Seminars in Fetal and Neonatal Medicine xxx (xxxx) xxx–xxx

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Seminars in Fetal and Neonatal Medicine

journal homepage: www.elsevier.com/locate/siny

Enteral feeding composition and necrotizing enterocolitis

Diomel de la Cruz∗, Catalina Bazacliu
University of Florida, Department of Pediatrics, Division of Neonatology, Gainesville, FL, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Enteral feeding and composition play a chief role in the prevention and treatment of necrotizing enterocolitis
Necrotizing enterocolitis (NEC). In the face of decades of research on this fatal disease, the exact mechanism of disease is still poorly
Human milk understood. There is established evidence that providing mother's own breast milk and standardization of
Donor breast milk feeding regimens leads to a decreased risk for NEC. More recent studies have focused on the provision of donor
Lactoferrin
human milk or an exclusive human milk diet in the endeavor to prevent NEC while still maintaining adequate
Human milk oligosaccharides
nutrition to the premature infant. There is growing literature on the provision of specific human milk compo-
nents and its effect on the incidence of NEC.

1. Introduction
Necrotizing enterocolitis (NEC) is the most common, life-threa-
tening gastrointestinal emergency in the neonatal period affecting ap-
proximately 7% of premature very low birth weight (VLBW) infants.
Mortality rates range from 15% to 30%, depending on the need for
surgical intervention or disease severity [1,2]. NEC significantly in-
creases medical care costs, especially if surgery is required [3]. Total
hospital costs for NEC are estimated at US$7 million per year [4,5]. The
death toll and the long-term sequelae make prevention and manage-
ment of this disease very important. Despite being studied for more
than six decades, the pathophysiology of NEC is still incompletely
deciphered and poorly understood. The underlying cause is considered
multifactorial, an association of intestinal and immune system im-
maturity, intestinal mucosal injury, bacterial dysbiosis, and type of
feeds, being widely accepted [6–11]. We know that a vast majority of
cases of NEC develop after the initiation of enteral feeding. Despite the
persistent challenges in the diagnosis and prevention of NEC, there has
been considerable evidence for the past few decades that two feeding
interventions decrease its incidence: provision of breastmilk and stan-
dardized feeding regimens. Specific human milk fractions and compo-
nents seemed promising for prevention of NEC in preclinical studies,
but there is scarce clinical evidence of significant impact on disease
prevention and treatment for any single one.
2. Human milk and necrotizing enterocolitis
Human milk is established to be the most favorable form of infant
nutrition [12]. The benefits of human milk are attributed to the pre-
sence of bioactive substances that act with bactericidal and im-
munomodulating properties. Evidence shows that exclusive human
milk appears to decrease the risk of late-onset sepsis and feeding in-
tolerance and other complications of prematurity such as retinopathy of
prematurity [13,14]. Furthermore, provision of human milk to pre-
mature infants is associated with improved neurodevelopmental out-
comes, shorter NICU stay, decreased hospital readmissions and lower
obesity and insulin resistance in adolescence [15–18].
2.1. Exclusive human milk
A large amount of data supports the concept that exclusive human
milk intake may reduce the incidence and severity of NEC [19–22].
Lucas et al. [23] demonstrated, in a landmark paper in 1990, that
human breast milk has protective effects against NEC when compared
with formula. Abrams et al. [24] performed a meta-analysis and re-
ported a lower risk of NEC in those who received an exclusive human
milk diet.
One challenge that confronts an exclusive human milk diet is the
matter of fortification. Human milk does not contain sufficient amounts
of protein, calcium, phosphorous and calories for the ideal growth of
the premature infant [12]. Most neonatal intensive care units use bo-
vine-based fortifier that may promote an environment conducive to
NEC. The most recent meta-analysis looking at 14 trials on bovine
fortification of breastmilk reports that human breastmilk fortification
results in slightly improved growth and alkaline phosphatase, without
increasing the risk of NEC [25]. Further studies on human milk-based

∗
Corresponding author. University of Florida, Department of Pediatrics, Division of Neonatology, 1600 SW Archer Road, PO Box 100296, Gainesville, FL 32610-
0296, USA.
