tag:theconversation.com,2011:/uk/topics/premature-infant-6309/articlesPremature infant – The Conversation2024-02-08T13:38:26Ztag:theconversation.com,2011:article/2145432024-02-08T13:38:26Z2024-02-08T13:38:26ZBreastfeeding benefits mothers as much as babies, but public health messaging often only tells half of the story<figure><img src="https://images.theconversation.com/files/558172/original/file-20231107-19-cjfj8i.jpg?ixlib=rb-1.1.0&rect=23%2C23%2C7961%2C5303&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Breastfeeding lowers the risk of diabetes as well as breast and ovarian cancers for mothers.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/smiling-mom-holding-her-baby-boy-in-her-arms-while-royalty-free-image/1370476365?phrase=black+mothers+breastfeeding&adppopup=true">Goodboy Picture Company/E+ via Getty Images</a></span></figcaption></figure><p>Four babies are born <a href="https://www.theworldcounts.com/populations/world/births">every second in the world</a>, and there are only two options for their first food at birth: human milk or formula. </p>
<p>Global and U.S. health authorities agree, however, that human milk provides the optimal nutrition for infants. The World Health Organization and the American Academy of Pediatrics <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_2">recommend exclusive breastfeeding</a> for the <a href="https://doi.org/10.1542/peds.2022-057988">first six months of an infant’s life</a>. Following the introduction of solid foods, these organizations recommend continued breastfeeding up to two years and beyond. </p>
<p>Human milk can be given to infants directly through breastfeeding or by pumping or expressing human milk into a cup or bottle. The health benefits of breastfeeding and human milk for infants stem from its composition, which includes <a href="https://www.aap.org/en/patient-care/newborn-and-infant-nutrition/newborn-and-infant-breastfeeding/">vitamins, minerals and antibodies</a> that can prompt its composition to change over time to meet the growing infant’s needs. The dynamic nature of human milk leads to commonly known benefits, such as <a href="https://doi.org/10.1111/apa.13151">lower risks of ear</a> and <a href="https://doi.org/10.1111/apt.14291">gastrointestinal infections among infants</a> who are breastfed. </p>
<p>However, there are other benefits for infants that many people aren’t aware of, as well as for the breastfeeding mother and society.</p>
<p>We are women’s health scholars with combined professional expertise in <a href="https://sc.edu/study/colleges_schools/nursing/faculty-staff/riversj.php">maternal obstetrics nursing</a> and <a href="https://sc.edu/study/colleges_schools/nursing/faculty-staff/feldert.php">public health</a>. Together, we co-founded <a href="https://www.instagram.com/mochamamasmilk/">Mocha Mamas Milk</a>, a research and support initiative focused on improving <a href="https://doi.org/10.1177/01939459211045431">breastfeeding among Black families in South Carolina</a>, a <a href="https://www.cdc.gov/mmwr/volumes/66/wr/mm6627a3.htm">state where just 55.1% of Black infants are breastfed</a>, compared with 75.2% of white infants. </p>
<p>Human milk is personalized medicine that can benefit both the mother and infant. We are personally and professionally passionate about this because many people are not aware that some of these benefits can save lives and reduce persistent health disparities.</p>
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<figcaption><span class="caption">Breast milk provides benefits to the infant that no other food source can.</span></figcaption>
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<h2>Lesser-known benefits of breastfeeding for infants</h2>
<p>One significant benefit of breastfeeding not widely known by the public is its ability to lower the risk of <a href="https://www.childrenshospital.org/conditions/sudden-infant-death-syndrome-sids#">sudden infant death syndrome</a>, or SIDS. SIDS, sometimes referred to as “crib death,” is the unexplained death of a baby, usually under 1 year of age. </p>
<p>Some risk factors include stomach- or side-lying sleep, low birth weight, sleeping on a soft surface or overheating. A large analysis of studies found that infants who received any human milk for at least two months had nearly a <a href="https://doi.org/10.1542/peds.2017-1324">50% lower risk of SIDS</a>. </p>
<p>This reduction is notable for two reasons. First, the reduction in risk occurs about 60 days following birth, which is several months before the six-month exclusive breastfeeding guideline is met. Second, the protection from SIDS was the same for infants who were exclusively breastfed compared to infants who may have received formula in addition to any breastfeeding. </p>
<p>In addition, breastfeeding can <a href="https://doi.org/10.1016%2Fj.pcl.2012.09.008">significantly protect premature infants</a> – those <a href="https://www.who.int/news-room/fact-sheets/detail/preterm-birth">born before 37 weeks of pregnancy</a> – from developing a condition called <a href="https://www.ncbi.nlm.nih.gov/books/NBK513357/#">necrotizing enterocolitis</a>, an inflammation of the intestines that <a href="https://doi.org/10.3390/nu12051322">can be fatal</a>. While this condition is rare in full-term infants, it <a href="https://doi.org/10.1097%2FNNR.0000000000000483">occurs in 5% to 15% of preterm infants</a>.</p>
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<h2>Benefits for mom, too</h2>
<p>Breastfeeding also provides important benefits for the mother, such as reducing <a href="https://doi.org/10.1001/jama.294.20.2601">risks of diabetes</a> and <a href="https://doi.org/10.1016/s0140-6736(02)09454-0">breast</a> and <a href="https://doi.org/10.1001/jamaoncol.2020.0421">ovarian cancers</a>. Breastfeeding for any length of time compared to never is associated with a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4855244">10% decrease in hormone receptor-negative breast cancers</a>, which are more common in younger women. These cancers cannot be treated with hormonal therapy and <a href="https://www.cancer.org/cancer/types/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-hormone-receptor-status.html">often grow faster</a> than the more commonly diagnosed hormone receptor-positive breast cancers. </p>
<p>The reduction in risk from breastfeeding is even greater for Black women, who are more likely to be diagnosed with these hormone receptor-negative breast cancers and <a href="https://doi.org/10.1158/1055-9965.EPI-20-1784">have worse prognoses and fewer treatment options</a>. Any way of reducing the risk for Black women is critically important because, compared to white women, Black women are 40% more likely to die from breast cancer, <a href="https://www.cancer.org/research/acs-research-news/breast-cancer-death-rates-are-highest-for-black-women-again.html">yet 4% less likely to be diagnosed </a> with the disease.</p>
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<figcaption><span class="caption">Tisha Felder explains the vision behind Mocha Mamas Milk to help improve the way that Black mothers think about breastfeeding. Figures presented in the 2021 film were from the National Immunization Survey, 2011–2015.</span></figcaption>
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<p>There is also growing research suggesting the positive impact of breastfeeding on a mother’s mental health. One possible reason for this is that <a href="https://www.yourhormones.info/hormones/oxytocin/">oxytocin</a> – often <a href="https://www.health.harvard.edu/mind-and-mood/oxytocin-the-love-hormone">called the “love hormone” because of its association with bonding</a> – plays a <a href="https://doi.org/10.1016%2Fj.ijnss.2019.09.009">role in the maternal-infant bonding process</a>. </p>
<p>After delivery, the release of oxytocin causes human milk to flow – a process called the <a href="https://www.ncbi.nlm.nih.gov/books/NBK148970/#">letdown reflex</a> – and initiate breastfeeding. This release of milk can satisfy the new baby and leave the mom with “warm and fuzzy” feelings toward her baby. Research also suggests that breastfeeding can <a href="https://doi.org/10.1017/s0033291713001530">reduce the risk of depression </a>. A 2021 study also found that the longer a woman breastfed, <a href="https://doi.org/10.1111/phn.12969">the lower her risk for postpartum depression</a>. </p>
<h2>Closing racial gaps</h2>
<p>Despite the benefits of breastfeeding to both infants and mothers, few U.S. families are able to sustain breastfeeding over time. The Centers for Disease Control and Prevention 2022 Breastfeeding Report Card – the latest data that is currently available – shows that more than 80% of infants start out receiving human milk, yet just over a quarter of them <a href="https://www.cdc.gov/breastfeeding/pdf/2022-Breastfeeding-Report-Card-H.pdf">are exclusively breastfed through six months</a>.</p>
<p>Black infant-mother pairs not only have the lowest breastfeeding rates in South Carolina, but they also have the lowest rates nationally, compared to other U.S. racial and ethnic groups. More recent data from the National Vital Statistics System of U.S. infants born in 2020 and 2021, shows that <a href="https://www.cdc.gov/pcd/issues/2023/23_0199.htm">only 74.5% of Black infants were breastfed</a>, compared with non-Hispanic Asian infants (90.1%), non-Hispanic white infants (84.0%) and Hispanic infants (86.8%), based on analysis of birth records collected by the CDC. </p>
<p>Black infants are also more likely <a href="https://www.ncbi.nlm.nih.gov/books/NBK513376/">to die from SIDS</a> and to be born prematurely. So <a href="https://www.contemporarypediatrics.com/view/breastfeeding-least-2-months-provides-sids-protection">increasing breastfeeding among Black families</a> could lead to saving significantly more Black infant lives. </p>
<p>The Southeast U.S. is where the <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7021a1.htm?s_cid=mm7021a1_w">widest racial gaps in breastfeeding exist</a>. In addition, infants living in Southern states are <a href="https://doi.org/10.1038%2Fs41372-022-01535-x">less likely to achieve national goals for breastfeeding</a> at 6 or 12 months old compared to infants living in other regions of the country.</p>
<h2>Removing barriers to breastfeeding</h2>
<p>Reducing barriers is critical to closing racial and geographic gaps in breastfeeding and allowing U.S. mothers and their infants the opportunity to benefit from the life-saving qualities of human milk. Studies show that addressing work-related barriers by making investments in paid family leave, for example, could <a href="https://doi.org/10.1016/j.ehb.2023.101308">increase exclusive breastfeeding rates by 15%</a>. </p>
<p>The U.S. is one of the only countries in the world that <a href="https://www.worldpolicycenter.org/policies/is-paid-leave-available-for-both-parents-of-infants">does not provide national paid family leave</a>. </p>
