Human milk (HM) is the preferred source of nutrition for preterm infants given its well-established clinical benefits. However, unfortified HM does not provide sufficient protein, energy, and micronutrients to meet the m...Human milk (HM) is the preferred source of nutrition for preterm infants given its well-established clinical benefits. However, unfortified HM does not provide sufficient protein, energy, and micronutrients to meet the metabolic demands of very low birth weight infants, making fortification necessary to support optimal growth and reduce the risk of adverse outcomes. This review examines contemporary strategies in human milk fortification, including the timing of initiation, differences between human milk-derived and bovine milk-derived fortifiers, with particular attention to the micronutrients essential for preterm infant growth. Current evidence supports the routine use of fortification to improve growth, and earlier initiation of fortification appears safe in stable preterm infants. However, available data do not consistently demonstrate superiority of one type of fortifier across all clinical outcomes, underscoring the importance of context-specific decision making. Increasingly, individualized approaches such as adjustable and targeted fortification, guided by human milk analysis, are being explored to address variability in milk composition and infant nutritional requirements. Future strategies will likely emphasize precision nutrition while preserving the biologic integrity of HM, ensuring that growth optimization and intestinal protection remain aligned rather than competing priorities.
The causative pathogens of neonatal early-onset sepsis (EOS) have changed over time with a shift towards gram-negative organisms. This change is likely multifactorial and due in part to a high prevalence of maternal intr...The causative pathogens of neonatal early-onset sepsis (EOS) have changed over time with a shift towards gram-negative organisms. This change is likely multifactorial and due in part to a high prevalence of maternal intrapartum antibiotic exposure leading to alterations in rectovaginal colonization with antibiotic-resistant organisms and subsequent neonatal colonization and infection. As a result, neonatal EOS secondary to gram-negative pathogens, particularly Escherichia coli (E. coli), is becoming more aggressive, resistant and difficult to treat, and not exclusive to very low birth weight infants with more EOS emerging in late preterm and term infants. Therefore, a heightened awareness regarding the dangers of resistant bacterial infections in neonates is critical, as well as a reevaluation of current maternal and neonatal surveillance and prevention efforts.
Neonatal nutrition experts traditionally recommend that preterm infants achieve postnatal growth approximating intrauterine fetal growth rates. Preterm infant growth has three phases: postnatal weight loss, approximately...Neonatal nutrition experts traditionally recommend that preterm infants achieve postnatal growth approximating intrauterine fetal growth rates. Preterm infant growth has three phases: postnatal weight loss, approximately parallel growth, and catch-up growth. Growth approximately parallel to growth chart curves can be appropriate even when plotting below any given percentile. Growth patterns are influenced by genetic potential, health determinants, pre-birth environment (maternal morbidities), post-birth morbidity, nutrition and feeding ability. To achieve genetic potential, some infants need growth to catch-up and some catch-down. There is considerable overlap between the growth of healthy infants and those with growth faltering. Growth expectations must be individualized in order to account for normal physiological and genetic variations and to help identify modifiable factors. No specific percentile, z-score or change in z-scores should be set as universal growth goals; rather, individual variability should be expected. The expert groups did not favour the words "failure" and "restriction" to describe postnatal growth perhaps because these words are usually based on arbitrary percentile/z-score cut-offs using one-point-in-time measures and ignore that postnatal weight loss places infants lower on growth chart curves. The word "failure" is pejorative while "faltering" suggests a temporary problem.
Semin Perinatol
· 2026 Jun · PMID 42049590
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NEC is a multifactorial gastrointestinal disorder affecting medically fragile infants in the neonatal intensive care unit (NICU) and is associated with significant morbidity and mortality. Although the precise pathogenes...NEC is a multifactorial gastrointestinal disorder affecting medically fragile infants in the neonatal intensive care unit (NICU) and is associated with significant morbidity and mortality. Although the precise pathogenesis of NEC is not well understood, prematurity remains a significant risk factor. Immature intestinal immunity, altered microbial colonization (dysbiosis), and dysregulated inflammatory responses contribute to NEC susceptibility in the preterm intestine. During NEC, an exaggerated inflammatory response can lead to intestinal tissue damage and in severe cases, surgical resection of necrotic bowel may be required. NEC affects 5-7% of very low birth weight (VLBW) infants according to large-scale estimates of >500,000 infants. In addition to biologic vulnerability related to prematurity, epidemiologic studies have identified associations between NEC and maternal health, racial and ethnic disparities, and socioeconomic factors. Herein we discuss the complex relationship between enteral feeding and NEC, focused on the complex relationships between environment, nutrient composition, and feeding practices on disease susceptibility.