E-mail address: ddelacruz@ufl.edu (D.d.l. Cruz).

https://doi.org/10.1016/j.siny.2018.08.003

1744-165X/ © 2018 Published by Elsevier Ltd.

Please cite this article as: Cruz, D.d.l., Seminars in Fetal and Neonatal Medicine (2018), https://doi.org/10.1016/j.siny.2018.08.003
D.d.l. Cruz, C. Bazacliu
human milk fortifier are still needed.
2.2. Donor human milk
Questions remain regarding whether donor human milk has the
same protective effect as mother's own milk. The evidence is less per-
suasive, given that most studies do not randomize infants to purely
donor breast milk versus formula. More recent meta-analyses have
concluded that infants fed donor breastmilk had poor growth but less
NEC compared to those fed formula [26,27]. Notably, in both meta-
analyses, the benefit of preventing NEC was lost when donor human
milk was used to supplement mother's own milk. Furthermore, most of
the studies used in the Cochrane review used studies published in the
1980s and excluded infants at the highest risk, namely the smallest
infants. Two randomized controlled trials (RCTs) have failed to de-
monstrate a reduction in NEC, whether on donor human milk or for-
mula, when mother's own milk was unavailable [21,28]. We found no
clinical trial directly comparing the impact of donor milk with mother's
own milk on the development of NEC. Given the current knowledge, an
RCT may even be considered unethical. Recently, the DoMINO trial
demonstrated no cognitive benefits when infants were randomized to
donor breastmilk versus formula [29]. Donor human milk differs from
mother's own breast milk with respect to caloric content and macro-
nutrient composition, as well as the amount of bioactive ingredients.
Holder pasteurization, performed to decrease bacteria and viruses, also
diminishes or inactivates protective elements of mother's own milk,
including secretory IgA, lactoferrin, commensal bacteria, and lysozymes
[30,31].
2.3. Dosing of human milk
Multiple studies examined the effect of different doses of human
milk on the incidence of NEC. In the secondary analysis of a meta-
analysis, Abrams et al. [24] reported that the percentage of diet other
than exclusive human milk was a significant predictor of NEC. The risk
for NEC increased by 11–21% for every 10% increase in non-human
milk in the diet. Two RCTs [21,32] reported that the incidence of NEC
appeared to decrease in those infants who received more than 50% of
their total feeds made up of mother's own milk. The basis of this see-
mingly dose-dependent response is unclear and may be related to more
protection provided by a greater intake of human milk, or less formula.
3. Standardized feeding regimens and necrotizing enterocolitis
The preterm gut is especially at risk for feeding intolerance. This is
most likely due to an immature gut barrier, microbial dysbiosis, limited
intestinal function and motility. A linear trajectory of feeding ad-
vancement is believed to be the most intuitive. Several studies have
shown that standardized feeding regimens result in a decreased in-
cidence of NEC [33–35].
3.1. Rate of advancement of feeds
At the present time, the subject of trophic feeding has divided
clinicians into those who delay the initiation of nutritive feeding, ex-
tended the duration of trophic feeding for a few days to a week, and
those who advance enteral feedings without offering trophic feeding.
There are clinical data suggesting that trophic feeding for a few days
lead to a decreased risk of NEC when compared to early progressive
feeding [36,37]. Conversely, prolonged trophic feeds have been shown
to a delay time to full enteral feeding [38,39]. A delay in achievement
of full enteral feeds increases risk for nosocomial sepsis and infection,
prolongs parenteral nutrition and central lines, extends length of hos-
pital stay, and increases risk for postnatal growth restriction [38–43].
Most current meta-analyses have not revealed any increased risk for
NEC or feeding intolerance with early progression from trophic feeds,
2
Seminars in Fetal and Neonatal Medicine xxx (xxxx) xxx–xxx
or even a more aggressive daily advancement of enteral feeds
(> 20 mL/kg/day) [39,40].