<p>Workplaces that support breastfeeding breaks and provide safe and clean spaces for expressing and storing human milk are also <a href="https://www.unicef.org/sites/default/files/2019-07/UNICEF-policy-brief-family-friendly-policies-2019.pdf">important in promoting breastfeeding</a>. Given that U.S. women’s labor force participation rates are <a href="https://www.bls.gov/opub/ted/2023/labor-force-participation-rate-for-people-ages-25-to-54-in-may-2023-highest-since-january-2007.htm">at a record high</a>, the importance of reducing barriers in the workplace cannot be overstated.</p>
<p>The U.S. Agency for International Development estimates that every U.S. dollar invested in breastfeeding <a href="https://www.usaid.gov/global-health/resources/fact-sheets/breastfeeding#">yields $35 in economic returns</a>.</p>
<p>Societal investments in breastfeeding-friendly workplace policies will not only yield cost savings and extend breastfeeding rates, but they will shift the burden of breastfeeding from simply being an individual choice to being a public health priority.</p><img src="https://counter.theconversation.com/content/214543/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tisha Felder receives funding from the Patient Centered Research Outcomes Institute (PCORI) and National Institutes of Health (NIH).</span></em></p><p class="fine-print"><em><span>Joynelle Jackson receives funding from Patient Centered Research Outcomes Institute (PCORI). </span></em></p>Some states, especially in the Southeastern US, have large disparities in breastfeeding among racial groups, making clear the need to lower barriers for breastfeeding in the workplace and elsewhere.Tisha Felder, Associate Professor of Behavioral Sciences, University of South CarolinaJoynelle Jackson, Associate Professor of Nursing, University of South CarolinaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1640042021-08-18T13:33:12Z2021-08-18T13:33:12ZPremature babies are prone to impaired brain development, but nutrients may reduce the risk<figure><img src="https://images.theconversation.com/files/415310/original/file-20210809-21-1pj2e23.jpg?ixlib=rb-1.1.0&rect=813%2C507%2C5019%2C3375&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Premature babies are at risk of impaired brain development, but adjusting the nutrients in intravenous feeding solutions may help reduce that risk.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Extreme preterm birth is associated with impaired brain development: defective executive function, disruptive behaviours and psychiatric issues are more common among those born preterm than those born at term. This <a href="https://doi.org/10.1213/ANE.0000000000000705">risk is greater at lower gestational ages</a>. </p>
<p>The current <a href="https://doi.org/10.1016/j.bpobgyn.2018.04.003">global incidence of preterm birth</a> is 11 per cent. With advancements in care before and after birth, an increasing number of extreme preterm (below 28 weeks of gestational age) babies survive. However, this increasing survival does not come with a reduction in the impaired brain development associated with premature birth. </p>
<p>As a neuroscience and nutritional biochemistry researcher, my focus is nutrition, neonatal brain development and associated brain disorders. <a href="https://doi.org/10.1542/peds.2017-2169">Optimizing nutrition is a promising avenue</a>: our research suggests that creatine, an energy-providing nutrient, may help mitigate the adverse brain development of these preterm babies. </p>
<h2>Premature babies and nutrition</h2>
<p>Premature infants often have immature digestive systems that aren’t ready to absorb adequate nutrients. As a result, they often depend on nutrients delivered intravenously, bypassing the digestive system. This method of feeding is called <a href="https://doi.org/10.1016/B978-0-12-384947-2.00520-1">parenteral nutrition</a>. </p>
<p><a href="https://doi.org/10.3945/jn.109.105411">Creatine is a natural compound that is produced mainly in the kidneys and liver</a> from three amino acids, the fundamental building blocks of proteins: arginine, glycine and methionine. </p>
<p>Healthy term babies <a href="https://doi.org/10.1017/s000711451300010x">receive nine per cent of their creatine requirements from their mother’s milk</a>. These healthy babies produce the remaining requirement of creatine in their bodies.</p>
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<a href="https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Infant with an intravenous tube on its wrist." src="https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/416357/original/file-20210816-6755-1rvpzku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Premature infants often receive parenteral nutrition through an intravenous tube, like the one on this baby’s wrist.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Unlike human milk, newborn parenteral nutrition solutions do not routinely contain creatine, which leaves newborn premature babies dependent on their own production to meet their creatine requirement. </p>
<p>In healthy term babies, the majority of arginine, a building block of creatine, is produced in intestinal cells. However, feeding via the baby’s veins bypasses the intestine, so intravenous feeding interferes with normal arginine production. Because these premature babies cannot make enough arginine, they can’t make their required creatine. </p>
<h2>Creatine and neurodevelopment</h2>
<p>Creatine provides quick, short-term energy to skeletal muscles and heart. Muscle stores most of the body’s creatine (95 per cent), but the brain stores the second-highest amount. The brain is also the body’s second-highest energy user, after muscle. </p>
<p>The brain needs a continuous energy supply, and certain regions of our brains <a href="https://doi.org/10.1111/j.1460-9568.1994.tb00298.x">rely on creatine</a> for energy. In the adult brain, interruption of this energy supply impairs brain function and leads to the <a href="https://doi.org/10.3389/fnmol.2018.00216">progression of neurodegenerative diseases</a> such as Parkinson’s, Alzheimer’s or Huntington’s diseases. </p>
<p>Creatine is also an important modulator of brain neuron systems, making it crucial for babies’ brain development. Babies born with inherited creatine deficiency disorders are not able to produce creatine. These babies experience frequent seizures, significant impairment in cognition, language development, upper or lower limb movements and behaviour problems. These outcomes clearly suggest the <a href="https://www.ncbi.nlm.nih.gov/books/NBK3794/">importance of creatine for normal brain function and development</a>. </p>
<h2>Supplementing creatine in parenteral nutrition solutions</h2>
<p>Human studies provide limited information on the long-term metabolic consequences of the complete absence of creatine in parenteral nutrition solutions. An animal model such as piglets is ideal to study this situation. <a href="https://doi.org/10.1038/pr.2017.208">Our research</a> showed neonatal piglets receiving parenteral nutrition intravenously for two weeks (which represents nine months for a human baby) did not sustain optimal creatine accumulation. </p>
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<a href="https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bar graph comparing parenteral nutrition with and without creatine, and showing levels achieved with mothers' milk." src="https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=725&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=725&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=725&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=910&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=910&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414019/original/file-20210731-32831-4engh3.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=910&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Piglets receiving parenteral nutrition supplemented with creatine accumulated similar creatine levels as those seen in piglets fed mothers’ milk.</span>
<span class="attribution"><span class="source">(O. Chandani Dinesh)</span>, <span class="license">Author provided</span></span>
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<p>When creatine was added to the piglets’ parenteral feeding solution, piglets’ creatine accumulation improved.</p>
<p>To address the inadequate arginine production associated with complete intravenous feeding, some premature human infants are fed small amounts of parenteral nutrition solution into their stomachs via a tube. (This is a form of enteral nutrition — enteral means via the digestive tract and parenteral means outside the digestive tract — but similar feeding solutions are sometimes used for both ways of providing nutrition.) The remainder of the parenteral nutrition solution is delivered intravenously. However, because organ levels of creatine cannot be tested in human babies without damaging organs or risking health, human studies are of limited value in assessing this approach. </p>
<p><a href="https://doi.org/10.1093/jn/nxaa369">We fed the parenteral nutrition solution into the stomachs</a> of our piglets. These neonatal piglets were not able to meet normal levels of creatine accretion without pre-made creatine in their parenteral nutrition solutions, even when the parenteral nutrition solution was delivered to their stomachs. </p>
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<a href="https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bar graph showing different approaches to raising creatine levels in piglets" src="https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=757&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=757&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=757&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=951&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=951&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415490/original/file-20210810-23-1q9bgoc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=951&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Creatine accumulation with and without creatine added to parenteral feeding solution in piglets.</span>
<span class="attribution"><span class="source">(O. Chandani Dinesh)</span>, <span class="license">Author provided</span></span>
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<p>Piglets fed parenteral solution to their stomachs with no pre-made creatine had very low levels of creatine in their blood. However, piglets fed parenteral solution to their stomach with pre-made creatine or extra building blocks (arginine and methionine) improved their creatine levels. These levels were similar to the creatine levels of piglets fed mothers’ milk. </p>
<p>Our findings were supported by a <a href="https://doi.org/10.1007/s00431-021-03950-2">recent review on human babies that concluded that hospital preterm babies</a> need adjustments to nutritional components in order to achieve normal brain development.</p>
<p>Premature babies rely on parenteral and/or enteral nutrition support during their stay at hospital. However, creatine is not a routine component of these newborn parenteral/enteral nutrition solutions. </p>
