Background
Human milk (HM) is the most ideal source of nutrition for newborns, especially preterm infants, on account of its short-term benefits, such as reducing the risk of necrotizing enterocolitis (NEC), sepsis, chronic lung disease(CLD), and mortality, and its long-term benefits, such as improving long-term neurodevelopment [
1]. Apart from its medical advantages, HM feeding also has economic advantages [
2]. Lactation onset is often delayed after premature delivery, and as a result, preterm infants receive an insufficient amount of milk during the first few critical days of life [
3]. Donor human milk (DHM) and preterm formula are used as supplements when MOM is insufficient, and DHM is preferred over preterm formula as it is better in terms of nutritional composition and biological value [
4,
5].
Therefore, the World Health Organization and the American Society for Parenteral Nutrition have emphasized the use of HM in preterm infants in their guidelines for the nutritional management of preterm/low-birth-weight infants [
6]. Similarly, China issued “Feeding Recommendations for Preterm Infants and Low Birth Weight Infants” in 2009, according to which mother’s own milk (MOM) was recommended as the first choice for preterm infants [
7]. Following these guidelines, the breastfeeding rate in China’s NICUs increased from 23% in 2009 to 58.2% in 2018 [
8]. However, the breastfeeding rate is still far lower than that in other countries [
9]. Furthermore, the situation of implementation of “Feeding Recommendations for Preterm Infants and Low Birth Weight Infants” for each NICU was still unclear. Therefore, the purpose of this study was to examine and compare the status of HM feeding and enteral feeding strategies in China’s level 3 NICUs. This is the first national-level survey on this topic in China, so the data obtained would be useful in the establishment of national enteral feeding guidelines for preterm infants and quality improvement of cooperation at the national level.
Discussion
Nutrition is important to standardize among different NICUs, even in terms of long-term outcomes. For example, the prevention of extra-uterine growth retardation (EUGR) in preterm infants through nutritional strategies is of extreme importance, as the achievement of adequate growth has been associated with a better neurodevelopmental outcome through childhood [
10], although there is still no consensus regarding the best definition of EUGR to use to predict neurological outcome [
11].
This is the first comprehensive study to investigate human milk feeding and enteral feeding practices in NICUs from all districts in mainland China. As evident in the survey responses, we found significant variations but also similarities in the status of human milk feeding and enteral feeding strategies among the examined NICUs. In general, all the NICUs encouraged breastfeeding, and breastfeeding education was provided by nurses in the neonatal units. The content of breastfeeding education covered benefits of breastfeeding, collection,storage,and transport of breast milk,kangaroo care, how to keep lactation,feedback of breastfeeding. Breastfeeding information was provided via channels such as oral instruction, video, paper materials,bedside education,WeChat or SMS platform and others. During the recent COVID-19 pandemic, parental visitation practices were suspended at many NICUs in China but once the pandemic was brought under control, most NICUs restarted their previous parental visitation policies. At most NICUs, communication about breastfeeding with parents was implemented online or through face-to-face meetings at least once a week. Further, at the majority of the hospitals (58 NICUs, 96.7%), MOM was obtained during neonatal hospitalization.
The present findings showed significant variations between the NICUs with regard to the provision of family rooms and FICare, the use of DHM, and enteral feeding strategies.55 NICUs (91.7%) provided KC. Accordingly, previous studies have documented that most NICUs in China were aware of the benefits of KC [
12,
13]. Compared to the high rates of implementation of KC, family rooms were provided in only 20 NICUs (33.3%) and only 33 units (55.0%) routinely provided FICare. Family rooms are known to be beneficial for both infants and parents, as they improve weight gain, promote breastfeeding after NICU discharge, reduce parental stress and anxiety, as well as reduce the incidence of health-assistance related infections [
14]. Additionally, FICare in Chinese NICUs was found to be associated with reduced hospital length of stay, medical expenditures, and rates of adverse outcomes [
15]. Therefore, in the future, NICUs in China should promote FICare vigorously.
Since the first HMB was established in Guangzhou in 2003, 20 HMBs have been established in China so far. All these HMBs provide their services free of charge to both donors and recipients of DHM. However, the cost of running HMBs is quite high [
16] and is almost entirely borne by the local hospitals, as shown by our findings. This is also one of the reasons for the small number of HMBs in China. Therefore, it is necessary to find alternate sources of funds for HMBs in China. In China, both parents and medical workers’ attitude about DHM is positive [
17‐
19], but in our survey, only 13 units (21.7%) used DHM. The most common reason for not using DHM was the lack of a license. This highlights the need to improve the process of using DHM in China.In the 7 units that established an HMB but did not use DHM, the reason was because the banks were awaiting for their licensing.Therefore, they could only manage and use MOM in the HMB.
Our study highlights the diversity of recommended feeding practices in NICUs across China. While most of the units initiated MEN for infants with birth weight < 1500 g (48.3%), the criteria for initiating MEN varied considerably across the remaining units. The optimal duration of MEN is still under debate [
20,
21], and this was also reflected in the results of our study. With regard to feed volume, we found that most units (83.3%) increased enteral feeding intake by 10 to 20 ml/kg daily. A Cochrane review compared daily feed intake increments of 15 to 20 ml/kg versus 30 to 35 ml/kg and concluded that more rapid advancement did not increase the risk of NEC, mortality, or interruption of feeds [
22]. Further, previous studies reported that early fortification (< 40 ml/kg daily) was safe and well tolerated [
23]. In the present study, we found a significant variation in both the recommended timing of initiation and the recommended initial volume of HMF. Another international survey-based study also reported large variations in the timing of initiation and volume of HMF at initiation [
24]. Given these variations in enteral feeding strategies and the previous findings, national-level guidelines should recommend standardized enteral feeding and human milk fortification strategies for NICUs in China.
Routine assessment of gastric residual content was reported by 31 units (51.7%).A previous study indicated that the omission of gastric residual evaluation increased the delivery of enteral nutrition as well as improved weight gain and led to earlier hospital discharge [
25]. This suggests that the NICUs in China should probably change the previous practice.A previous study reported that feeding during pharmacological PDA closure in preterm neonates was not associated with delay to reach full feeds, NEC incidence, or gastric residuals; nonetheless, feeding management of this population should be carefully evaluated [
26]. Our study showed that 41 units (68.3%) did not make any changes in their enteral feeding regimen during drug treatment for PDA. Further, feeding during blood transfusions may increase the risk for mesenteric ischemia and the development of transfusion-related NEC in preterm infants [
27]. In the present study, 29 units (48.3%) instated stop feeding for 1 or 2 feeds during blood transfusion, but 15 units (25.0%) reported that did not introduce any changes and only closely monitored the situation.
There are some limitations to this study. As with other surveys, a responder bias could not be ruled out, and the responses may, potentially, not be representative of the practices of the unit. We also did not evaluate whether the variation in feeding practices are associated with infant growth and outcomes such as NEC.
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