3.2. Early fortification of feeds
It is generally recognized that fortification of human milk is re-
quired to deliver adequate calories, calcium and phosphorous and
protein to the preterm infant [25,44]. However, early fortification and
increasing osmolality of feeds has raised questions on its safety [45].
Two RCTs have shown that early fortification of enteral feeds did not
increase the risk of NEC or feeding intolerance while presenting the
benefit of improved growth and protein delivery [46,47].
4. Colostrum
Produced in the first few days postpartum, colostrum has a higher
concentration of proteins and immunoactive components than the
mature milk [48]. The application of both bovine and human colostrum
had been studied recently.
Studies in a preterm piglet NEC model suggest that bovine colos-
trum protects against NEC improves the intestinal architecture and
decreases inflammation [49]. Based on these data, a feasibility and
tolerability pilot safety study on bovine colostrum administration in
preterm infants was initiated in Denmark and China. The researchers
found no difference in feeding tolerance or clinical adverse outcomes
during the first two weeks of life, except a transient elevation of plasma
tyrosine on day 7 in infants receiving bovine colostrum, an effect at-
tributed to their increased protein intake [50].
Several studies on the effect of oral human colostrum administration
in preterm infants and its relationship with the immune system con-
cluded with contradictory results. In a retrospective cohort, Seigel et al.
demonstrated that colostrum could be safely administered orophar-
yngeally to ELBW infants in the first two days of life and might provide
the benefit of a better weight gain at 36 weeks [51]. This study was
followed by an RCT of oral colostrum priming that showed significant
reduction in the median length of hospitalization as compared to in-
fants who did not receive oral colostrum, but no impact on salivary
immune peptides and oral microbiota in preterm infants receiving oral
colostrum versus the control group [52]. Two other RCTs in preterm
infants demonstrated increase in salivary secretory IgA [53] and cir-
culating secretory immunoglobulin A [54]. Lee et al. noted a significant
decrease in clinical sepsis, as well as an increase in immunoprotective
factors and a decrease in pro-inflammatory cytokines in the colostrum
group [54].
5. Human milk components
5.1. Lactoferrin
Known for its antimicrobial properties, lactoferrin is the most
abundant protein in human milk whey [48] and may be effective in
preventing NEC. Bovine lactoferrin (BLF) has a 69% similarity with the
human lactoferrin [48] but has a much lower concentration in bovine
milk. Animal studies demonstrated that lactoferrin might prevent in-
testinal inflammation and NEC by interfering with activation of the pro-
inflammatory cascade. It may compete with LPS in binding on Toll-like
receptor-4, inhibiting the activation of nuclear factor-κβ-regulated
genes [55].
A large multicenter trial comparing BLF, bovine lactoferrin with
Lactobacillus rhamnosus (BLF + LGG) and placebo in VLBW infants
showed a statistically significant reduction in NEC in the BLF + LGG
group and a trend towards decreasing NEC in BLF in comparison with
controls [56]. Of note, the incidence of NEC in the control group was
relatively low, at 5.3%. Another small trial from Turkey showed de-
creased sepsis but no difference in NEC, even though there was no NEC
case in the lactoferrin-treated group [57]. A Cochrane review of
D.d.l. Cruz, C. Bazacliu
lactoferrin in preterm infants concluded that lactoferrin decreased NEC
stage II or greater by 30%, but the quality of evidence was marginal
[58]. Administration of recombinant human lactoferrin had no effect on
NEC rates, but significantly reduced in hospital-acquired infection in
the treatment group [59]. The results of the “Enteral lactoferrin in
neonates” (ELFIN), a large RCT of lactoferrin in infants less than 32
weeks gestation that finished enrolling in 2017, is expected to shed
more light on the role lactoferrin may play in NEC prevention in the
future (www.npeu.ox.ac.uk).