<p>Supplementing these nutrition solutions with creatine to increase or regulate local energy stores and to regulate neuromodulation may help protect the developing brain. This approach represents a therapeutic tool for reducing the risks of developing abnormal neurological conditions in premature babies. Furthermore this approach may reduce the incidence of neurodegenerative diseases later in life of those born premature.</p><img src="https://counter.theconversation.com/content/164004/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Olupathage Chandani Dinesh does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Premature infants are at risk of impaired brain development. Adding creatine to the intravenous solution used to feed them may lower that risk.Olupathage Chandani Dinesh, Postdoctoral Researcher (Department of Psychology) & Course Instructor (Department of Biochemistry), Memorial University of NewfoundlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1483052020-11-11T16:04:35Z2020-11-11T16:04:35ZThe power of parents: 3 ways you can reduce your baby’s pain during medical procedures<figure><img src="https://images.theconversation.com/files/367544/original/file-20201104-15-khd3h7.jpg?ixlib=rb-1.1.0&rect=0%2C2057%2C3817%2C3035&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Parents can provide effective comfort and pain management for their infants.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>All babies undergo painful procedures, including injections of medications, <a href="https://www.aboutkidshealth.ca/article?contentid=1986&language=english">injections of vaccines</a> and <a href="http://www.iwk.nshealth.ca/women-and-newborns-health/services#/women-and-newborns-health/newborn-screening">heel sticks to collect blood for routine tests</a>. These procedures occur shortly after birth, during the first few days after birth and throughout a baby’s first year. </p>
<p>Thanks to over two decades of research, we know that there are highly effective strategies to help reduce babies’ pain when they have to undergo painful procedures: Breastfeeding and parent-infant skin-to-skin contact. </p>
<p>These strategies are safe, accessible, supported by science and recommended by organizations such as the <a href="https://doi.org/10.1542/peds.2006-2277">Canadian Paediatric Society</a> for minimizing pain in infants up to 12 months old. They are also parent-led — meaning that parents are the source of comfort for their newborns. </p>
<p>However, despite the pain-reducing benefit of using these strategies, they are not always used to manage infant pain. In fact, studies show that <a href="https://doi.org/10.1097/AJP.0b013e3181fe14cf">less than 50 per cent of newborns receive any form of pain relief</a> during routine medical procedures. In addition to causing unnecessary suffering, unmanaged pain in early life is associated with negative consequences, such as feeling <a href="https://doi.org/10.1016/j.pain.2009.02.012">increased pain during later procedures</a>.</p>
<p>As nurse scientists and experts in infant pain management, we want to highlight key tips and tricks to help you use these parent-led strategies (as well as a few additional ways to reduce your baby’s pain) during their next painful procedure. </p>
<h2>1. Breastfeeding</h2>
<p><a href="https://doi.org/10.1097/JPN.0000000000000253">Direct breastfeeding should be considered the preferred treatment</a> for full-term infants undergoing procedures, such as injections and blood draws, in the first year of life. Breastfeeding babies have lower pain responses, including less crying, less change in their heart rate and lower scores on tools developed to measure infant pain. Consider the following when using breastfeeding as a pain-management strategy for your infant: </p>
<figure class="align-right ">
<img alt="A mother breastfeeding her infant." src="https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/367497/original/file-20201104-15-1q9k48u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ideally, breastfeed your baby for at least two minutes before a painful procedure.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>• Work with your health-care provider to find a place where you can comfortably breastfeed your baby while they complete the procedure. As a breastfeeding parent, you are the expert in feeding your baby! There is no recommended breastfeeding positioning that is best for pain management — simply what works best for you and your baby to achieve an optimal latch so your baby is able to suck effectively. It is also important that the health-care provider is able to conduct the procedure. </p>
<p>• Ideally, you want to breastfeed your baby for a minimum of two minutes prior to the painful procedure. They should be latched to the breast and actively sucking and swallowing before the painful procedure. Don’t worry, breastfeeding during procedures is safe! There are no reports of baby’s choking while breastfeeding during procedures. </p>
<p>• Continue breastfeeding your baby throughout the painful procedure and for as long as your baby wants to breastfeed afterwards. </p>
<h2>2. Skin-to-skin contact</h2>
<p>Skin-to-skin contact, also sometimes called kangaroo care, involves holding a baby wearing only a diaper against your bare chest. Studies show that babies who are in <a href="https://doi.org/10.1002/14651858.CD008435.pub3">skin-to-skin contact during painful procedures experience less pain</a> during the painful procedure and they recover faster — meaning that if they do experience some pain or distress, it is for less time than if they were not in skin-to-skin contact. While breastfeeding is the best treatment for full-term babies, skin-to-skin contact is recommended for babies who are born prematurely or infants unable to breastfeed. </p>
<p>Using skin-to-skin contact for pain relief is simple and easy. Follow these steps:</p>
<p>• Work with your health-care provider to find a comfortable place to sit, where you can cuddle your baby for 10-15 minutes.</p>
<p>• Undress your baby so they are wearing only a diaper and hold them facing inward with their chest against your bare chest. You can use a blanket over you both for comfort, warmth and privacy. </p>
<p>• Hold your baby in skin-to-skin contact for at least 10 minutes before the painful procedure — up to 15 minutes is ideal. Your baby should be calm and relaxed before the procedure is done. </p>
<p>• Keep your baby in skin-to-skin contact during the procedure and afterwards to help them stay calm and relaxed. </p>
<figure class="align-center ">
<img alt="A mother with her infant on her chest, covered by a sheet." src="https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368405/original/file-20201109-17-q28915.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Skin-to-skin contact is recommended for babies who are born prematurely or infants unable to breastfeed.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Research shows that infants who are in <a href="http://doi.org/10.1001/archpediatrics.2011.130">skin-to-skin contact with mothers during painful procedures have lower pain responses</a>. Fathers, adoptive parents, co-parents and other family members such as grandparents can also provide skin-to-skin contact to help reduce pain during procedures.</p>
<h2>3. Additional ways to reduce your baby’s pain</h2>
<p>If you are not breastfeeding your baby or cuddling your baby in skin-to-skin contact, having them suck on a pacifier or your clean finger during the procedure can reduce their pain as well. You can also use a sweet tasting solution, such as a <a href="https://www.aboutkidshealth.ca/article?contentid=3628&language=english">small amount of sugar water on your baby’s tongue</a>, prior to the procedure or add a <a href="https://www.aboutkidshealth.ca/Article?contentid=3627&language=English">numbing cream</a> about an hour before the procedure to help numb the skin where a needle is to be injected. </p>
<p>Always remember to keep your baby <a href="https://theconversation.com/fear-of-needles-5-simple-ways-to-ease-vaccination-pain-for-your-child-and-yourself-134328">upright and close to you</a>. Babies become more distressed if they are lying flat during injections or procedures. </p>
<p>Many parents do not realize what an important role they can play in reducing their baby’s pain during routine needles and pricks. <a href="https://www.youtube.com/watch?v=3nqN9c3FWn8">Parents are the most important person to their baby</a> and science shows they can provide the ideal pain management and comfort during procedures. Parents also know their baby best, so are in the best position to advocate for the use of strategies that work for managing their baby’s pain. </p>
<p>Talking with your health-care provider about using these pain management strategies for your baby’s next painful procedure will help ensure that they are used. <a href="https://www.kidsinpain.ca/">Solutions for Kids in Pain</a> is also a great resource for up-to-date and evidence-based information on pain in children to help give you the knowledge you need to manage your baby’s pain well. </p>
<p><em>This story is part of a series produced by <a href="https://www.kidsinpain.ca">SKIP (Solutions for Kids in Pain)</a>, a national knowledge mobilization network whose mission is to improve children’s pain management by mobilizing evidence-based solutions through co-ordination and collaboration.</em></p><img src="https://counter.theconversation.com/content/148305/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Britney Benoit receives funding from the QEII Foundation and Nova Scotia Health. </span></em></p><p class="fine-print"><em><span>Marsha Campbell-Yeo receives funding from CIHR, IWK Health, Dalhousie University, ACOA, CCHCSP, NSHRF, and Nova Scotia COVID-19 Health Research Coalition. </span></em></p>There are effective ways to help reduce babies’ pain during blood draws and injections, but they are used in less than 50 per cent of newborns. Here’s how to ease your infant’s pain.Britney Benoit, Assistant Professor of Nursing and Health Sciences Research Chair, St. Francis Xavier UniversityMarsha Campbell-Yeo, Professor, School of Nursing, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1286072019-12-19T13:50:23Z2019-12-19T13:50:23ZGiving pregnant women antibiotics could harm the lungs of preemies, according to study in mice<figure><img src="https://images.theconversation.com/files/306434/original/file-20191211-95149-1gyrcya.jpg?ixlib=rb-1.1.0&rect=71%2C44%2C5919%2C3943&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Premature infants are at higher risk for lung diseases.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-premature-baby-being-held-fathers-580721992">Sarahbean/Shutterstock.com</a></span></figcaption></figure><p>Born after just 23 of the normal 40 weeks of pregnancy, the extremely preterm baby is small enough to fit in the palm of my hand and weighs just one and a quarter pounds. <a href="https://www.researchgate.net/profile/Kent_Willis">I am a neonatologist</a>, a physician that cares for these preterm babies in intensive care. Most of these preterm infants, particularly the smallest and sickest who require oxygen to help them breathe, are at high risk of developing lung inflammation and <a href="http://dx.doi.org/10.1016/S1084-2756(02)00193-8">scarring</a>. </p>