Semin Perinatol
· 2026 Jun · PMID 42034480
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OBJECTIVE: Summarize the role of iron in fetal and neonatal nutrition. FINDINGS: Iron is an essential micronutrient that plays key roles in growth and development of the fetus and neonate. Iron deficiency compromises ery...OBJECTIVE: Summarize the role of iron in fetal and neonatal nutrition. FINDINGS: Iron is an essential micronutrient that plays key roles in growth and development of the fetus and neonate. Iron deficiency compromises erythropoiesis, immune competency, and when present during critical periods of brain development, long-term neurodevelopmental outcomes. Due to the critical role of iron in shaping brain structure and development, these deficits may be irreversible with later repletion. Conversely, oversupplementation with iron, a potential pro-oxidant, may also have detrimental effects. Therefore, neonatal iron supplementation should be individualized and monitored through iron measures in those at high-risk for iron deficiency to optimize outcomes. A variety of enteral and parenteral iron approaches are available to meet the needs of infants at low and high risk of iron deficiency. CONCLUSION: Optimizing iron status in neonates is key to improving growth and development in infants. Preterm infants are at particular risk for disruptions in iron status and thus warrant iron supplementation and close surveillance of iron status.
BACKGROUND: Maternal diet is an important clinical adjunct to care for optimal infant outcome. Clinicians should have a heightened awareness to the importance of the first 1000 days from conception to 2 years for key cri...BACKGROUND: Maternal diet is an important clinical adjunct to care for optimal infant outcome. Clinicians should have a heightened awareness to the importance of the first 1000 days from conception to 2 years for key critical nutrients. The Registered Dietitian can be a key partner to ensure mothers are assessed nutritionally for food insecurity and dietary adequacy in pregnancy and lactation. METHODS: A clinical review of the PubMed literature was done to establish recent guidelines for pregnancy and lactation- highlighting key dietary patterns, calories and nutrients that have been associated with pregnancy, human milk composition, and impacting fetal, neonatal, and lifelong health outcomes. RESULTS: Critical nutrients such as calories, Docosahexaenoic acid (DHA), choline, folate, Vitamin B1,B2, B12, D, minerals, trace elements, and fiber were found to play key roles in optimizing pregnancy and lactation and resultant infant growth, development, and the microbiome. CONCLUSION: The perinatal provider should incorporate key maternal nutrient recommendations into dietary guidelines to ensure a healthy trajectory for the mother-infant dyad.
Provision of mother's milk for very premature infants (≤32 weeks' gestation) is a critical, modifiable factor that improves outcomes in this highly vulnerable population. Despite this, however, longstanding lactation dis...Provision of mother's milk for very premature infants (≤32 weeks' gestation) is a critical, modifiable factor that improves outcomes in this highly vulnerable population. Despite this, however, longstanding lactation disparities persist. Mothers who are non-Hispanic Black, non-English speaking, have lower income, lower educational attainment, or public insurance are less likely to provide mother's milk, and these inequities have remained largely unchanged over decades. For mothers of very preterm infants, sustaining lactation presents unique challenges. Mothers are typically dependent on breast pumps to express milk every 3-4 h due to infant physiologic immaturity and prolonged hospitalization. They must do so while navigating the physical separation from their infant, transportation barriers, and financial strain from a NICU admission. Although NICUs commonly provide hospital-grade pumps and specialized lactation support in the hospital, mothers may face multi-level barriers to lactation, including limited access to equipment at home, difficulty visiting the NICU, and inadequate social or resource support. These barriers often intersect to contribute to disparate lactation outcomes, as racially and ethnically minoritized mothers are disproportionately affected by adverse social drivers of health. Addressing inequities in lactation requires multilevel, evidence-based interventions. In this report, we structure barriers and proposed interventions within a socio-ecological framework.
This review examines how Quality Improvement (QI) methodology bridges the gap between evidence-based research and bedside practice to optimize human milk provision. Even though data shows significant improved clinical ou...This review examines how Quality Improvement (QI) methodology bridges the gap between evidence-based research and bedside practice to optimize human milk provision. Even though data shows significant improved clinical outcomes, support for neurodevelopment, and reduces comorbidities with breast milk provision to NICU patients, there remains varying breast milk utilization and discharge rates. Successful initiatives apply QI framework including multidisciplinary stakeholders' engagement, plan-do-study-act cycles, collaboration, guideline, education to implement strategies for successful outcomes and across neonatal care continuum: antenatal education, peripartum initiation, and postpartum maintenance. Key interventions include early pumping initiation, oral immune therapy, skin-to-skin care, lactation support, and standardized feeding protocols. This review highlights impactful projects which improved the provision of breast milk. Furthermore, targeted QI efforts in diverse populations have shown success clinically and with hospital resource utilization. Ultimately, systematic QI efforts that address cultural barriers and redefine provider roles are essential to decreasing institutional variation and ensuring the most vulnerable infants receive optimal nutrition.