5.2. Human milk oligosaccharides
Human milk oligosaccharides (HMOs) are a major bioactive com-
ponent of human milk that varies with maternal genetics and stage of
lactation [60]. HMOs play an important role in microbial colonization
of the gut after birth, as suggested by the increase in fucosyltransferase
activity during the first postnatal weeks [61], and subsequently serve as
nutritional substrate for “good” bacteria influencing the development of
intestinal microbiome [60]. HMOs also inhibit bacterial pathogen ad-
herence to mucosal surfaces, protecting breast-fed infants against var-
ious infections [62]. A sialated isomer, disialyllacto-N-tetraose, that
confers protection from NEC was identified in animal models by Jant-
scher-Krenn et al. [63]. Sialylated galacto-oligosaccharides and 2′-fu-
cosyllactose were also shown to reduce NEC in neonatal rodents [64].
Mechanistically, 2′-fucosyllactose improves intestinal perfusion by up-
regulating endothelial nitric oxide synthase in a mouse model [65].
Colostrum HMOs can also be protective by attenuating the in-
flammatory response and promoting the maturation of the intestinal
mucosal immune system in ex-vivo immature intestinal cells culture
[66]. A large amount of fucosylated oligosaccharides, including se-
cretor antigen (H) are found in milk. The secretory status of the mother
determines the fucosylation of glycans in the milk [60] which may
further increase the risk of developing NEC in low or non-secretory
infants, as Morrow et al. demonstrated that premature infants with
fucosyltransferase-2 low secretor phenotype have a ten-fold increase in
NEC [67].
5.3. Other milk components
A few other human milk components that have been studied for
their potential in preventing NEC are listed in Table 1.
6. Summary
Enteral feeds with mother's own milk and consistent feeding prac-
tices are the only proven and modifiable interventions that help prevent
a significant number of NEC cases. Exclusive human milk diet could,
theoretically, be better than the more customary combined mother's
Table 1
Milk components contributing to necrotizing enterocolitis (NEC) prevention.
Component Proposed mechanism
Transforming growth factor- • Bound to glycans: bioavailability is increased by
β2 low pH [48]
• Decreases
[68]
inflammation and promotes repair
Immunoglobulins
Glutamine • Decreases gut permeability and preserves villi
structure in mature human intestine [71]
Arginine • Plasma concentration lower in infants who
developed NEC [73]
3
Seminars in Fetal and Neonatal Medicine xxx (xxxx) xxx–xxx
own milk combined with bovine milk fortifier, but the current evidence
is insufficient to support this practice. Due to composition changes in-
duced by pasteurization and thawing to which human donor milk is
subjected, it does not seem to have the same protective effects against
NEC without the presence of mother's own milk. Due to its undeniable
benefits, extensive research aimed to identify protective components
has been done. Even though animal studies demonstrated that a variety
of human milk components seem to be effective in preventing and de-
creasing severity of NEC, the few tested in human trials fail to show a
significant improvement. More research in this area is needed, though it
faces a few problems. The animal models for NEC do not completely
recapitulate the premature infants' disease and it is likely that the array
of bioactive components from human milk act synergistically to
dampen the immune system response and to nourish and protect the
intestinal epithelium. Clinically, NEC is a disease with an overall low
incidence, making clinical trials require a high number of patients to
enroll to adequately power for effect.
6.1. Practice points
• Two feeding interventions decrease the risk for necrotizing en-
terocolitis: provision of mother's breast milk and standardization of
feeding regimens.
• Early progressive feeding and fortification are safe with the benefit
of better growth and shorter time to full feeds.
• Donor human breastmilk and human milk-based human milk for-
tifier may contribute to NEC prevention.
• A higher dose of human breast milk (> 50% of feeds) reduces the
incidence of NEC.
• Human milk components could not be recommended for prevention
or treatment of NEC at this time.
6.2. Research directions
• The role of human milk-based human milk fortification in the nu-
trition of the preterm infant and the prevention of NEC.
• The role of donor human milk in the nutrition of the extremely
premature infant.
