Outcomes of Donor Breast Milk and Prolacta Use in an Urban Level IV Neonatal Intensive Care Unit

Background: Exposure to formula is an independent risk factor for necrotizing enterocolitis (NEC), and is associated with increased risk of neonatal morbidities. To provide an exclusive human milk diet to neonates, donor breast milk (DBM) and human-milk-based human milk fortifier (Prolacta) have been introduced in our urban Level IV NICU. Despite potential for decreased NEC incidence, concern exists for poor growth and decreased maternal breast milk (MBM) provision. The objective of this study was to assess the effect of DBM and Prolacta introduction on growth, incidence of morbidities, and characteristics of feeds during admission.

Methods: Retrospective medical record review of neonates born <1250 grams admitted to an urban Level IV NICU. We compared infant characteristics between those who received vs. did not receive Prolacta. In order to control for changes in feeding strategies over time, we also compared three nutritional time-epochs: 1) MBM, formula, and bovine fortifier use only (8/2015-4/2016); 2) DBM introduction (5/2016–10/2018); 3) Prolacta introduction (11/2018–8/2020).

Results: We identified 367 infants, of whom 26% received Prolacta. Neonatal characteristics were similar over time including birth weight (BW), birth gestational age (GA), race, and small for GA (SGA) status. The later epochs were associated with significant reduction in time to first feed (p < 0.0001), full feeds (p=0.0024), duration of parenteral nutrition (p < 0.0084), duration of central access (p < 0.0001), although we saw increased late onset sepsis (LOS) over time. There was no significant change in rates of NEC, intraventricular hemorrhage, retinopathy of prematurity, or oxygen requirement at 36 weeks despite decreasing formula exposure over time. Later time-epochs were associated with slower growth velocity (p=0.0128). We found no association between exclusive human milk diet with Prolacta and improvement in NEC. Although infants fed Prolacta had lower birth GA, they had similar BW and SGA status. Feeds with Prolacta did not affect provision of MBM (p=0.75), but were associated with slower growth velocities during the first month of life (8.8g/kg/day vs. 11.1g/kg/day, p=0.0165). There were no differences in frequency of MBM feeds at discharge between the 3 time-epochs, but those infants fed Prolacta were more likely to receive BM at discharge (p=0.005).

Conclusion: Our study found that introduction of DBM and Prolacta were associated with more rapid feed advancement and fewer central line days. There was no decrease in use of MBM with introduction of DBM, and fewer neonates went home on formula after receiving Prolacta. However, timeframes after introduction of DBM and Prolacta were not associated with decreased morbidities such as NEC, but were associated with increased LOS. Infants fed Prolacta had significantly slower early weight gain. Identifying benefits and risks of introducing DBM and Prolacta feeds to early preterm infants will allow researchers and clinicians to allocate funding and resources appropriately.