But breastfeeding does not happen in a vacuum. Its success is shaped by social determinants of health: paid maternity leave, workplace lactation spaces, access to skilled lactation support, income, housing stability, and freedom from the pressures of returning to work too soon. A mother's ability to breastfeed is inseparable from the conditions society creates around her. And this is precisely why breastfeeding cannot be framed as a woman's individual responsibility or failure. It is a shared societal task — one that requires partners, families, employers, health systems, and policymakers to build environments where breastfeeding is genuinely possible, not just recommended.

Brazil has particular reason to lead this conversation. Decades ago, the pioneering work of Cesar Victora and colleagues helped establish, with rigorous epidemiological evidence, the profound impact of breastfeeding on child survival, cognitive development, and long-term chronic disease risk — research that reshaped global health policy and remains foundational to how we understand infant nutrition today.

Brazil also holds the largest human milk bank network in the world (Rede Brasileira de Bancos de Leite Humano — BLH-BR). Crucially, Brazilian milk banks never sell human milk — every donation is voluntary, and every drop is provided to preterm infants during NICU stay free of charge. Beyond supplying donor milk to NICUs, these centers offer something remarkable: free, hands-on support to any breastfeeding woman who walks through their doors — help with latch, engorgement, low supply, or simply the reassurance of having questions answered by someone who knows what she's going through. This support is not restricted to Brazilian citizens or mothers with a baby in the hospital; it is also open to foreign women living in or visiting Brazil, with no cost or bureaucracy involved.

It's a model built on solidarity rather than transaction, and it raises a genuine question: how does breastfeeding support work in other countries? Is free, walk-in lactation help as accessible elsewhere, or is Brazil's network something closer to an outlier worth learning from? I'm curious to read about practices in other countries.

But what is the role for higher rates of enteral feeding on Day 1 in the otherwise well infant without significant respiratory distress? Breastfeeding and EBM where possible, but also either a term formula (~7.5 g carb/100mL) or preterm (8.3 g/100mL) with the additional option to add dextrose (eg 4 mL of 50% added to 100 mL of formula) or a dextrose polymer (poly-joule) which would allow even greater amounts to be added without excessive osmolality. How high can we go with these options, both in terms of concentration and volume?

Do any units use Dextrose 10% solutions enterally to manage the sugars without needing formula?

Theoretically we can max-out the gut glucose transporters even when there is no actual gut pathology - quoted max active absorption is 6 to 8 mg/kg/min only but I'm not sure how well-evidenced that is.

I'd like to get a sense of what other teams are doing to optimise enteral feed options in hypoglycemia so will try to post a very short survey.

I would like your expertise in a patient case. We have a preterm infant born at 28+2 weeks of gestation following PPROM and chorioamnionitis, treated with SALSA for RDS, and subsequently managed on HFNC until a week ago. The infant is now at 34+0 weeks postmenstrual age and is off all respiratory support. Aside from this, the infant is very healthy, with no IVH, no PDA, and adequate growth. Enteral nutrition was initiated with donor breast milk, and the infant reached full enteral feeds of 150 mL/kg by 7 days of age.

The infant’s mother has complex epilepsy and was maintained on Tegretol (carbamazepine) 800 mg + 1200 mg/day, Briviact (brivaracetam) 200 mg + 200 mg/day, and mirtazapine 45 mg once daily throughout the entire pregnancy. She began pumping early on and expressed a strong desire to feed the baby with her own milk. Initially we were hesitant, however, given her strong wishes and our goal to promote the use of mother's own milk, we have permitted partial feeding with MOM 12 mL out of 50 mL per feed, 8 times a day. The infant currently weighs 2340 g.

We now need to decide whether to allow her to transition to full breastfeeding. While we do use Briviact to treat some of our pediatric patients, this scenario presents a complex preterm polypharmacy issue, and our experience with Briviact safety during breastfeeding is limited. The straightforward approach would be to transition directly to formula, but the mother has worked incredibly hard for this, and we want to support her wishes if it is safe to do so. I read @Dotan S framework on polypharmacy (https://www.nature.com/articles/s41390-025-04416-z) and I know that @Mariana Oliveira usually has great insights on this topic.

What would be an acceptable approach according to you? Allt toughts are welcome to help us make the most reasonable decision.

