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Breast milk feeding in premature infants with persistent ductus arteriosus

Pediatric Research (2024)Cite this article

We read with interest the comments by Porta et al.1 on our recently published manuscript in Pediatric Research.2 The aim of our manuscript was to review the current state of knowledge on nutritional issues related to patent ductus arteriosus (PDA) in preterm infants. Our review highlighted three key points that are difficult to dispute: (1) Preterm infants with PDA are particularly prone to suboptimal feeding, poor postnatal growth and gastrointestinal complications. (2) In PDA infants, fluid restriction can lead to inadequate nutrient intake, which can have a negative impact on postnatal growth and long-term health. (3) The consequences of PDA on mesenteric blood flow and splanchnic oxygenation, as well as the side effects of drugs used to treat PDA, are likely the main reasons for increased intestinal morbidities. Our review also highlighted the wide heterogeneity in neonatologists’ practice in feeding preterm infants with PDA, probably due to the lack of solid data on the safety or harm of enteral feeding in these infants. We also emphasized that the amount of enteral feeding during PDA treatment varies by a factor of ~10 in different neonatal units. Porta et al.1 claim that we limited ourselves to “concluding that initiation or maintenance of enteral nutrition can be recommended in infants with PDA.” The question of whether enteral feeding should be withheld or continued during treatment of hemodynamically significant PDA is still debated, as both strategies can potentially lead to unfavorable outcomes.3 In the absence of well-designed studies to assess the safety of maintaining enteral feeding, but given the data showing that mesenteric blood flow or splanchnic oxygenation is maintained in response to enteral feeding, and that the most common practice today is to maintain enteral feeding unchanged during treatment (rather than reducing enteral feeding, as has been the practice for decades), we clearly endorse the position of maintaining enteral feeding and indeed stated in the conclusions that “initiation or maintenance of enteral nutrition can be recommended.” We reiterate here that basic research and sufficiently conclusive studies are urgently needed to clarify this question.

The use of human milk, especially mother’s milk, is supported by all scientific societies. We have recently reaffirmed this through the position paper of the ESPGHAN Committee on Nutrition,4 to which many of us have contributed. This letter is an opportunity to emphasize that we strongly recommend breast milk as the first choice for feeding preterm infants. In addition, we emphasize the potential beneficial effects of administering buccal colostrum, while acknowledging that no clear clinical benefit has been demonstrated in high-income countries.4 We also emphasize that human milk contains large amounts of other factors that have an immunological or trophic effect. Finally, for very preterm infants, when not enough breast milk is available, fortified donor milk is recommended instead of preterm milk.4 These recommendations apply to all preterm infants and there is no reason to limit them to infants without PDA or without PDA treatment. Therefore, we agree with Porta et al.1 that breast milk should be the first choice for feeding infants with PDA. However, we believe that the studies cited in our review and highlighted by Porta et al.1 do not allow us to disentangle the role of breast milk feeding in PDA infants. Rather, they investigated the effect of minimal enteral nutrition compared to not feeding,5 the effect of a feeding protocol during PDA treatment6 and the tolerability of early enteral feeding during PDA treatment.7 These studies were, therefore, conducted primarily to test the tolerability of minimal and early feeding in the context of PDA and none investigated the effects of formula vs. human milk feeding in infants with PDA. However, it is true that they were conducted using human milk as the standard practice, as recommended. We agree that these studies have contributed to the knowledge about the use of human milk for safe feeding of preterm infants, but it should be noted that the majority of the infants in these studies were received a volume equivalent to minimal enteral feeding. Breast milk offer better antioxidant protection than infant formulas,8,9 but data are currently lacking on the kinetics of oxidative stress biomarkers and the antioxidant effects of breast milk in the context of PDA. Therefore, we cannot make safe recommendations for the management of enteral feeding in preterm infants treated for hemodynamically significant PDA with certainty. We take the opportunity here to emphasize that fortified breast milk is preferable in preterm infants4 but that further studies are needed to assess the tolerability of large volumes of fortified breast milk in the context of PDA.

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References

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Funding

This project has been funded by the non-profit organization ARFEN. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. Department of Neonatology, APHP, Necker-Enfants Malades Hospital, Paris, France

    Alexandre Lapillonne & Chiara Lembo

  2. EHU 7328 PACT, Paris Cite University, Paris, France

    Alexandre Lapillonne

  3. Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX, USA

    Alexandre Lapillonne

  4. Réanimation Néonatale et Pédiatrique, CHU La Réunion, Saint-Pierre, France

    Silvia Iacobelli

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  1. Alexandre Lapillonne
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A.L., C.L., and S.I. drafted the manuscript, reviewed, and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

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Correspondence to Alexandre Lapillonne.

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Lapillonne, A., Lembo, C. & Iacobelli, S. Breast milk feeding in premature infants with persistent ductus arteriosus. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03048-z

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