Much has been learned about breast milk composition in recent decades, but little is documented on donor human milk (DHM). Breast milk becomes DHM when it is donated by screened and approved lactating persons, pasteurize...Much has been learned about breast milk composition in recent decades, but little is documented on donor human milk (DHM). Breast milk becomes DHM when it is donated by screened and approved lactating persons, pasteurized, and tested for absence of biological pathogens before being dispensed to hospitals and families for infants in need. However, DHM is different from a parent's own milk. DHM composition is affected by individual milk donor characteristics and expression and storage processes, as well as milk bank thawing and pooling practices, mixing, and heat processing. In this review, we discuss what is known regarding macronutrient, micronutrient, and bioactive content in Holder-pasteurized DHM, how it differs from parent's own milk, and how infrared milk analysis is utilized by non-profit milk banks.
Despite advances in neonatal intensive care and increased availability of randomized clinical trial data, optimal enteral nutrition strategies remain debated, with significant gaps between evidence and practice. We revie...Despite advances in neonatal intensive care and increased availability of randomized clinical trial data, optimal enteral nutrition strategies remain debated, with significant gaps between evidence and practice. We reviewed current evidence for enteral feeding in neonates. Recent clinical trials support the early progression of enteral feeding within 96 h of birth and faster advancement rates of 30-40 mL/kg/day in preterm infants. Evidence demonstrates that these strategies reduce the time to full feeds and decrease the risk of sepsis without increasing the risk of necrotizing enterocolitis. A recent multicenter trial confirmed that, when maternal milk supply is limited, donor human milk reduces necrotizing enterocolitis incidence compared to formula, however, without neurodevelopmental advantages. Multiple trials found no superiority of human milk-based over bovine-based fortifiers. Abandoning routine gastric residual assessment reduces time to full feeds without increasing complications, but a large confirmatory trial is underway. Evidence now supports low-volume feeding during therapeutic hypothermia for hypoxic-ischemic encephalopathy, with fed infants achieving full feeds earlier and having a shorter hospital stay. For congenital heart disease, hemodynamically stable infants can safely receive minimal human milk feeding pre and post-operatively within 5-7 days. Future trials need to focus on precision nutrition, optimal fortification strategies, and long-term effects.
Human milk is a complex tissue that is uniquely transferred from one individual to another and changes over time. Beyond energy, macronutrients, minerals, and vitamins, human milk contains numerous cell populations and k...Human milk is a complex tissue that is uniquely transferred from one individual to another and changes over time. Beyond energy, macronutrients, minerals, and vitamins, human milk contains numerous cell populations and key compounds that communicate to the offspring and protect them from a potentially harmful environment. In recognition of this evolving complexity, this review will describe the compositional changes of human milk across lactation stages, beginning with colostrum, identify nutritional gaps that may exist for some term and most preterm infants provided an exclusive human milk diet, and highlight key differences between term, preterm, and donor human milk that are relevant for infant caregivers.
Early-onset sepsis (EOS), defined as infection within the first 72 h of life, remains a major concern in neonatal care. Historically, many late preterm (≥34 weeks) and term infants at risk for infection (e.g., exposure t...Early-onset sepsis (EOS), defined as infection within the first 72 h of life, remains a major concern in neonatal care. Historically, many late preterm (≥34 weeks) and term infants at risk for infection (e.g., exposure to maternal intraamniotic infection [chorioamnionitis], or prolonged rupture of membranes) received empiric antibiotics after birth. However, most of these infants were ultimately without infection, leading to unnecessary antibiotic exposure, NICU admissions, and disruptions in maternal-infant bonding. Recent evidence and guidelines support serial physical examinations (SPEs) or structured clinical observation as a safe and effective alternative to routine empiric antibiotics in well-appearing infants. The purpose of this review is to describe the evidence supporting SPEs as a safe and effective strategy for managing well-appearing late preterm and term infants at risk for early onset sepsis.