• The role of oral colostrum in modulation of immune system and
microbiota.
• The role of individual or combination of human milk component in
prevention and treatment of disease.
Conflicts of interest
None declared.
Human studies
• Highest in colostrum, decreased during lactation [69]
• small
Low TGF-β2 in the milk of mothers whose infants developed NEC, but the study had a
sample size and was not powered for NEC [69]
• Trials used IgG, IgG/IgA and IgG/IgA/IgM
• Cochrane review of oral immunoglobulins for NEC prophylaxis concluded that oral Ig
did not result in significant reduction of NEC [70]
• No trial for IgA alone was done
• Cochrane review meta-analysis of glutamine supplementation oral or enteral to
prevent mortality and morbidity included 12 studies did not show any differences in
mortality or morbidities, including NEC [72]
• Three small trials with contradictory results
• Cochrane review found some reduction in NEC stage I and III, but concluded that there
is insufficient evidence to support supplementation [74]
D.d.l. Cruz, C. Bazacliu
Funding sources
None.
References
[1] Neu J, Walker WA. Necrotizing enterocolitis. N Engl J Med 2011;364:255–64.
[2] Horbar JD, Carpenter JH, Badger GJ, et al. Mortality and neonatal morbidity among
infants 501 to 1500 grams from 2000 to 2009. Pediatrics 2012;129:1019–26.
[3] Ganapathy V, Hay JW, Kim JH. Costs of necrotizing enterocolitis and cost-effec-
tiveness of exclusively human milk-based products in feeding extremely premature
infants. Breastfeed Med 2012;7:29–37.
[4] Ganapathy V, Hay JW, Kim JH, Lee ML, Rechtman DJ. Long term healthcare costs of
infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal
study among infants enrolled in Texas Medicaid. BMC Pediatr 2013;13:127.
[5] Bisquera JA, Cooper TR, Berseth CL. Impact of necrotizing enterocolitis on length of
stay and hospital charges in very low birth weight infants. Pediatrics
2002;109:423–8.
[6] Neu J. Necrotizing enterocolitis: the mystery goes on. Neonatology
2014;106:289–95.
[7] Torrazza RM, Neu J. The altered gut microbiome and necrotizing enterocolitis. Clin
Perinatol 2013;40:93–108.
[8] Patole S. Prevention and treatment of necrotising enterocolitis in preterm neonates.
Early Hum Dev 2007;83:635–42.
[9] Morowitz MJ, Poroyko V, Caplan M, Alverdy J, Liu DC. Redefining the role of in-
testinal microbes in the pathogenesis of necrotizing enterocolitis. Pediatrics
2010;125:777–85.
[10] Carlisle EM, Morowitz MJ. The intestinal microbiome and necrotizing enterocolitis.
Curr Opin Pediatr 2013;25:382–7.
[11] Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet 2006;368(9543):1271–83.
[12] Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics
2012;129:e827–41.
[13] Bharwani SK, Green BF, Pezzullo JC, Bharwani SS, Bharwani SS, Dhanireddy R.
Systematic review and meta-analysis of human milk intake and retinopathy of
prematurity: a significant update. J Perinatol 2016;36:913–20.
[14] Patel AL, Johnson TJ, Engstrom JL, et al. Impact of early human milk on sepsis and
health-care costs in very low birth weight infants. J Perinatol 2013;33:514–9.
[15] Lechner BE, Vohr BR. Neurodevelopmental outcomes of preterm infants fed human
milk: a systematic review. Clin Perinatol 2017;44:69–83.
[16] Singhal A, Cole TJ, Fewtrell M, Lucas A. Breastmilk feeding and lipoprotein profile
in adolescents born preterm: follow-up of a prospective randomised study. Lancet
2004;363(9421):1571–8.
[17] Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood
pressure: two cohorts after randomised trials. Lancet 2001;357(9254):413–9.
[18] Isaacs EB, Fischl BR, Quinn BT, Chong WK, Gadian DG, Lucas A. Impact of breast
milk on intelligence quotient, brain size, and white matter development. Pediatr
Res 2010;67:357–62.