<p>This early damage will lead to a chronic lung disease called <a href="https://www.nhlbi.nih.gov/health-topics/bronchopulmonary-dysplasia">bronchopulmonary dysplasia</a>. Bronchopulmonary dysplasia can be one of the most severe and long-lasting complications of being a preterm baby. Many require oxygen for years and often have severe asthma-like episodes during which they are hospitalized for difficulty breathing. </p>
<p>Bronchopulmonary dysplasia affects many of the tiniest preterm babies that I care for and often leads to severe long-term disability. But it’s tricky to prevent preterm babies from developing bronchopulmonary dysplasia, and the situation is a bit of a Catch-22. That is because oxygen and breathing machines, which are essential for keeping these babies alive, also increase the likelihood of developing bronchopulmonary dysplasia. This dilemma has inspired my research into lung disease in preterm babies to discover new ways of preventing bronchopulmonary dysplasia.</p>
<h2>The gut-lung axis</h2>
<p>In newborns, research into <a href="http://dx.doi.org/10.1126/scitranslmed.aab2271">asthma</a> and <a href="http://dx.doi.org/10.1126/scitranslmed.aaf9412">pneumonia</a> has indicated that the microbial communities, known as the microbiome, that live inside the human gut can influence inflammation – the response of the body to pathogens or cellular damage – in their host. This may happen because of changes in the host immune system, which in turn may shape the course of lung diseases that result from <a href="http://dx.doi.org/10.1016/j.jaci.2014.06.027">inflammation</a>.</p>
<p>This recently discovered connection between the gut microbes and lung health or disease is called the <a href="https://doi.org/10.1513/AnnalsATS.201503-133AW">gut-lung axis</a>, and it may reveal new ways to treat lung diseases.</p>
<p>Over the last several years, neonatologists have done retrospective studies in which they looked back over several years of babies’ records to see if they could identify events that happened to babies who later developed bronchopulmonary dysplasia. These studies were designed to try to identify new exposures that might cause bronchopulmonary dysplasia. </p>
<p>One potential trigger for bronchopulmonary dysplasia was <a href="http://dx.doi.org/10.1016/j.jpeds.2014.09.041">antibiotics</a>. One thing that stood out to researchers, including myself, was a potential link between the mother being exposed to antibiotics and babies who developed <a href="http://dx.doi.org/10.1016/j.jaci.2014.06.027">bronchopulmonary dysplasia</a>. However, because a lot of babies and mothers are given antibiotics, this research wasn’t enough to prove that antibiotic exposure causes bronchopulmonary dysplasia.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=369&fit=crop&dpr=1 600w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=369&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=369&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=464&fit=crop&dpr=1 754w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=464&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/306454/original/file-20191211-95165-1y2x986.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=464&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A premature baby with neonatal infant pulse oximeter.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/premature-baby-legs-neonatal-infant-pulse-1073367044">Kristina Bessolova/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Maternal antibiotic exposure worsens bronchopulmonary dysplasia</h2>
<p>In my <a href="https://doi.org/10.1152/ajplung.00561.2018">latest study</a>, I used mice to test whether there was a causal link between the state of the gut-lung axis and how bronchopulmonary dysplasia develops. </p>
<p>I wanted to investigate how maternal exposure to antibiotics affects the lung development of offspring. I thought this research would not only lead to a better understanding of the gut-lung axis but also identify a new way to potentially prevent bronchopulmonary dysplasia. </p>
<p>My colleagues and I sorted pregnant mice into four groups and exposed the mothers to antibiotics at different points during gestation. </p>
<p>The first group of mother mice was exposed to antibiotics throughout their pregnancy and for the first two weeks of their pups’ life while they nursed. The second group was exposed just during pregnancy, but not after. Group three was exposed just while nursing. The fourth group wasn’t exposed at all. After the pups were born, we also exposed some to oxygen – just as we would do for a premature infant – which triggered bronchopulmonary dysplasia. </p>
<p>At the end of the experiment we looked at the lung structure of the baby mice. All the newborn mice that were exposed to oxygen developed bronchopulmonary dysplasia to some extent, but the mice whose mothers were exposed to antibiotics developed more severe disease. In fact, mice exposed to antibiotics at any stage were more deformed and had a more simplified structure than the animals that were never exposed to antibiotics. </p>
<p>A simplified lung structure, with giant, partially formed air sacs instead of tiny, well-shaped air sacs, is the hallmark of bronchopulmonary dysplasia. The more abnormal the air sac structure, the worse the bronchopulmonary dysplasia. These changes in lung structure are evidence that antibiotic exposure caused more severe bronchopulmonary dysplasia in these mice. </p>
<p>My colleagues and I were also surprised to find that antibiotics given to the mother also increased scarring in the lungs of their babies, abnormal blood vessel structure and more white blood cells in their lung tissue. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307531/original/file-20191217-58353-am76m.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Giving antibiotics during pregnancy causes more severe lung damage in the pups. This figure created with the aid of BioRender.</span>
<span class="attribution"><span class="source">Kent Willis</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Reshaping the gut-lung axis to prevent bronchopulmonary dysplasia</h2>
<p>Finally, to understand what the gut-lung axis had to do with bronchopulmonary dysplasia, we looked at the microbes in the guts of the baby mice during the first two weeks of life. My colleagues and I found that that giving antibiotics to their mothers likely prevented them from acquiring normal bacterial communities like those found in the guts of pups with no antibiotic exposure.</p>
<p>However, the way we administered the antibiotics did not directly affect the pups. Rather, the antibiotics altered the mother’s microbiome. The pups then inherited this altered set of bacteria from her. We also showed that molecules that allow gut microbes to signal to the lungs about the status of the microbial communities in the gut in newborn mice were reduced in newborn mice with abnormal microbial communities.</p>
<p>These experiments imply that the gut-lung axis may be involved in causing bronchopulmonary dysplasia. Because a lot of human mothers and preterm babies are given antibiotics, our research suggests that physicians should consider the risks to the fetus when giving a pregnant mother antibiotics and only do so when there are no other alternatives.</p>
<p>A lot more research needs to be done. First, we would like to test if we can change the microbial communities in newborn mice so that they are more resistant to getting bronchopulmonary dysplasia. Next I plan to investigate what part of the microbial communities alters the gut-lung axis. This may reveal a way to make human preterm babies resistant to developing bronchopulmonary dysplasia.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/128607/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kent Willis does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prenatal and postnatal antibiotic exposure combined with oxygen treatment led to lung inflammation and altered immunity in a study in mice.Kent Willis, Assistant Professor of Neonatology, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1231232019-09-13T11:37:30Z2019-09-13T11:37:30ZThe womb isn’t sterile – healthy babies are born with bacteria and fungi in their guts<figure><img src="https://images.theconversation.com/files/291348/original/file-20190906-175686-1xbfpqd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New research suggests that a newborn is exposed to bacteria and fungi in the womb.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/search/newborn+baby+and+hospital?search_source=base_landing_page">stockce/Shutterstock</a></span></figcaption></figure><p>For the last hundred years, scientists have believed that humans develop in a womb that remains sterile and completely isolated from the collection of bacteria, fungi and viruses that make us sick when we emerge into the outside world. </p>
<p>This theory was largely based on the fact that it was very difficult to grow live microorganisms collected from this part of the body in the lab – so scientists assumed there <a href="http://doi.org/10.1038/d41586-018-00664-8">weren’t any to find in the womb</a>.</p>
<p>However, there have been several important findings this year in this area of research. My team at the University of Tennessee and two other groups showed evidence that microorganisms are likely present inside the womb during normal development. Specifically, my team has discovered <a href="http://doi.org/10.1096/fj.201901436RR">fungi in the gut of newborns at birth</a>. Our work suggests that fungal DNA and possibly live fungi may cross the placenta from mother to fetus as a normal part of pregnancy.</p>
<p>In addition to being a research scientist, I am also a physician who cares for preterm infants in intensive care. My work with these tiny babies got me wondering about when human bodies begin their first partnership with the fungi that naturally live in our guts. Humans all have bacteria and microscopic fungi, like the yeasts that make bread rise or beer ferment, that live in and on our bodies as our partners. In my laboratory we are striving to understand when the bacteria and fungi that live in and on the baby begin to form this healthy relationship. </p>
<h2>Is the womb really sterile?</h2>
<p>The question of whether the womb is sterile began several years ago when a team in the maternal-fetal medicine laboratory of <a href="https://www.bcm.edu/people/view/kjersti-aagaard-m-d-ph-d/b153a614-ffed-11e2-be68-080027880ca6">Kjersti Aagaard</a> published <a href="https://directorsblog.nih.gov/2014/05/28/not-sterile-after-all-the-placentas-microbiome/">impressive research</a> revealing the <a href="http://doi.org/10.1126/scitranslmed.3008599">fetus could be exposed to bacteria</a> during pregnancy – effectively debunking the century old sterile womb hypothesis. </p>
<p>But in the past few months a heated debate has erupted as a group of <a href="https://doi.org/10.1111/1471-0528.15896">scientists suggested</a> that researchers, including Aagaard, had mistaken environmental bacteria contaminating their samples for bacteria living in the placenta. They claimed there were not any bacteria in the placenta and that the womb was sterile, as most scientists had originally believed.</p>
