Neonatal Care Research
Below is a selection of recent research on the effects of breastfeeding and breastmilk on neonatal outcomes. For more information on embedding Baby Friendly care in the neonatal unit, see our dedicated guidance document.
Randomised controlled trial of human derived breast milk fortifier versus bovine milk fortifier on body composition in very preterm babies
This study compared the effect of an exclusive human milk based diet (intervention) with a diet containing cow milk products (control) on body composition in infants born below 30 weeks gestation. Randomised multicentre, open label, controlled trial. Infants preferentially received their own mother’s milk. Infants were randomised to either an exclusive human milk diet (human milk formula to make up a shortfall in own mother’s milk and human milk derived fortifier) or cow milk-based supplementation (preterm formula to make up a shortfall in own mother’s milk and cow milk-based fortifier). Fortification began at an enteral intake of 150 ml/kg/day. Infants underwent whole-body magnetic resonance imaging at term. We randomly assigned 38 infants to intervention (n = 19) and control arms (n = 19). Primary outcomes were analysed in 15 infants in the intervention arm and 12 in the control arm. We identified no clinically relevant differences in body composition in preterm babies <30 weeks gestation receiving a macronutrient-equivalent exclusive human milk diet compared with a diet containing cow milk products.
Associations of Maternal Milk Feeding With Neurodevelopmental Outcomes at 7 Years of Age in Former Preterm Infants
This study examined the extent to which maternal milk feeding after very preterm birth is associated with cognitive, academic, and behavioral outcomes at school age. This prospective cohort study assessed 586 infants born at less than 33 weeks’ gestation at 5 Australian perinatal centers and enrolled in the Docosahexaenoic Acid for Improvement of Neurodevelopmental Outcomes study (January 1, 2001, to December 31, 2005) who were evaluated at a corrected age of 7 years. The statistical analysis was completed on January 19, 2022. Findings indicated maternal milk feeding during the neonatal hospitalization and after discharge were associated with better school-age performance IQ and academic achievement and with a reduction in ADHD symptoms, particularly among infants born at less than 30 weeks’ gestation.
Parent-infant interaction quality is related to preterm status and sensory processing
The effects of thawing and warming on the secretory immunoglobulin A (SIgA) level and lysozyme activity in frozen HM should be investigated to identify optimal methods for preserving immune factors in frozen HM. The SIgA level in HM frozen at -18 °C for two months was stable after overnight thawing in the refrigerator (4 °C for 12 h) before warming to 37 °C compared with that in fresh milk. The thawing of HM in the refrigerator overnight (and then warming to 25 °C or 37 °C for 30 min) has the potential to preserve the SIgA concentration and lysozyme activity to a greater extent than heating immediately after removal from the freezer. Broader temperature ranges should be analyzed to determine the temperature that minimizes the losses in SIgA concentration and lysozyme activity in HM.
Hypernatremia in Newborns: A Practical Approach to Management
Hypernatremia is a potentially serious condition in both term and preterm babies, which can lead to severe and permanent neurological damage. Understanding this physiological process, early anticipation of hypernatremia and familiarization with the neonatal management of hypernatremia can prevent mortality and long-term morbidity associated with this condition. This review aims to provide a practical and understandable approach to the diagnosis and management of hypernatremia in neonates.
The impact of a Donor Human Milk Program on the provision of mothers’ own milk at discharge in very low birth weight infants
This single center retrospective analysis examines the effect of a donor human milk (DHM) program on mothers’ own milk feedings at discharge for very low birth weight (VLBW) infants. Both the percentage of mothers’ own milk feeds and percent of infants exclusively receiving mothers’ own milk at discharge were increased in the <1500 g (p = 0.003, p = 0.002) and the ≥1500 g group (p = 0.007, p = 0.004) respectively, following the introduction of DHM for VLBW infants. Practice changes that accompany a donor milk program likely play a prominent role in the provision of mothers’ own milk and exclusivity of breastmilk feedings at discharge for very low birth weight infants.
Impact of Kangaroo Care on Premature Infants’ Oxygenation: Systematic Review
Kangaroo care (KC) is an effective method of promoting health and wellbeing of infants and their families. This systematic review analysed a total of 345 articles on KC, with 25 studies included. Physiological parameters monitored (heart rate, arterial oxygen saturation, regional cerebral oxygen saturation, and fractional oxygen extraction) showed no significant changes at different study periods: pre-KC, during KC, and post-KC. Findings concluded that stable preterm infants receiving or not respiratory support show no significant differences in heart rate, arterial oxygen saturation or fractional oxygen extraction during KC compared to routine incubator care. Regional cerebral oxygen saturation remains stable during KC with slight upward trend. Further studies with a higher level of methodological quality are needed to confirm these findings.