Maternal medical conditions are associated with significant obstetric complications including preterm birth and hypertensive disorders of pregnancy as well as impacting maternal health. This manuscript focuses on the evi...Maternal medical conditions are associated with significant obstetric complications including preterm birth and hypertensive disorders of pregnancy as well as impacting maternal health. This manuscript focuses on the evidence based advances in diabetes, asthma, and the presence of Factor V Leiden mutation in pregnancy that have changed practice. Large randomized controlled trials of mild gestational diabetes addressed the longstanding controversy concerning the benefit for the identification and treatment of GDM by demonstrating the benefit of treatment in pregnancy. Trials of medical management of diabetes in pregnancy provided the data for glyburide and metformin as compared to insulin. Addressing the need for evidence based data for treatment of asthma in pregnancy, a large trial demonstrated the benefit of inhaled steroids for the treatment of asthma in pregnancy. The Factor V Leiden study provided the needed data that the risk of thromboembolic events in untreated heterozygotes for the FVL mutation without evident risk factors for thrombosis is low and is not different from noncarriers. pivoting providers from routine universal screening for FVL mutation. These seminal trials demonstrate that evidence based management in pregnancy is not only feasible, but is essential to ensure the interventions are beneficial.
Semin Perinatol
· 2026 May · PMID 41453814
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Hypertensive disorders of pregnancy are major contributors to adverse maternal, fetal and neonatal outcomes. This review summarizes pivotal clinical and translational studies that have shaped the clinical approach to the...Hypertensive disorders of pregnancy are major contributors to adverse maternal, fetal and neonatal outcomes. This review summarizes pivotal clinical and translational studies that have shaped the clinical approach to the prevention and treatment of preeclampsia. Early preclinical trails established the pathophysiological basis and rationale for prevention strategies culminating in the standard use low dose aspirin and the emerging potential of statins. Recent randomized trials have also demonstrated that treatment of mild chronic hypertension reduces the risk preeclampsia and associated complications. Furthermore, clinical studies examining the use of magnesium sulfate for seizure prophylaxis and the optimal delivery timing have defined key aspects of evidence-based preeclampsia management. Further research to identify novel therapeutic targets and refine management strategies to mitigate the persistent burden of preeclampsia is urgently needed.
Mental illness affects up to 20 % of women of reproductive age. Maternal mental illness pre-pregnancy and/or during pregnancy is an independent risk factor for prematurity, stillbirth and small for gestational age. Data...Mental illness affects up to 20 % of women of reproductive age. Maternal mental illness pre-pregnancy and/or during pregnancy is an independent risk factor for prematurity, stillbirth and small for gestational age. Data on maternal mental illness and other birth outcomes are mixed. There are several different screening tools available to identify mothers with mental illness. Although the timing of screening varies among providers, antenatal screening provides more opportunities to identify and support mothers with mental illness. If identified prior to potential maternal mental illness exacerbations complicating decision-making capacity there may be an opportunity for advanced directives. This review focuses on the impact of maternal mental illness on delivery mode and timing, birth outcomes, and breastfeeding. We discuss maternal mental illness screening tools, relevant benefits and disadvantages as well as timing and location (obstetric and pediatric settings). Finally, ethical and policy implications are detailed.
Landmark trials impact how we care for patients. These studies often have convincing data that lead to new or updated practice guidelines by professional societies and other organizations. In this review, we present four...Landmark trials impact how we care for patients. These studies often have convincing data that lead to new or updated practice guidelines by professional societies and other organizations. In this review, we present four such studies of maternal interventions that defined standards of care and continue to influence what we do today. The first found that the rate of perinatal HIV transmission was reduced in women with HIV in pregnancy with treatment of zidovudine in the antepartum, intrapartum, and neonatal periods. The second found that postoperative infections and use of resources were reduced in women who received a single intravenous dose of azithromycin in addition to their standard preoperative antibiotics for cesarean delivery. The third study did not find any benefit in treating subclinical hypothyroidism or hypothyroxinemia in pregnancy preventing routine use of levothyroxine for these patients. The fourth showed that the treatment of non-severe chronic hypertension in pregnancy safely resulted in improved pregnancy outcomes.
Preferring a language other than English (LOE) is associated with numerous disparities across healthcare. Despite the federally mandated requirement for use of medical interpreters, utilization is suboptimal. Families fa...Preferring a language other than English (LOE) is associated with numerous disparities across healthcare. Despite the federally mandated requirement for use of medical interpreters, utilization is suboptimal. Families facing language barriers experience difficulties in accessing care, receive inadequate counselling, and are at high risk for preventable medical errors. Emerging evidence suggests maternal and infant health outcomes surrounding childbirth are worse for patients with a LOE preference. This review will address the impact of preferring a LOE on perinatal health outcomes from preconception care, throughout pregnancy, and into the neonatal period. We discuss quality improvement initiatives that promote language equity by sustainably increasing interpreter use. Future directions and opportunities will be explored.