<p>Adding more support to her previous findings, <a href="https://doi.org/10.1016/j.ajog.2019.04.036">Aagaard published a study in August</a> that used a glowing dye to see bacteria in the placenta under a microscope. Another group also <a href="http://doi.org/10.1172/jci.insight.127806">published similar findings in humans and mice</a>. These studies and our own lend even more support to the new idea that the womb in not sterile. </p>
<p>But still no one knew when infants come in <a href="https://doi.org/10.1096/fj.201901436RR">contact with their first fungi</a>. Before I could understand if this process was going wrong in preterm babies and making them sick, I needed first to learn how it is supposed to happen in healthy babies. </p>
<h2>Detecting fungi</h2>
<p>To address that question, my colleagues and I collected samples of meconium from 37 mature-term babies, who were born after 37 weeks of pregnancy. We also collected samples from 34 preterm babies who were born before this stage. Meconium is the sticky tar-like material that babies pass within the first day or two of birth before they produce normal stools. </p>
<p>We then grew the microorganisms from the meconium using oxygenless chambers that mimic the airless environment of the gut. To categorize the microbes, we employed a new technique that uses DNA to identify the genus of microbes in a sample. </p>
<p>To our surprise we found fungal DNA in nearly all the babies – even in preterm infants born after only 23 instead of the normal 40 weeks of pregnancy.</p>
<p>We measured a gradual increase in the amount and kinds of fungi from each baby, depending on how long he or she had stayed inside the mother before birth. This increase over time supports the idea that colonization by fungi is a natural process and that fungi slowly and steadily accumulate in the fetus during pregnancy.</p>
<p>The differences in gut bacteria and fungi between preterm and term babies were very consistent and stark. It was possible to accurately predict whether the meconium sample came from a baby that was full-term or premature. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/292134/original/file-20190912-190016-8gciyn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Could the birth of babies prematurely be linked to the types of microbes and fungi in the womb?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-auscultate-premature-newborn-on-breathing-765326704?src=So92oqKALiQ1M6TDtevScg-1-28">mindfullness/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Fungi are in the normal newborn gut at birth</h2>
<p>However, one striking difference was that the fungi <em>Candida</em> was found in more preterm infants. The gut communities of several preterm infants in our study were dominated by <em>Candida</em> – some were almost entirely <em>Candida</em>. Unlike the majority of the fungi we studied, which are naturally present in the gut, this made us wonder if having too much of this fungi too early in life might be one of the many causes of preterm birth. Normally <em>Candida</em> lives harmlessly in our guts, but it can occasionally trigger yeast infections; if it invades the blood, it can make a preterm infant very sick.</p>
<p>Our team is exploring how fungi begin to colonize the newborn gut and what happens when this process goes awry. While there are many possibilities that remain to be explored, if the formation of early fungal communities does not proceed as usual it could lead to developing <a href="http://doi.org/10.1016/j.jaci.2017.08.041">asthma</a> and potentially <a href="http://doi.org/10.1038/srep14600">obesity</a>. In order for scientists to understand if this process is not happening correctly, we need to understand how the first fungal communities are supposed to form in newborns. Our study is a key first step down this path.</p><img src="https://counter.theconversation.com/content/123123/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kent Willis does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fungi live in everyone’s gut – but now a new study reveals that this colonization may begin before birth.Kent Willis, Assistant Professor of Neonatology, University of TennesseeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1152622019-04-16T14:01:23Z2019-04-16T14:01:23ZKenyan hospital opens human milk bank – a rarity in sub-Saharan Africa<figure><img src="https://images.theconversation.com/files/268687/original/file-20190410-2901-k2szwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Human milk banks collect, pasteurise, test, store, and distribute donated breastmilk.</span> <span class="attribution"><span class="source">NataBU/Shutterstock</span></span></figcaption></figure><p><em>Kenya’s first human milk bank has opened at Pumwani Maternity Hospital. Moina Spooner, from The Conversation Africa, spoke to the team spearheading APHRC’s research efforts in the establishment of Kenya’s first milk bank.</em></p>
<p><strong>How long has it taken to open? What were the biggest obstacles?</strong></p>
<p>The process of establishment of human milk banking in Kenya started in 2016. It was spearheaded by the NGO <a href="https://www.path.org/">PATH</a>, in partnership with APHRC and Kenya’s Ministry of Health, among other partners. It was rolled out in two phases. </p>
<p>During phase one <a href="http://aphrc.org/wp-content/uploads/2017/07/Human-Milk-Bank-Project-Briefing-Paper-APHRC.pdf">we assessed</a> people’s perceptions and acceptability of using donated human milk. We also looked at how feasible it would be to set a bank up. The results were encouraging. About 90% of participants were positive about it, 80% would donate their breast milk, and about 60% indicated that they would allow their children to be fed with donated human milk. </p>
<p>A committee was also set-up to provide oversight and guidance on human milk bank work in Kenya. They were sent to South Africa to learn more about the human milk banking process. Finally, local strategies were developed. </p>
<p>We are now in phase two of the project: the establishment of a pilot human milk bank in Pumwani Maternity Hospital. This includes the launch of a research project which examines its feasibility, effectiveness, acceptability and aims to estimate the cost of establishing an actual human milk bank in Kenya. </p>
<p>There have been challenges. Being a new concept, there have been some logistical challenges, for instance some of the equipment wasn’t locally available so it took longer to get it all done and installed. </p>
<p>There have also been concerns by some community members and health workers over the safety and quality of the donor human milk. </p>
<p>However, we’ve had support from the government which has been critical in addressing the logistical challenges. Advocacy and communication activities are also being rolled out to create awareness on human milk banking and address any concerns. </p>
<p><strong>What is a milk bank and how does it work?</strong></p>
<p>Human milk banks are facilities that systematically collect, pasteurise, test, store, and distribute donated breast milk. </p>
<p>An effective system has many <a href="https://path.azureedge.net/media/documents/MCHN_strengthen_hmb_frame_Jan2016.pdf">operational processes</a> to ensure it provides safe, high quality donor milk. They start with screening and recruiting donors who must be healthy mothers with surplus milk beyond the needs of their own child’s. Donors must undergo health checks including tests that screen for HIV, syphilis, and hepatitis B and C. Diseases could be passed to children through breastmilk.</p>
<p>Donors must then express milk in hygienic conditions, after which the milk is pasteurised. This involves heating the milk in a water bath at 62.5°c for 30 minutes followed by rapid cooling. </p>
<p>At the bank, the milk is frozen and stored at -20c. When needed, <a href="https://www.ncbi.nlm.nih.gov/pubmed/28103607">it’s thawed</a> to room temperature and issued to children who don’t have access to their own mothers’ milk. A prescription by a qualified health professional is needed for this. </p>
<p><strong>Why are they needed?</strong></p>
<p>Although breastfeeding is the most natural and best way to feed infants, many babies may lack access to their mother’s milk. This could’ve happened for many reasons – maybe the mother is sick, hasn’t got enough breast milk or is dead. </p>
<p>From our formative research, 44% of newborns in urban health facilities were separated from their mothers for varying periods of time. This ranged from less than an hour to more than 6 hours and even days after birth. Of these infants, only 14% were fed on mother’s own milk during separation. 36% of the newborns weren’t fed on anything during this period and an additional 23% were fed on formula or cow’s milk. </p>
<p>When breastfeeding is not an option, the World Health Organisation (WHO) <a href="https://www.who.int/elena/titles/feeding_vlbw_infants/en/">recommends</a> donated human milk as a lifesaving alternative. Particularly for babies that were born early, have low birth weight, are orphaned, malnourished or are severely ill. </p>
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Read more:
<a href="https://theconversation.com/why-kenya-needs-to-adopt-milk-banks-to-reduce-infant-deaths-80755">Why Kenya needs to adopt 'milk banks' to reduce infant deaths</a>
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<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/24752468">Evidence</a> paints a very strong picture in favour of donated human milk over infant formula. It’s <a href="https://www.ncbi.nlm.nih.gov/pubmed/24752468">more effective</a> in reducing the risk of disease and infections – <a href="http://www.ncbi.nlm.nih.gov/pubmed/22371471">like</a> inflammatory bowel disease, leukemia and respiratory tract infections – in newborn babies and is <a href="https://www.ncbi.nlm.nih.gov/pubmed/16556615">better tolerated</a> by babies that are born prematurely. </p>
<p>In the US and Brazil, the use of donated human milk was <a href="https://www.ncbi.nlm.nih.gov/pubmed/23241582">reported to reduce</a> the length of hospital stay for sick infants and save on the cost of health care. </p>
<p>Given the benefits of using donated human milk over infant formula, the WHO has called for the global scale-up of human milk banks. These are expected to increase access to safe donor human milk.</p>
<p><strong>Is this the first of many?</strong></p>
<p>Although WHO recommends that the milk banks be set up, Kenya is just the second, after South Africa, to establish a human milk bank in sub-Saharan Africa – even though it is a pilot. </p>
<p>We hope that human milk banking will be scaled up in Kenya and the rest of sub-Saharan Africa, using the evidence we generate from our research. </p>
<p><em>Milka Wanjohi, Taddese Zerfu, Esther Anono and Eva Kamande from the African Population and Health Research Center contributed to the writing of this article.</em></p><img src="https://counter.theconversation.com/content/115262/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Kimani-Murage works for the African Population and Health Research Center (APHRC). She is also a Fellow of the Wellcome Trust.
