1. In a small randomized controlled trial, the median velocity of weight gain was significantly higher at 30 days post-operatively in infants with single ventricle physiology receiving an exclusive human milk diet compared to a control group receiving a mixed human and cow’s milk diet.
2. The rate of necrotizing enterocolitis was significantly higher in the control group (15.4%) than in the exclusive human milk group (3.6%).
Evidence Rating Level: 1 (Excellent)
Study Rundown: Ensuring adequate neonatal nutrition and weight gain is particularly challenging in infants with serious congenital morbidities, including cyanotic congenital heart disease. This study aimed to assess the effect of a postoperative exclusive human breast milk diet compared to a mixed breast milk and cow’s milk diet for infants undergoing cardiac surgery for single ventricle physiology, including hypoplastic left heart syndrome. Breast milk was fortified earlier (once the infant’s intake reached 60 mL/kg/day) and to 30 calories per ounce, whereas in the formula group, fortification was initiated when infants’ intake reached 100 mL/kg/day to a goal of 26 calories per ounce or higher if indicated based on weight gain. Among 107 randomized neonates, those receiving human milk exclusively had a significantly higher median velocity of weight gain at 30 days post-operatively than those receiving a mixed diet. The prevalence of necrotizing enterocolitis was 3.6% in the exclusive human milk group compared to 15.4% in the control group. There was no significant difference between groups in the rate of linear growth or head circumference growth, other complications such as sepsis, length of hospitalization, or in-hospital mortality. Previously, the benefit of fortified human milk’s high caloric density compared to the risks of increased fluid volume in the cardiac surgical setting had been unclear. This randomized trial indicates that exclusive fortified human milk feeding is associated with both a growth benefit and decreased risk of necrotizing enterocolitis, providing a model for future post-operative feeding practice.
In-Depth [randomized controlled trial]: Newborns with single ventricle physiology delivered at term at 10 centers and expected to receive cardiac surgery within 30 days of birth were included; the median age at operation was five days. Infants with other major anomalies including chromosomal or metabolic disorders as well as infants requiring cardiopulmonary resuscitation or extracorporeal membrane oxygenation before surgery were excluded. Both groups were fed with human milk preoperatively. Randomization in permuted blocks at a 1:1 ratio by study site was completed preoperatively. Dietary intervention was begun postoperatively and continued for 30 days or until discharge. In the primary intention-to-treat analysis, the median weight gain velocity at 30 days was 25 g/day [interquartile range (IQR) 11-43] with exclusive human milk compared to 17 g/day (IQR 2-26) with a mixed diet (p=0.008). Infants in the exclusive human milk group received feeds with caloric density >26 Kcal/oz during 67% of the postoperative period compared to 15% in the control group.
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