation induction process was so effective that she became a milk donor even before she received her adopted child. She had not previously used hormone treatment. She was given domperidone as a galactogogue for 1 month. The pumping protocol began with a double electric breast pump combined with manual pumping 6 months before her child was delivered, and 3 months later, she was accepted as a donor by our milk bank. This highlights the importance of regular stimulation as a milk production mechanism. This is the first case of human milk donation in an adoptive mother described in the literature.

Impact of Freezing Time on Dornic Acidity in Three Types of Milk: Raw Donor Milk, Mother's Own Milk, and Pasteurized Donor Milk.

OBJECTIVE: Although under certain circumstances it is necessary to express milk, there are not many recommendations about the ideal storage conditions for human milk. The objectives of this study were to analyze the effects on Dornic acidity of frozen storage at -20 °C in three types of milk: raw donor milk, mother's own raw milk, and pasteurized donor milk. METHODS: Forty-three samples of raw donor milk, 40 samples of pasteurized donor milk, and 16 samples of mother's own milk were analyzed. Dornic acidity was measured at time 0, before freezing. The remaining aliquots were frozen and analyzed after 1, 2, 3, and 4 weeks and after 2 and 3 months. RESULTS: In raw donor milk, the median acidity at the start was 3 °D (interquartile range [IQR] 2-3 °D); after 3 months, it was 5 °D (IQR 3-7 °D), with a significant increase in acidity after the second week. In mother's own milk, the mean acidity at the start was 3 °D (IQR 2-4 °D) and 7 °D (IQR 4-8 °D) at 3 months. The increase was significant after the third week. In pasteurized donor milk, the mean acidity was 3 °D (IQR 2-3 °D) at the start and 2 °D (IQR 2-3 °D) at the end. When comparing the three types of milk, there were significant differences from the first week between the two types of raw milk and the pasteurized milk (p < 0.01), but not between the two raw milks (p = 0.77). CONCLUSIONS: Dornic acidity in unpasteurized milk significantly increases with the duration of freezing, probably due to the action of lipases, which is lost with pasteurization. It would be advisable to reduce the length of freezing time for unpasteurized milk.

Cruces de leche materna en las unidades neonatales / Cruces maternal milk in neonatal units

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Donor milk volume and characteristics of donors and their children.

BACKGROUND: Little is known regarding the effect of the characteristics of donors and their children on the volume of donor milk delivered to a human milk bank (HMB). AIMS: Our study aimed to determine the relationship between different social and demographic variables of donors and their infants with the volume of human milk delivered. METHODS: We included donors accepted at the Hospital Doce de Octubre HMB from January 1st, 2009 until April 31st, 2013, and who had finished their donation. Data of social and demographic characteristics of the donors and their children, and the total volume of DHM given were obtained from our HMB database. Included variables were previous donors, donor age, number of children, place of residence, gestational age of the infant at birth, child's age at the start of the donation, hospital admission, and death of the infant. A linear regression model was used to study the relationship between independent variables that were significant in bivariate analysis and the volume of donated milk. RESULTS: A total of 415 donations from 391 women were included. The median volume of milk delivered was 3.1l (IQR-interquartile range-1.3-8.3l). In the linear regression model, previous donors, smaller gestational age of children, and the start of donation at earlier stages of lactation were associated with a larger quantity of HMB donated (p≤0.001). CONCLUSION: Previous donors, smaller gestational age of children, and the start of donation at earlier stages of lactation are associated with a larger quantity of milk donated to the HMB.