Human milk feeding, fortification initiation, and clinical outcomes in neonates with critical congenital heart disease: A multi-institutional study
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Background
Neonates with critical congenital heart disease (CCHD) are vulnerable to feeding-related complications including necrotizing enterocolitis (NEC). Human milk and direct breastfeeding (BF) may offer protection, but multisite evidence is limited. We aimed to determine relationships between the proportion of human milk received (ie, human milk percentage) or BF frequency during the neonatal period and NEC, sepsis, infectious complications, or length of stay (LOS). We also determined whether bovine-derived fortification or formula initiation was associated with NEC.
Methods
This retrospective study included neonates from 25 US pediatric centers who underwent surgery with cardiopulmonary bypass. Outcomes were NEC (modified Bell’s Stages II–III), sepsis, infection, and LOS. Disease risk score case-control matching and energy balancing weighted regression balanced multiple relevant covariates.
Results
Among 822 neonates, the percentage of human milk received during the neonatal period was not associated with NEC, sepsis or infection. Initiation of fortification or formula was associated with 3-fold higher odds of developing NEC within 5 days (OR:3.10, 95%CI:1.10–8.12, p=0.025). In energy balancing weighted regression models, higher neonatal human milk percentage and more frequent BF were strongly associated with shorter LOS: 100% versus 0% human milk with 9.33 days shorter (4.47–14.19, p<0.001); each additional BF session with 0.48 days shorter (0.31–0.65, p<0.001).
Conclusions
In this multisite cohort, fortification or formula initiation was associated with increased odds of NEC; and neonatal human milk percentage and BF with shorter LOS. Given limited evidence to guide practice, caution in introducing bovine-derived formula for high-risk infants with CCHD may be warranted.
Clinical Perspective
What Is New?
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This study including 822 neonates with critical congenital heart disease from 25 US pediatric cardiac centers identified a relationship between bovine-derived fortification or formula initiation and increased likelihood of developing necrotizing enterocolitis (modified Bell’s stage II–III) within 5 days.
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A higher proportion of human milk and more frequent direct breastfeeding during the neonatal period were strongly associated with a shorter hospital length of stay, even when accounting for more than 20 relevant clinical variables.
What Are the Clinical Implications?
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Clinical support of human milk and direct breastfeeding is important for infants born with critical congenital heart disease. Based on our findings, caution in introducing bovine-derived fortification or formula for high-risk infants with critical congenital heart disease may be warranted.