Mother-Newborn Care Unit (MNCU) Experience in India: A Paradigm Shift in Care of Small and Sick Newborns
Analysis of salivary cortisol levels in preterm infants and their mothers in this study found that skin-to-skin contact reduced experiences of stress. The study included 60 preterm infants with gestational age less than 32 weeks, who were treated in the neonatal intensive care unit, and their mothers. The overall design was a baseline-response design. Saliva was collected before (baseline) and after skin-to-skin contact to measure free cortisol by enzyme immunoassay method.
This study assessed whether kangaroo mother care (KMC) in infancy affects brain volumes in young adulthood. Bivariate analysis of 178 adults born preterm showed larger volumes of total grey matter, basal nuclei, cerebellum and white matter in the 97 participants who had received KMC, indicating that the neuroprotective effects of KMC for preterm infants persisted beyond childhood and improved their lifetime functionality and quality of life.
Preterm birth during the COVID-19 pandemic: Parental experience
Results of an online survey of 107 participants share insights on the experiences of parents with a preterm or unwell neonate during the Covid-19 pandemic. Findings showed significant psychological and emotional impacts due to restrictions imposed on the units, with parents also reporting concerns about bonding with their baby. Read more from this study below.
Breastmilk exposure is associated with cortical maturation in preterm infants
This study combined nutritional data with brain MRI to explore the extent to which breastmilk exposure in preterm infants during neonatal care resulted in a cortical morphology more closely resembling that of term infants. A total of 135 preterm and 77 term infants took part in this study, with results indicating that high breastmilk exposure was associated with reduced cortical gray matter volume, thickness and radial diffusivity, and increased fractional anisotropy after adjustment for age at MRI.
Family Integrated Care: A Framework for Practice
Family Integrated Care (FICare) is a model of neonatal care which promotes a culture of partnership between families and staff and enables parents to become confident, knowledgeable and independent primary caregivers. This BAPM framework describes a model of FICare and provides a structure for implementation in UK neonatal units and networks.
ABM Clinical Protocol #35: Supporting Breastfeeding During Maternal or Child Hospitalisation
This protocol outlines recommended care for hospitalised lactating mothers and breastfeeding children and serves to set the standards to implement these model policies.
Cue-based versus scheduled feeding for preterm infants transitioning from tube to oral feeding: the Cubs mixed-methods feasibility study
This mixed-methods intervention study analysed current approaches and understanding of cue-based feeding and the transition between preterm tube to oral feeding in neonatal units. Findings indicated that a cue-based feeding intervention was acceptable to parents and staff and would be feasible to implement. However, results also showed that this would require improvements to both staff training and data recording.
Bliss research shows young parents face ‘double whammy’ of being underprepared and under-supported when their babies are in neonatal care
More than half of a group of 200 parents with a baby born premature or sick felt they were not as involved in care giving or decision making as they would have liked, a study by Bliss shares. One in five parents indicated that communication was often unclear, with some feeling they were excluded from care discussions because they were assumed to be incapable of contributing. Read more by visiting the Bliss website.
Preterm nutrition and neurodevelopmental outcomes
Inoculation of mother’s own milk could personalize pasteurized donor human milk used for feeding preterm infants
In an in-vitro study, pasteurized donor human milk was inoculated at 10% v/v using ten preterm milk samples and analysed in order to evaluate the effect in terms of bacterial growth, human milk microbiome and proteolytic phenomena. Findings showed that IM samples at T2 showed a Total Bacterial Count were not significantly different (p > 0.01) compared to preterm milk samples, demonstrating that inoculation of PDHM with mother’s own milk could restore bacterial growth and personalize human milk microbiome in PDHM. This effect could be beneficial because of the presence of maternal probiotic bacteria which make PDHM more similar to mother’s own milk.
Breastfeeding promotes early neonatal regulatory T-cell expansion and immune tolerance of non-inherited maternal antigens
Cardiac Performance in the First Year of Age Among Preterm Infants Fed Maternal Breast Milk
Preterm infants with higher consumption of mother’s own milk were found to have enhanced cardiac performance at age 1 year, suggesting that mother’s own milk consumption may play a dynamic modulator role on cardiac mechanics in preterm-born infants. This cross-sectional study of cardiac and nutritional data included 80 individuals born preterm and 100 individuals in the control group born full-term born between 2011 and 2013.
Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother’s own milk by encouraging early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding. Mother’s own milk is the optimal nutrition source for very low birth weight babies (≤1500 g), providing short- and long-term health benefits.
Parker, M. et al. 2020. Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant.
Is preterm donor milk better than preterm formula for very-low-birth-weight infants?
This single-centre prospective cohort study explored the effects of donor milk and preterm formula on growth, feeding tolerance and severe morbidity in 304 very-low-birth-weight infants. Results indicate that preterm donor milk does not affect growth in preterm infants, however it does significantly reduce feeding intolerance, helps to achieve full enteral feeding early, and lowers infection rates.
