Nasuf, Amna Widad Ahmed
(2019)
Early provision of maternal colostrum by the oropharyngeal route to preterm infants.
PhD thesis, University of Nottingham.
Abstract
Preterm infants are those born before 37 completed weeks of gestation. Worldwide, about one million children die each year due to complications of prematurity and survivors may face lifelong disabilities. Approximately 50% of neonatal deaths and 17% of deaths among children under five are affected by prematurity. Colostrum is the first milk produced by the mother within the early few days after birth. Colostrum is very rich in immunological and growth factors that indicates its primary functions are protective and trophic. Oropharyngeal administration of colostrum (OPC) is a novel route that involves coating the infant’s oropharynx with a small amount of colostrum (0.1 to 0.5 ml) during the early neonatal period. Immune and growth factors in colostrum might interact with the oropharyngeal mucosal-associated lymphoid tissues to modulate the infant’s immune system and promote intestinal growth, potentially reducing infection and necrotising enterocolitis (NEC), improving survival and health outcomes. Ultimately OPC could provide a potential target to prevent mortality and morbidities of preterm and sick infants. This thesis aimed to investigate whether OPC administration during the early neonatal period prevents deaths, improves health outcomes and promotes the growth of preterm infants.
To achieve the aim of this thesis; initially, an online survey targeted neonatal professionals was performed to evaluate the current practice and perception of OPC administration in the UK neonatal units. Oropharyngeal colostrum has been introduced into UK neonatal practice despite a lack of high-quality evidence regarding its efficacy and safety. OPC practice was variable, frequently without written guidelines.
A Cochrane systematic review was conducted to synthesis and appraise the currently available randomised controlled trials (RCTs), which evaluated if early OPC given within the first 48 hours has a positive impact in preterm infants (< 37 weeks gestation) compared with control. Six RCTs were eligible for inclusion in this systematic review. Meta-analysis showed that early OPC could shorten the time to reach full enteral feeds but did not reduce the incidence of late-onset infection (LOI), NEC and death nor the length of hospital stay. Available evidence is insufficient due to lack of participants and very low quality to demonstrate the benefits effects of OPC for preterm infants.
The third study, a matched case-control study evaluated the effects of OPC administration on the short-term health outcomes in preterm (≤ 32 weeks) infants. Eligible infants who were admitted to the Nottingham neonatal units after the implementation of OPC in the care of preterm infants, and received OPC, compared with those who were admitted before the use of OPC in the units. Preterm infants who received OPC within the first 96 hours of life achieved full enteral feeding (150 ml/Kg/day for consecutive 72 hours) earlier than those infants who did not receive OPC. A higher rate of receiving breast milk at discharge to home was also observed. However, the two groups had a similar length of hospital stay, weight Z-score at hospital discharge, and incidences of NEC, LOI and deaths.
Finally, a non-randomised observational study evaluated the response of gut hormones to OPC administration in preterm (< 37 weeks of gestation) and ill infants requiring neonatal intensive care (NIC). Preliminary results demonstrated a rising trend in plasma gut hormone concentrations in response to OPC administration in the participant preterm and full-term infants. This study is ongoing, and more infants are required before final conclusions can be elicited.
In conclusion, OPC administration is a potentially feasible intervention that shortens time to attain full enteral feeds in preterm infants. Given the high risk for preterm infants and the benefits of maternal colostrum, OPC may have preventive implications for improving the health outcomes of this vulnerable population. This work expands the current knowledge about the use of OPC in the care of preterm and sick newborn infants and could benefit efforts to improve preterm birth outcomes by informing guidelines, clinical decision and future research. Larger, well-designed, high-quality research with sufficient power are needed to assess the efficacy and safety of this intervention.
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