This work has been funded by DFID through the County Investment Challenges Fund.</span></em></p>The WHO has called for the global scale-up of human milk banks.Elizabeth Kimani-Murage, Research Scientist at the African Population and Health Research Center and Adjunct Assistant Professor, Brown UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909712018-02-06T14:07:04Z2018-02-06T14:07:04ZHow the placenta can shed light on HIV mothers and their babies<figure><img src="https://images.theconversation.com/files/204268/original/file-20180131-157477-1dhbsa2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Shutterstock</span> </figcaption></figure><p>In many parts of the world, the human placenta (the after birth) is discarded once a baby is born and considered waste. The focus is on the child and the new mother. </p>
<p>But scientists have started to wake up to the fact that the placenta has many important cells – and that they are able to gain valuable insights into a baby’s development by harnessing modern technologies to understand this transient organ.</p>
<p>A lot is <a href="https://www.ncbi.nlm.nih.gov/pubmed/15507270">known</a> about the placenta already. It starts to develop a few weeks after the egg has been fertilised and the foetus has started to grow. During the pregnancy, as the foetus grows, the placenta develops into a well-structured and highly specialised organ. </p>
<p>As an organ it plays numerous critical roles. It provides the foetus with oxygen, water and nutrients. It ensures all waste products including carbon dioxide are eliminated and it acts as the conduit for hormones like progesterone and estrogen between the mother and the foetus. </p>
<p>But what still remains a mystery is how it develops in HIV positive pregnant women. Several <a href="https://academic.oup.com/jid/article/206/11/1695/896109">studies</a> in sub-Saharan Africa have shown that when a mother-to-be has HIV there is a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940209/">significant likelihood</a> that she’ll face challenges. This includes stillbirth, a preterm delivery, delivering a baby that is <a href="https://academic.oup.com/humrep/article/27/6/1846/620226">small for its gestational age</a> or having a baby that dies within the first month. If the baby survives, it is likely to be very ill in its first year of life. </p>
<p>This has led scientists to start looking at the placenta to try and gain insight into the effect of HIV on the time of delivery and the health of the newborn babies. </p>
<p>But accessing the placenta isn’t easy. Firstly, it’s difficult to study it at various times of the pregnancy because the unborn child is fully reliant on it and any adjustment could negatively affect the baby. Getting access to the placenta is also a very costly and time consuming exercise. </p>
<p>And lastly early onset of HIV treatment for HIV positive pregnant women makes it hard to tell whether its the actual virus or the treatment that alters the placenta. </p>
<p>But as the only link between the mother and child it is the only avenue to understand the baby’s development.</p>
<p>All this points to why it’s important that novel approaches are used to investigate the link between HIV, treatment regimens, and adverse birth outcomes as well as the effect of HIV on quality of life after birth. </p>
<h2>Next steps</h2>
<p>There are several ways the placenta could be evaluated. One way of understanding the placenta’s role is to look at its cells. It’s home to millions of cells grouped into different cell types. Each cell type plays an important role during pregnancy. </p>
<p>One subset is the regulatory T cells. They regulate how certain systems in the human body function. In a <a href="http://www.jimmunol.org/content/jimmunol/180/8/5737.full.pdf">normal setting</a>, these cells should increase in number during pregnancy. <a href="http://www.jimmunol.org/content/jimmunol/194/4/1534.full.pdf">Research suggests</a> these cells actually migrate from the mothers blood, towards the placenta to ensure that the foetus remains protected. </p>
<p>Research into blood going into the placenta in HIV infected mothers shows that these cells <a href="http://www.bloodjournal.org/content/117/6/1861?sso-checked=true">don’t increase as steadily</a> as in healthy uninfected mothers. That means that the baby is less protected.</p>
<p>A second approach is to evaluate the actual structure and size of the placenta. The average weight of a placenta at 40 weeks is between 500 grams and 700 grams. But, in some cases, the placentas of HIV positive mothers are marginally smaller. The placentas from HIV infected mothers have also been found to have increased inflammation, and develop lesions that block blood supply and oxygen. This may be the underlying reason why the newborns are small for their gestational age. </p>
<h2>Challenges</h2>
<p>There are a number of limitations to studying the placenta. </p>
<p>One of the challenges in studying the placenta of HIV positive women is that most are <a href="http://www.who.int/hiv/PMTCT_update.pdf">now treated</a> as soon as their HIV status is known. This makes it very difficult to tease out whether complications are being caused by the HIV virus or the treatment regimen the mother is taking. </p>
<p>Secondly, research is limited because of the complexity and expense involved in carrying out investigations into placentas </p>
<p>Thirdly, because the unborn child relies on the placenta, it’s difficult to study it without compromising the safety of the baby. This means that placentas are usually evaluated during early pregnancy (first trimester), after an elective abortion or miscarriage or late pregnancy (third trimester), when the baby is born. They are seldom studied during the second trimester. </p>
<p>Despite these limitations, the placenta is an organ that can tell a very interesting story. By investigating the placentas of both HIV infected and uninfected mothers, scientists may be able to get a sneak peek into life inside the womb.</p><img src="https://counter.theconversation.com/content/90971/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nadia Chanzu-Ikumi is an AXA Research Fund fellow.</span></em></p>The placenta could hold the answers to why HIV positive women report higher rates of premature deliveries.Nadia Chanzu-Ikumi, AXA Research Fund-Post doctoral research fellow, Division of Immunology, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/693512017-01-19T19:07:22Z2017-01-19T19:07:22ZBreast milk banking continues an ancient human tradition and can save lives<figure><img src="https://images.theconversation.com/files/148787/original/image-20161206-25738-1aab226.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Screening and sterilisation processes mean human breast milk can be safely collected and frozen for use at a later time. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/525212020?src=_xixqQTZWEfP4f4UJXemyA-1-3&id=525212020&size=huge_jpg">www.shutterstock.com </a></span></figcaption></figure><p>Around 2000 BC <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684040/#__sec1title">breastfeeding</a> was considered a religious obligation. </p>
<p>Now we understand why breast milk is the ideal food for babies, with evidence showing it <a href="http://www.who.int/maternal_child_adolescent/topics/newborn/nutrition/breastfeeding/en">provides substantial benefits</a> to health even beyond the period of breastfeeding.</p>
<p>The <a href="http://www.nhmrc.gov.au/guidelines/publications/n55">Australian Dietary Guidelines</a> recommend exclusive breastfeeding for around six months, followed by introduction of solid foods and continued breastfeeding. In <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/6664B939E49FD9C1CA257B39000F2E4B">Australia</a>, over 90% of infants start breastfeeding, and 39% are exclusively breastfed at four months of age. </p>
<p>Although the majority of mothers can breastfeed, some are unable or choose not to. Infant formula is a readily available option. But as the nutritional and developmental value of breast milk becomes better known, more people are trying to source breast milk from another mother. </p>
<p>Breast milk banking provides a safe source of human breast milk in some states in Australia, but greater accessibility is highly desirable. </p>
<h2>What’s so good about human breast milk?</h2>
<p>The nutritional value of human breast milk is uniquely matched to the needs of human babies. <a href="http://www.who.int/nutrition/publications/infantfeeding/9789241597494/en/">Nutrients</a> such as iron and zinc are provided in a form that is easily absorbed by baby’s immature digestive system and are highly bioavailable; that is, they are in a form that is usable by the body. This ensures nothing goes to waste, and the demands on the mother’s body are minimal. </p>
<p>Specific kinds of fats known as <a href="http://www.who.int/nutrition/publications/infantfeeding/9789241597494/en/">long-chain fatty acids in breast milk</a> are absorbed by the infant, and incorporated into brain and eye tissues.</p>
<p>Breast milk also contains many other valuable <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586783/">bioactive components</a> such as oligosaccharides, immunoglobulins and a molecule called epidermal growth factor. </p>
<p>Oligosaccharides are carbohydrates that are resistant to digestion, remaining relatively intact as they transit through the gut. An example is “bifidus factor”, which acts as a prebiotic (food for bacteria) to promote the growth of the healthy gut bacteria <em>Lactobacillus bifida</em>. Other oligosaccharides stop disease-causing bacteria from attaching to the surface of the gut and urinary tract. </p>
<p>Immunoglobulins are antibodies that help provide immunity, and coat the lining of the gut to prevent attachment of disease-causing bacteria. </p>
<p>Epidermal growth factor stimulates growth and maturity of the infant gut. </p>
<h2>What methods have women used to share milk over history?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684040/#__sec1title">Wet nursing</a> is a human tradition that has existed for at least 4000 years. It was the only alternative feeding available for babies before the introduction of bottles and formula. Anecdotally, this is still practised in Australia, with sisters or friends with similar aged babies sharing breast feeding. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=871&fit=crop&dpr=1 600w, https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=871&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=871&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1094&fit=crop&dpr=1 754w, https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1094&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/148789/original/image-20161206-25721-1jc7vsa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1094&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A wet nurse breast feeding the Duke of Burgundy, grandson of Louis XIV.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:A_wet_nurse_breast_feeding_the_Duke_of_Burgundy,_grandson_of_Wellcome_L0007082.jpg">Wellcome Images via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>An increasing trend is <a href="http://www.smh.com.au/national/online-communities-revive-wetnurse-tradition-20130203-2dsj4.html">informal milk sharing</a>, where mothers seeking breast milk post a request on a dedicated social media page. Examples include <a href="http://hm4hb.net/">Human Milk 4 Human Babies</a> (HM4HB, which has about 4000 Australian members) and <a href="http://www.eatsonfeets.org/">Eats on Feets</a>. </p>