Variation in Oxygen Saturation by Pulse Oximetry During and After Breastfeeding Among Healthy Term Neonates During Early Postnatal Life at Tertiary Care Hospital
Variations in oxygen saturation levels of 60 healthy term infants were found to be significantly higher after breastfeeding, highlighting the crucial role effective breastfeeding plays in infant growth. Greater research is needed on infant breathing and sucking patterns to enable healthcare professionals to identify feeding difficulties and suggest effective breastfeeding methods.
Locked out: the impact of Covid-19 on neonatal care
Findings from a survey of 70 NHS Trusts and over 500 parents of neonatal babies born between March 2020 and February 2021 indicate ongoing challenges faced by parents in spending time with their infants in the critical first days and weeks of life. This has a negative impact on bonding, attachment, and parental mental health, with parents 70% more likely to say they found it difficult to bond with their baby if Covid-19 had resulted in restricted access to the neonatal unit.
Bliss. 2021. Locked out: the impact of Covid-19 on neonatal care
Intervention Strategies for the Poor Feeder in the Newborn Intensive Care Unit: External Pacing versus Imposed Regulation
This article compares and contrasts external pacing, a method of feeding developed in the 1980s as a cue-based technique to aid infants who were experiencing discomfort or distress – and imposed regulation – a diagnostic-based intervention strategy developed in the 1990s and implemented following a diagnosis of a disorganised suck on the Neonatal Oral-Motor Assessment Scale (NOMAS®).
Early breastmilk exposure modifies brain connectivity in preterm infants
Preterm infants are at increased risk of alterations in brain structure and connectivity and subsequent neurocognitive impairment. This study explores the extent to which breastmilk exposure is associated with improved markers of brain development and connectivity in preterm infants at term equivalent age. Findings from an analysis of data on 47 preterm infants’ neonatal breastmilk exposure and brain MRI suggests that breastmilk feeding in the weeks after preterm birth is associated with improved structural connectivity of developing networks and greater fractional anisotropy in major white matter fasciculi.
Nurturescience versus neuroscience: A case for rethinking perinatal mother–infant behaviors and relationship
With the understanding that there has not been a significant improvement in the outcomes for babies who were separated from their mothers due to prematurity or birth defects in the past two decades, and that current neuroscience-based theories and treatment paradigms have not yet generated explanatory mechanisms that work, or provided testable hypotheses, a new field of scientific investigation titled “nurturescience” is proposed in this article, described as being drawn from biology, anthropology, sociology, physiological, and clinical research, and based on the basic needs of all newborns, mothers and families. Key themes in this new field include that the mother–infant dyad should not be separated, skin-to-skin contact, and infant and family centered developmental care .
Neuroscience meets nurture: challenges of prematurity and the critical role of family-centred and developmental care as a key part of the neuroprotection care bundle
This review examines the developmental milestones of fetal brain development and how preterm birth can disrupt this trajectory. Authors review the common morbidities associated with premature birth, and outline a range of sustainable and effective non-medical, family-centred and developmental care strategies which have the potential to improve neurodevelopmental outcomes and which and need to be considered part of the future neuroprotection care bundle.
Positive Effects of Kangaroo Mother Care on Long-Term Breastfeeding Rates, Growth, and Neurodevelopment in Preterm Infants
This study investigates the impact of kangaroo mother care (KMC) on breastfeeding and health outcomes in Chinese preterm infants. A longitudinal randomised controlled study was conducted with 79 preterm infant-mother dyads. The KMC group (n = 36) was provided 2.5 hours/day KMC during the neonatal intensive care unit (NICU) hospitalization, while the control group (n = 43) received standard care. Infant’s feeding regimens and physical growth were documented daily at NICU. Physical growth and Neonatal Behavioral Neurological Assessment were measured at 40 weeks, 3 months, and 6 months of corrected age (CA). Breastfeeding outcomes were documented at 6 months of CA. Findings showed that the KMC infants received higher mothers’ milk proportion during hospitalisation, less feeding intolerance at discharge, and higher exclusive breastfeeding proportion at 6 months CA. They also had increased body weight and measurements at discharge, along with higher neurobehavioral scores. Authors concluded that longitudinal KMC effects are significant in promoting preterm infants’ breastfeeding outcomes, growth, and neurodevelopment. Early initiation of KMC practice is highly recommended to the parent-infant population in Chinese NICUs to promote breastfeeding and developmental outcomes.
