The study is in the current issue of Pediatrics so is not available online to anyone without a subscription at present.  Pediatrics is, however, available in any hospital or medical school library.
 
I have been silent up to this point as I was disappointed with the results of Dr. Schanler et al?s study, but I cannot let smears on his and his colleagues? research go unanswered.  Many neonatologists will use this study as a reason not to use donor milk.  If you are to challenge them, you must be aware of the true positive and negative aspects of this study.  As usual for Dr. Schanler, the study is extremely well done with careful outcome definition and randomization, standardized feeding protocols, and sophisticated statistical analysis.
 
-Intention- to-treat analysis is a very appropriate way to analyze this data as the infants were switched to preterm formula supplementation because of failure to grow on fortified donor milk.
-It is true that fortifiers are not sterile and seem to compromise the infection-fighting potential of human milk, but both the mother?s own milk group (MM) and donor human milk (DM) groups were fortified.  The change in brand of fortifiers affected both groups equally. 
-Using donor milk does not avoid using (unsterile) powdered fortifiers, as donor human milk needs fortification even more than mothers? own milk.  Powdered fortifiers are simply fancy powdered formulas.
 
That said, the most important facet of this study that calls into question the importance of some of the results is that both the DM and PF (preterm formula) groups did receive approximately 50 % of their enteral intake as their mother?s own milk.  There was no pure donor milk group. This may have washed out some of the differences. Interestingly, despite help from lactation consultants in the NICU, only 27 % of the mother?s had enough milk to meet all their infant?s needs.  
 
Other interesting findings were the significant decrease in chronic lung disease with both MM and DM as compared with PF (Table 1) and the tendency (not statistically significant) for decreased ventilator days in both the MM and DM groups (Table 2). Because their overall incidence of NEC was so small, the numbers were too small to reach statistical significance for NEC, but both MM and DM groups had 6 % NEC, while the PF group had 11 % (Table 2).  Less ROP was found in the MM group.
 
The growth parameters were also interesting with length increment (cm/wk) significantly shorter in the MM group vs. the DM or PF groups!  There was no difference in head circumference increment between any of the 3 groups. Weight gain was slowest for the DM and fastest for the PF group as expected, but the authors do point out in the discussion that faster growth may not be better.  They also point out that they did not study long-term outcomes such as IQ, blood pressure, obesity, etc.
 
The references regarding milk processing were somewhat old (1977, 1979) but valid.
There is no mention of what each infant received as a FIRST feeding.  I believe what the infant received first, may have an impact on later NEC.
 
There was a huge difference in skin-to-skin contact time between the MM group and the other 2 groups (Table 5).  Skin-to-skin contact was correlated with the percentage of mother?s own milk intake, and not correlated with any infection-related events.  We need to push skin-to skin care even more.
 
I am interested in further results from this study, such as nutritional chemical markers (BUN, pre-albumin, alkaline phosphatase, Ca, Phos, etc.) and bone densities.  I am sure they were collected in the routine management of these patients.  Perhaps they will be a separate paper.
 
The authors concluded that fortified donor human milk did not offer any short-term advantages over preterm formula, and indeed resulted in slower weight gain.  They therefore recommend that every effort be made to support mothers in the NICU providing their own milk for their infants.  They again confirmed the decrease in NEC, other infections and length of stay for mother?s own milk.  I think we can all agree that mother?s own milk is the best.  I am not ready to give up on pasteurized donor milk yet.  I think we need a multicenter trial in order to find enough infants who receive ONLY fortified donor milk.  Despite my disappointment at some of the outcomes, I think there are some real pearls in this study that we can all use.
 
 Nancy E. Wight MD, FAAP, IBCLC
Attending Neonatologist,
Children's Hospital & Health Center, and
Sharp Mary Birch Hospital for Women
Medical Director, Sharp HealthCare Lactation Services

 

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