[19] Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is
associated with a lower rate of necrotizing enterocolitis than a diet of human milk
and bovine milk-based products. J Pediatr 2010;156. 562–567.e1.
[20] Cristofalo EA, Schanler RJ, Blanco CL, et al. Randomized trial of exclusive human
milk versus preterm formula diets in extremely premature infants. J Pediatr
2013;163. 1592–5.e1.
[21] Schanler RJ, Lau C, Hurst NM, Smith EO. Randomized trial of donor human milk
versus preterm formula as substitutes for mothers' own milk in the feeding of ex-
tremely premature infants. Pediatrics 2005;116:400–6.
[22] Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of
human milk in extremely low birth weight infants' risk of necrotizing enterocolitis
or death. J Perinatol 2009;29:57–62.
[23] Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet
336(8730):1519–1523.
[24] Abrams SA, Schanler RJ, Lee ML, Rechtman DJ. Greater mortality and morbidity in
extremely preterm infants fed a diet containing cow milk protein products.
Breastfeed Med 2014;9:281–5.
[25] Brown JV, Embleton ND, Harding JE, McGuire W. Multi-nutrient fortification of
human milk for preterm infants. Cochrane Database Syst Rev 2016;5. CD000343.
[26] Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or
low birth weight infants. Cochrane Database Syst Rev 2014;4. CD002971.
[27] Boyd CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for
preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal
Ed 2007;92:F169–75.
[28] Corpeleijn WE, de Waard M, Christmann V, et al. Effect of donor milk on severe
infections and mortality in very low-birth-weight infants. JAMA Pediatr
2016;170:654.
[29] O'Connor DL, Gibbins S, Kiss A, et al. Effect of supplemental donor human milk
compared with preterm formula on neurodevelopment of very low-birth-weight
infants at 18 months. J Am Med Assoc 2016;316:1897.
[30] Peila C, Moro GE, Bertino E, et al. The effect of holder pasteurization on nutrients
and biologically-active components in donor human milk: a review. Nutrients
2016;8(8).
[31] Ewaschuk JB, Unger S, O'Connor DL, et al. Effect of pasteurization on selected
immune components of donated human breast milk. J Perinatol 2011;31:593–8.
[32] Corpeleijn WE, Kouwenhoven SMP, Paap MC, et al. Intake of own mother's milk
during the first days of life is associated with decreased morbidity and mortality in
4
Seminars in Fetal and Neonatal Medicine xxx (xxxx) xxx–xxx
very low birth weight infants during the first 60 days of life. Neonatology
2012;102:276–81.
[33] Wiedmeier S, Henry E, Baer V, et al. Center differences in NEC within one health-
care system may depend on feeding protocol. Am J Perinatol 2008;25:5–11.
[34] Patole SK, de Klerk N. Impact of standardised feeding regimens on incidence of
neonatal necrotising enterocolitis: a systematic review and meta-analysis of ob-
servational studies. Arch Dis Child Fetal Neonatal Ed 2005;90:F147–51.
[35] Jasani B, Patole S. Standardized feeding regimen for reducing necrotizing en-
terocolitis in preterm infants: an updated systematic review. J Perinatol
2017;37:827–33.
[36] Berseth CL, Bisquera JA, Paje VU. Prolonging small feeding volumes early in life
decreases the incidence of necrotizing enterocolitis in very low birth weight infants.
Pediatrics 2003;111:529–34.
[37] Henderson G, Craig S, Brocklehurst P, McGuire W. Enteral feeding regimens and
necrotising enterocolitis in preterm infants: a multicentre case–control study. Arch
Dis Child Fetal Neonatal Ed 2009;94:F120–3.
[38] Leaf A, Dorling J, Kempley S, et al. Early or delayed enteral feeding for preterm
growth-restricted infants: a randomized trial. Pediatrics 2012;129:e1260–8.