The Economic Impact of Donor Milk in the Neonatal Intensive Care Unit
Researchers conducted a retrospective analysis of 319 infants with very low birth weight born before (January 2011-December 2012, mother’s own milk + formula, n = 150) and after (April 2013-March 2015, mother’s own milk + donor milk, n = 169) to assess the cost-effectiveness of mother’s own milk supplemented with donor milk vs mother’s own milk supplemented with formula for infants of very low birth weight in the neonatal intensive care unit (NICU). Results found that infants receiving mother’s own milk + donor milk had a lower incidence of necrotizing enterocolitis (NEC) than infants receiving mother’s own milk + formula (1.8% vs 6.0%, P = .048). Mother’s own milk + donor milk was associated with $15 555 lower costs per infant (P = .045) and saved $1812 per percentage point decrease in NEC incidence.
The stepwise assembly of the neonatal virome is modulated by breastfeeding
Whilst healthy human neonates typically do not have viruses at birth, they can quickly become colonised which can lead to gastrointestinal disorders. This takes place in distinct steps: early after birth, bacteria colonises the infant gut and by one month can lead to virus-like particles. By four months of life, these viruses can become more prominent. The findings of this study concur with other reports that breastmilk can provide protection against viral infections.
Preterm Infants Fed Cow’s Milk-Derived Fortifier Had Adverse Outcomes Despite a Base Diet of Only Mother’s Own Milk
This study re-analysed a 12-centre randomised trial that compared exclusive human milk feeding, including mother’s own milk, donor milk and human milk-derived fortifier versus a cow’s milk exposed group fed mother’s own milk, preterm formula and cow’s milk derived fortifier (CMDF). To allow for an isolated comparison of fortifier type and to evaluate rates of necrotizing entercolitis (NEC), severe morbidity index of NEC surgery or death and other outcomes, a subgroup analysis (n = 114) selecting only infants receiving 100% mother’s own milk plus fortification/fed no donor milk or preterm formula was conducted. The study concluded that available evidence points to an increase in adverse outcomes with CMDF, including NEC and severe morbidity comprising NEC surgery or death.
National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis
This study from the London School of Hygiene & Tropical Medicine, the World Health Organization (WHO) and UNICEF estimates that globally 20.5 million babies were born with a low birthweight in 2015 – around 1 in 7 babies. The findings show that the problem is substantial in both high and low income countries, and highlight the need for more action to help tackle the underlying causes of low birthweight as well as improve care for low birthweight babies and their families. In the UK, the Unicef UK Baby Friendly Initiative neonatal standards support units to empower parents to be active partners in their baby’s care, support the development of close and loving parent-infant relationships, and enable babies to receive breastmilk, which gives them vital protection against infection and supports their short and long-term health outcomes.
The effects of kangaroo mother care on the time to breastfeeding initiation among preterm and low birthweight infants: a meta-analysis of published studies
This review of studies found that preterm and low birthweight infants receiving a kangaroo mother care intervention initiated breastfeeding 2 days 14 h 24 min earlier than infants who received the “conventional” care of the radiant warmer/incubator method.
Reducing parental trauma and stress in neonatal intensive care: systematic review and meta-analysis of hospital interventions
This review of studies suggests that interventions designed to support parents on a neonatal unit can be successful in reducing parental distress – in particular, complementary/alternative medicine and family-centered instruction interventions each decreased distress symptoms, with fathers and mothers improving to similar extents. The authors recommend further research into the issue, and argue for the importance of developing psychosocial interventions that serve NICU parents at large, including fathers and parents of full-term infants.
Older research
- The type of feeding at discharge of very preterm infants: Neonatal intensive care units policies and practices make a difference
- Parental experience of interaction with healthcare professionals during their infant’s stay in the neonatal intensive care unit
- Breastfeeding and risk for ceasing in mothers of preterm infants—Long‐term follow‐up
- The impact of preterm infants’ continuous exposure to breast milk odour on stress parameters: A pilot study
- Parents as partners in care: Lessons from the Baby Friendly Initiative in Exeter
Read, K, and Rattenbury, L (2018). Parents as partners in care: Lessons from the Baby Friendly Initiative in Exeter, Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2017.11.006
- Personalization of the Microbiota of Donor Human Milk with Mother’s Own Milk
- The Dual Nature of Early-Life Experience on Somatosensory Processing in the Human Infant Brain
- A Comparison of Breast Milk and Sucrose in Reducing Neonatal Pain During Eye Exam for Retinopathy of Prematurity (ROP)
- Beyond necrotizing enterocolitis prevention: Improving outcomes with an exclusive human milk–based diet
- Kangaroo mother care for preterm infants
- Beyond necrotizing enterocolitis prevention: Improving outcomes with an exclusive human milk–based diet
- Breastmilk Feeding, Brain Development, and Neurocognitive Outcomes: A 7-Year Longitudinal Study in Infants Born at Less Than 30 Weeks’ Gestation
- “Giving us hope”: Parent and neonatal staff views and expectations of a planned family- centred discharge process