<p>Health professionals warn of the small, but real, potential risks of transmission of diseases such as HIV and Hepatitis C through unscreened breast milk. Some donors provide lifestyle information and antenatal blood screening results to recipients, and these are usually private arrangements between individuals. </p>
<p>Women need to be fully informed about the potential risks of using unscreened milk, and balance these with the decision to use formula. Risks associated with formula include a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/">higher incidence</a> of ear infection, gastroenteritis and respiratory infections in infants, and an increased incidence of diabetes, obesity, leukemia, allergy and asthma in later life.</p>
<p>In circumstances where people pay for breast milk, extra caution must be exercised, as there have been <a href="http://www.nature.com/jp/journal/v36/n5/full/jp2015207a.html">reports</a> of dilution of breast milk with water or cow’s milk.</p>
<h2>What is a human milk bank, and where are they in Australia?</h2>
<p>A human milk bank collects, stores, processes and dispenses donated human milk.</p>
<p>Milk banking was quite common until the 1980s, when the AIDS epidemic sparked concerns about <a href="http://www.who.int/maternal_child_adolescent/documents/9789241599535/en/">viral transmission through milk</a>. There is now a <a href="http://www.health.gov.au/breastfeeding">re-emergence of milk banking in Australia</a>, with five milk banks currently operating;</p>
<ul>
<li><a href="http://www.kemh.health.wa.gov.au/services/PREM_Bank/">PREM Milk Bank, Perth</a></li>
<li><a href="http://www.slhd.nsw.gov.au/rpa/neonatal/breastfeeding.html">Royal Prince Alfred Hospital, Sydney</a></li>
<li><a href="http://www.mercyhealthbreastmilkbank.com.au/">Mercy Health Breastmilk Bank, Melbourne</a></li>
<li><a href="http://www.rbwhfoundation.com.au/index.php?option=com_content&view=article&id=224&Itemid=242">Royal Brisbane and Women’s Hospital Milk Bank, Brisbane</a></li>
<li><a href="http://www.mothersmilkbank.com.au/">Mothers Milk Bank Pty Ltd, Gold Coast</a></li>
</ul>
<h2>Who donates breast milk to banks, and how it is processed?</h2>
<p>Donors of human milk are often mothers of a premature infant, women who have milk surplus to their needs, or mothers in the community.</p>
<p>Donors undergo rigorous screening, similar to blood donors. Their blood is collected and tested for diseases that could be transmitted through the milk, such as <a href="https://www.nice.org.uk/guidance/cg93/chapter/1-guidance#serological-testing">HIV, hepatitis B and C and syphilis</a>. Lifestyle questions related to drug and alcohol use are also used to identify risk of diseases. </p>
<p>Milk is expressed in the donor’s home, or in the neonatal unit (in the case of mothers of a premature infant) under hygienic conditions. It is then frozen for transport to the milk bank. Milk is then thawed, tested for bacterial count and pasteurised, usually using the <a href="https://www.hmbana.org/milk-processing">Holder method</a>, where the milk is heated to 62.5ºC for 30 minutes and then rapidly cooled. The milk is then re-tested for bacterial count, and frozen for dispensing. The combination of freezing and pasteurisation kills harmful viruses and bacteria.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/151224/original/image-20161221-3380-505dcx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sterile collection of human milk with a breast pump.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/476196007?src=_A93MSKP-e9iJNhsCgImwA-2-59&id=476196007&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Who can access banked milk in Australia?</h2>
<p>Of the five milk banks currently operating in Australia, only the <a href="http://www.mothersmilkbank.com.au/">Mothers Milk Bank</a> supplies milk to babies in the community. All other milk banks supply milk exclusively to premature and sick hospitalised infants. </p>
<p>Australian milk banks do not pay their donors, nor can the milk be bought. The cost of milk banks associated with neonatal units is absorbed within the health system. Community milk banks may ask for a donation. </p>
<p>The most recent <a href="https://npesu.unsw.edu.au/sites/default/files/npesu/data_collection/Report%20of%20the%20Australian%20and%20New%20Zealand%20Neonatal%20Network%202013.pdf">statistics</a> report there were 7,887 babies who required care in neonatal intensive care units in 2013. Representing 2.6% of all live births, these highly vulnerable infants stand to benefit the most from access to safe human breast milk. </p>
<p>Breast milk protects high risk infants against life threatening conditions such as neonatal sepsis (a dangerous, multi-system infection) and necrotising enterocolitis (a severe disease of the intestine). It has been <a href="http://www.health.gov.au/breastfeeding">estimated</a> using donor human milk will provide cost savings of $13 million per year to the Australian health care system by reducing the number of necrotising enterocolitis cases alone. </p>
<h2>What happens in states without milk banks?</h2>
<p>In Australia, 18 out of 24 neonatal intensive care units do not currently have access to pasteurised donor human milk. As a result, approximately three out of four babies with a high risk of developing necrotising enterocolitis or other neonatal complications do not have access to pasteurised donor human milk. </p>
<p>Although there are significant cost savings linked with preventing necrotising enterocolitis in premature infants on a national basis, the expense of establishing and running a milk bank is often prohibitive for small neonatal intensive care units with relatively low numbers of high risk premature babies. </p>
<p>Recently the <a href="http://www.donateblood.com.au/">Australian Red Cross Blood Service</a> has been considering establishing a national human milk bank, in line with its blood bank service. This would be a welcome adjunct to neonatal units and an important health initiative to improve health outcomes for these vulnerable infants. While this is still in the planning phase, we look forward to hearing more about this possibility soon.</p><img src="https://counter.theconversation.com/content/69351/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacqueline Miller is affiliated with the Red Cross advisory committee on human milk banking. </span></em></p><p class="fine-print"><em><span>Carmel Collins does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Banked breast milk is a safe source of shared human milk, and can be a life-saver for very premature babies.Jacqueline Miller, Senior Lecturer and SAHMRI Fellow, Flinders UniversityCarmel Collins, Senior Research Fellow and Head of Neonatal Nutrition Research Unit SAHMRI, South Australian Health & Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/675342016-10-31T18:51:11Z2016-10-31T18:51:11ZThe number of premature baby deaths is still too high. What can be done about it<figure><img src="https://images.theconversation.com/files/143904/original/image-20161031-15793-wnxv7q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A mother holds the foot of her premature baby. Prematurity is the most common cause of neonatal death globally. </span> <span class="attribution"><span class="source">UNICEF Ethiopia/2012/Pudlowski</span></span></figcaption></figure><p>In 2015 just under 6 million children under the age of five died across the globe. Of these, about 2.6 million died within the first month of being born. And more than 60% of these deaths took place in Africa and South Asia. Just over a third of these babies died as a result of complications because they were born premature. </p>
<p>Prematurity is the most common cause of neonatal deaths globally. Babies are considered premature if they are born before the mother reaches 37 weeks of pregnancy.</p>
<p>In developed countries, the main causes of preterm deaths are well known and studied. Some babies develop infections, others have breathing problems such as birth asphyxia or lung immaturity. They also have feeding problems or experience metabolic and electrolyte disturbances and congenital malformations. </p>
<p>But in low resource countries, the causes of preterm deaths is much less understood. Anecdotal evidence from experts and clinicians in neonatal intensive care units is that infections such as neonatal sepsis and asphyxia are common. But there is no data to back this up.</p>
<p>It is therefore critical to identify the most “treatable and preventable” causes of death in low resource settings. These findings would help inform the tools and interventions that must be developed and included in national programmes to reduce neonatal mortality in the developing world.</p>
<h2>Approaches that work</h2>
<p>Reducing the high rates of children under the age of five who die has been a global health priority since the early 1990s. At the time diarrhoea, pneumonia and malaria were the three leading killers of children under the age of five. </p>
<p>To tackle these several interventions were rolled out and since deaths of children under five has <a href="http://www.who.int/mediacentre/factsheets/fs178/en/">more than halved</a>. The interventions were simple: oral rehydration solutions and zinc for diarrhoea, a pneumococcal vaccine and antibiotics for pneumonia and antimalarial medicines and long-lasting insecticide treated nets for malaria. </p>
<p>But these reductions has meant that the proportion of deaths in the neonatal age group has increased. Just under half of all the <a href="http://www.who.int/mediacentre/factsheets/fs178/en/">under-five deaths</a> are due to neonatal mortality. </p>
<p>The thinking behind these interventions is based on the principles of precision medicine where the right solution is delivered to the right population at the right time. </p>
<p>The same approach can be used to deal with neonatal mortality. And these interventions can then be deployed based on the number and type of preterm birth risk factors in particular women. </p>
<h2>Risk factors</h2>
<p>There are four groups of factors that increase the likelihood of a woman having a preterm baby:</p>