[39] Morgan J, Young L, Mcguire W. Delayed introduction of progressive enteral feeds to
prevent necrotising enterocolitis in very low birth weight infants. Cochrane
Database Syst Rev 2014;12. CD001970.
[40] Morgan J, Young L, Mcguire W. Slow advancement of enteral feed volumes to
prevent necrotising enterocolitis in very low birth weight infants. Cochrane
Database Syst Rev 2014;12. CD001241.
[41] Stoll BJ, Hansen NI, Adams-Chapman I, et al. Neurodevelopmental and growth
impairment among extremely low-birth-weight infants with neonatal infection.
J Am Med Assoc 2004;292:2357.
[42] Karagol BS, Zenciroglu A, Okumus N, Polin RA. Randomized controlled trial of slow
vs rapid enteral feeding advancements on the clinical outcomes of preterm infants
with birth weight 750–1250 g. J Parenter Enteral Nutr 2013;37:223–8.
[43] Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage LA, Poole WK. Growth in
the neonatal intensive care unit influences neurodevelopmental and growth out-
comes of extremely low birth weight infants. Pediatrics 2006;117:1253–61.
[44] Picaud J-C, Houeto N, Buffin R, Loys C-M, Godbert I, Haÿs S. Additional protein
fortification is necessary in extremely low-birth-weight infants fed human milk.
J Pediatr Gastroenterol Nutr 2016;63:103–5.
[45] Rosas R, Sanz M, Fernández-Calle P, et al. Experimental study showed that adding
fortifier and extra-hydrolysed proteins to preterm infant mothers' milk increased
osmolality. Acta Paediatr 2016;105:e555–60.
[46] Shah SD, Dereddy N, Jones TL, Dhanireddy R, Talati AJ. Early versus delayed
human milk fortification in very low birth weight infants – a randomized controlled
trial. J Pediatr 2016;174. 126–31.e1.
[47] Mukhopadhyay K, Narnag A, Mahajan R. Effect of human milk fortification in ap-
propriate for gestation and small for gestation preterm babies: a randomized con-
trolled trial. Indian Pediatr 2007;44:286–90.
[48] Ballard O, Morrow AL. Human milk composition. Pediatr Clin 2013;60:49–74.
[49] Shen RL, Thymann T, Østergaard MV, et al. Early gradual feeding with bovine
colostrum improves gut function and NEC resistance relative to infant formula in
preterm pigs. Am J Physiol Gastrointest Liver Physiol 2015;309:G310–23.
[50] Juhl SM, Ye X, Zhou P, et al. Bovine colostrum for preterm infants in the first days of
life. J Pediatr Gastroenterol Nutr 2018;66:471–8.
[51] Seigel JK, Smith PB, Ashley PL, et al. Early administration of oropharyngeal co-
lostrum to extremely low birth weight infants. Breastfeed Med 2013;8:491–5.
[52] Romano-Keeler J, Azcarate-Peril MA, Weitkamp J-H, et al. Oral colostrum priming
shortens hospitalization without changing the immunomicrobial milieu. J Perinatol
2017;37:36–41.
[53] Glass K, Greecher C, Doheny K. Oropharyngeal administration of colostrum in-
creases salivary secretory IgA levels in very low-birth-weight infants. Am J
Perinatol 2017;34:1389–95.
[54] Lee J, Kim H-S, Jung YH, et al. Oropharyngeal colostrum administration in ex-
tremely premature infants: an RCT. Pediatrics 2015;135:e357–66.
[55] Actor JK, Hwang S-A, Kruzel ML. Lactoferrin as a natural immune modulator. Curr
Pharmaceut Des 2009;15:1956–73.
[56] Manzoni P, Meyer M, Stolfi I, et al. Bovine lactoferrin supplementation for pre-
vention of necrotizing enterocolitis in very-low-birth-weight neonates: a rando-
mized clinical trial. Early Hum Dev 2014;90:S60–5.
[57] Akin IM, Atasay B, Dogu F, et al. Oral lactoferrin to prevent nosocomial sepsis and
necrotizing enterocolitis of premature neonates and effect on T-regulatory cells. Am
J Perinatol 2014;31:1111–20.
[58] Pammi M, Abrams SA. Oral lactoferrin for the prevention of sepsis and necrotizing
enterocolitis in preterm infants. Cochrane Database Syst Rev 2015;2. CD007137.
[59] Sherman MP, Adamkin DH, Niklas V, et al. Randomized controlled trial of ta-
lactoferrin oral solution in preterm infants. J Pediatr 2016;175. 68–73.e3.
[60] Underwood MA, Gaerlan S, De Leoz MLA, et al. Human milk oligosaccharides in
premature infants: absorption, excretion and influence on the intestinal microbiota.
Pediatr Res 2015;78:670–7.
[61] Nanthakumar NN, Dai D, Newburg DS, Walker WA. The role of indigenous mi-
croflora in the development of murine intestinal fucosyl- and sialyltransferases.
Faseb J 2003;17:44–6.
[62] Morrow AL, Ruiz-Palacios GM, Jiang X, Newburg DS. Human-milk glycans that
inhibit pathogen binding protect breast-feeding infants against infectious diarrhea.
J Nutr 2005;135:1304–7.
[63] Jantscher-Krenn E, Zherebtsov M, Nissan C, et al. The human milk oligosaccharide
disialyllacto-N-tetraose prevents necrotising enterocolitis in neonatal rats. Gut
2012;61:1417–25.
[64] Autran CA, Schoterman MHC, Jantscher-Krenn E, Kamerling JP, Bode L. Sialylated
D.d.l. Cruz, C. Bazacliu
galacto-oligosaccharides and 2′-fucosyllactose reduce necrotising enterocolitis in
neonatal rats. Br J Nutr 2016;116:294–9.
[65] Good M, Sodhi CP, Yamaguchi Y, et al. The human milk oligosaccharide 2′-fuco-
syllactose attenuates the severity of experimental necrotising enterocolitis by en-
hancing mesenteric perfusion in the neonatal intestine. Br J Nutr
2016;116:1175–87.
[66] He Y, Liu S, Leone S, Newburg DS. Human colostrum oligosaccharides modulate
major immunologic pathways of immature human intestine. Mucosal Immunol
2014;7:1326–39.
[67] Morrow AL, Meinzen-Derr J, Huang P, et al. Fucosyltransferase 2 non-secretor and
low secretor status predicts severe outcomes in premature infants. J Pediatr
2011;158:745–51.
[68] Maheshwari A, Kelly DR, Nicola T, et al. TGF-β2 suppresses macrophage cytokine
production and mucosal inflammatory responses in the developing intestine.
Gastroenterology 2011;140:242–53.
Seminars in Fetal and Neonatal Medicine xxx (xxxx) xxx–xxx
[69] Frost BL, Jilling T, Lapin B, Maheshwari A, Caplan MS. Maternal breast milk
transforming growth factor-beta and feeding intolerance in preterm infants. Pediatr
Res 2014;76:386–93.
[70] Foster JP, Seth R, Cole MJ. Oral immunoglobulin for preventing necrotizing en-
terocolitis in preterm and low birth weight neonates. Cochrane Database Syst Rev
2016;4. CD001816.
[71] van der Hulst RR, van Kreel BK, von Meyenfeldt MF, et al. Glutamine and the
preservation of gut integrity. Lancet 1993;341(8857):1363–5.
[72] Moe-Byrne T, Brown JVE, McGuire W. Glutamine supplementation to prevent
morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2016;1.
CD001457.
[73] Becker RM, Wu G, Galanko JA, et al. Reduced serum amino acid concentrations in
infants with necrotizing enterocolitis. J Pediatr 2000;137:785–93.
[74] Shah PS, Shah VS, Kelly LE. Arginine supplementation for prevention of necrotising
enterocolitis in preterm infants. Cochrane Database Syst Rev 2017;4. CD004339.