<ul>
<li><p>Age: women who fall pregnant under the age of 20 when their bodies are physiologically unable to handle a baby or over the age of 35 when their bodies’ fertility functions start to decline are at risk of having a preterm baby.</p></li>
<li><p>Illness: women who develop diabetes during pregnancy or suffer from chronic illnesses such as hypertension, asthma or heart disease have a higher risk of delivering a preterm baby. In addition, women with tuberculosis, HIV/AIDS, persistent malaria, urinary tract infections and vaginal infections are also at risk.</p></li>
<li><p>Bad habits: smoking and alcohol drinking also contribute. </p></li>
<li><p>Socio-economic conditions: being single, having a low income and low levels of education also have an effect on a baby being born prematurely. This is mainly due to them having a lack of proper nutrition or being overworked.</p></li>
</ul>
<h2>Old and new interventions</h2>
<p>For these risks to be dealt with, health authorities make the best use of existing tools. But in addition to this, they must remain receptive to new approaches. </p>
<p>There are several existing interventions that could reduce preterm deliveries and prevent poor pregnancy outcomes. Some are based on improving the access to preconception packages while others include enhanced care packages for women at higher risk of preterm birth. Women with hypertensive disease, for example, could be identified and treated. </p>
<p>Similarly, teenage girls could be given family planning lessons and all women receive regular antenatal care during pregnancy. Those with infections such as tuberculosis, HIV, syphilis, and urinary tract infections could be treated promptly. </p>
<p>But there are also new interventions that should be explored. For a pregnant young woman working long hours in a remote agricultural area, the intervention package could include prepaid transport to a facility for delivery, decreased working hours as pregnancy progresses as well as nutritional supplements. </p>
<p>For an urban woman with a sedentary desk job in an area where there is a high prevalence of sexually transmitted infections, the intervention package might focus on treating the infection and recommendations for gentle exercise. But in this case transport would not be a priority.</p>
<h2>Defining concrete interventions</h2>
<p>Preterm mortality is a major contributor to overall child mortality.</p>
<p>The challenge is that there is a lack of research to define and prioritise the specific causes of mortality of preterm infants. There is also no research defining concrete interventions that can be scaled up. </p>
<p>The lens of precision thinking can help with this challenge as it can help develop a more focused and targeted intervention package that can be implemented.</p><img src="https://counter.theconversation.com/content/67534/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lulu Mussa Muhe receives funding from Bill and Melinda Gates Foundation. </span></em></p>In developed countries, the main causes of preterm deaths are well known and studied.But in low resource countries, the causes are much less understood.Lulu Mussa Muhe, Professor of Paediatrics, Addis Ababa UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/469922015-09-03T14:05:42Z2015-09-03T14:05:42ZPremature birth linked with lower wealth: how education could help bridge the gap<figure><img src="https://images.theconversation.com/files/93759/original/image-20150903-8830-2yeiks.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Not too soon. </span> <span class="attribution"><span class="source">herjua/www.shutterstock.com</span></span></figcaption></figure><p>Normal pregnancy is intended to last 40 weeks. However, <a href="http://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf">every year around the world 11%</a> of births, or 15m children, are preterm – before 37 weeks gestation. Being born too soon is associated with <a href="http://fn.bmj.com/content/early/2010/05/18/adc.2009.161117">increased costs of care</a> in infancy and childhood. But recently, there has been growing concern that premature birth may throw a long shadow over a child’s life chances as they grow up. </p>
<p>Large studies have found that being born preterm is related to having less wealth – including research that has shown them as more likely to earn less or receive more <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0706475">social benefits in adulthood</a>. This may be due to <a href="http://cercor.oxfordjournals.org/content/early/2014/06/13/cercor.bhu133.abstract">long lasting alterations</a> in brain development that affect learning, academic achievement and by extension, a person’s ability to earn. Others <a href="http://fn.bmj.com/content/92/1/F11">have suggested</a> that preterm birth is related to social inequality because mothers who are socio-economically deprived are more likely to give birth preterm. </p>
<p>In <a href="http://pss.sagepub.com/content/early/2015/08/28/0956797615596230.abstract">recent research</a> I investigated the impact of being born preterm on a person’s wealth through two large longitudinal studies: the <a href="http://www.cls.ioe.ac.uk/page.aspx?&sitesectionid=724">National Child Development Study</a> (NCDS), started in 1958 and the <a href="http://www.cls.ioe.ac.uk/page.aspx?sitesectionid=795sitesectiontitle=Welcome+to+the+1970+British+Cohort+Study+%28BCS70%29">British Cohort Study</a> (BCS) which began in 1970. Both of the studies recruited all children born in a single week in England, Scotland and Wales, and followed them from birth through to adulthood. My colleagues and I assessed the participants’ wealth at age 42, using a combination of their family income and social class, housing and employment status, and their own perceptions of their financial situation. Most of those people in the study who were premature had been born after 32 weeks, and the average was around 35 weeks. </p>
<h2>Different trajectories</h2>
<p>The results were consistent in both of the two cohorts: people who had been born prematurely tended to be less well-off at age 42 and have lower educational qualifications in adulthood than those who had been born full-term. By looking at the NCDS study, we found that people born preterm were more likely to be manual workers, to be unemployed and to report financial difficulties than those born full-term. They were also more likely to have below average family income and were less likely to own a house.</p>
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<p>The effects we saw on wealth were not as a direct result of being born preterm, but also depended on a person having lower mathematics and reading achievement and lower intelligence in primary school compared with their full-term peers. This means the fact that prematurely born children had on average lower academic abilities, meant that they were more likely to have lower educational qualifications and subsequently lower wealth in adulthood. And these indirect effects continued despite controlling for the effects of socio-economic status at birth. </p>
<p>Mathematics achievement in primary school was, however, directly associated with wealth in adulthood – whether or not a person had a high level of education qualification.</p>
<h2>Where to intervene</h2>
<p>These new findings suggest that premature birth does not inevitably lead to poor wealth but that being born preterm sets children on a different trajectory. You can think of this trajectory in terms of <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8624.2012.01849.x/abstract">“developmental cascades”</a> that may be altered at certain junctions. Some of these junctions are the transition into primary school and then navigation through to successful educational qualifications. </p>
<p>Educational interventions that address the special needs of preterm children and in particular their progress in <a href="http://www.nature.com/pr/journal/v77/n2/abs/pr2014184a.html">mathematics</a> may provide an avenue to alter the long-term effects on individuals’ and nations’ wealth. Improving support for preterm children’s education will require better understanding of their specific problems and needs by teachers and parents. </p>
<p>However, <a href="http://onlinelibrary.wiley.com/doi/10.1111/dmcn.12683/abstract">recent research has shown</a> that teachers have most likely not received any training about the specific difficulties in mathematics, learning and attention that preterm children more often face. Most teachers would be open to learning more about the special needs of prematurely born children and how to support their education – but this is currently not provided in their training or in school. </p>
<p>Such support may include <a href="http://www.ncbi.nlm.nih.gov/pubmed/22608065">more individualised mathematics teaching</a>, interventions to improve attention, <a href="http://www.sciencedirect.com/science/article/pii/S0022347614000973">offering teaching material in smaller chunks</a>, and interventions aimed <a href="http://wrap.warwick.ac.uk/71505/">at improving working memory</a>.</p>
<h2>Giving parents support</h2>
<p>Parents also have an important role in supporting the education of children who are born preterm. Mothers of pre-term children are, on average, as attuned or sensitive in <a href="http://pediatrics.aappublications.org/content/early/2015/05/26/peds.2014-3570.abstract">their parenting</a> as mothers of full-term children. However, preterm children are <a href="http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12331/abstract">more vulnerable</a> to poor or average parenting. They are often compared to “orchids” who need the right conditions to grow while healthy full-term children are compared to “dandelions” who may grow well in all but the most adverse conditions. </p>
<p>So interventions that help parents of school-age children who were born prematurely to meet their special needs and vulnerabilities may be another avenue to <a href="http://www.sciencedirect.com/science/article/pii/S1054139X13003479">improve</a> these children’s academic success.</p>
<p>Preterm birth is frequent and <a href="http://www.ncbi.nlm.nih.gov/pubmed/22682464">rates are increasing</a>. To improve the wealth and life chances of individuals born preterm we need to bridge the current divide from intensive medical care in infancy and early childhood to more appropriate and adaptive educational provisions for preterm children and their parents.</p><img src="https://counter.theconversation.com/content/46992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dieter Wolke receives funding from Nuffield Foundation, ESRC, EU, BMBF, MRC</span></em></p>People who were born preterm earn less and are more likely to be unemployed, research shows.Dieter Wolke, Professor of Psychology, University of WarwickLicensed as Creative Commons – attribution, no derivatives.