Best Gustaf

As a teritary unit now rising to the challenge of delivering and optimising the care of our nano prem infants can I enquire if any Units have identified particular challenges of nutritional delivery and surveillance (parenteral and enteral) biomarkers (UE/LFT/Bone/Trigs etc)

Thank you in advance. Here's to the next 20 years of the '99'

Al

Allow me to share with you some thoughts on non-nutritive feeding. We all know the important role of non-nutritive sucking, its significance in the formation of a healthy infant gut microbiota and psychological comfort for mother and child. But we rarely consider the differences in the structure of the nipple skin from the rest of the skin. The nipple skin is extremely resistant to mechanical and chemical stress, and the breastfeeding period is a case in point. Any other area of skin becomes malignant as a result of chronic mechanical and chemical trauma associated with breastfeeding. Any area, but not the nipple skin. And I thought about the epidermis that the infant receives during feeding, which enters the bloodstream and serves as an important factor in training the immune system to recognize cells susceptible to mutagenic activity. The initial learning period occurred in utero, and the baby's immune system, already well-acquainted with the cell membrane proteins of various maternal cells (primarily blood cells), continues this training after birth through numerous nutritional and non-nutritive factors in feeding. What is so special about the nipple skin that it is responsible for training the infant's immune system, even if my description is rather primitive? What are the significant differences between the skin of the mother's nipple? Quite recently, a very simple idea occurred to me while examining the baby while the mother was breastfeeding. Unlike the rest of the skin, the nipple skin is pigmented. Why this particular area of skin, and what is its evolutionary significance? Could melanin not be the cause not only of these external differences, but also be the main factor in the nipple skin's increased stress resistance to external influences and a factor in the fine-tuning of the infant's immune system, ensuring effective antimutagenic activity throughout childhood, despite rapid growth and high proliferative cellular activity?

Sincerely, Alex Nouzdin

We are currently rewriting our internal protocols regarding bacteriological screening and CMV management of maternal milk (MOM) for hospitalized preterm infants.

While our primary goal is maximum safety, we are guided by the principle of non-maleficence (Primum non nocere). This creates a complex clinical challenge: how do we protect the infant from potential pathogens (infection risk) without causing harm by destroying vital bioactive and immunological components through over-processing (nutritional/developmental risk)? Furthermore, we must avoid the harm of unnecessarily discarding precious breastmilk—a practice that exhausts resources and can lead to "pumping fatigue," discouraging mothers from continuing their lactation journey.

We have observed that practices vary widely between centers and countries, often based on historical habits rather than robust data. We are seeking a secure yet pragmatic solution and would value your insights on the following:

• Patient Selection & Duration: Do you perform systematic bacteriological controls on MOM for specific populations (e.g., all VLBW, or only those <28 weeks, none of them)? For how long do you continue these controls (e.g., until a specific post-natal age)?

• Frequency & Uncertainty: How often do you test the milk (weekly, every batch)? More importantly, how do you manage the "window of uncertainty" between controls?

• Bacteriological Thresholds: How do you pragmatically define "acceptable" milk?

• The CMV Challenge: For CMV-seropositive mothers, do you mandate Holder pasteurization? If so, for which gestational age groups and for what duration ?

• Resource Management: How do you ensure your protocol doesn't lead to excessive milk disposal or discourage the mother's involvement?

We look forward to hearing about your center's experience, the evidence-base you utilize, and how you navigate these "grey areas."

Thanks in advance for your valuable contributions.

A few years ago, our team cared for a remarkable mother whose story reminded us how much nuance—and teamwork—breastfeeding counseling can require. She had undergone a liver transplant as a teenager and remained on lifelong anti-rejection medications. Years later, she delivered a healthy full-term baby and had a strong, heartfelt wish to breastfeed.

As you can imagine, her medications raised questions about safety and infant exposure. Instead of defaulting to “no,” our team—neonatologist, clinical pharmacist, and the mother’s own transplant specialist—reviewed each drug carefully. We dove deep into pharmacokinetics and pharmacodynamics, half-lives, peak serum times, and milk-plasma ratios. The goal was to adapt the medication schedule to support breastfeeding, rather than ask her to give up breastfeeding because of the medications.

Together, we developed a practical plan:
• She could directly breastfeed from 7 AM to 7 PM.
• She would take her immunosuppressive dose immediately after 7 PM and avoid breastfeeding until 7 AM the next morning.
• She would pump at least twice overnight to maintain supply, but this milk would be discarded.
• Her baby would receive formula as needed during the nighttime window.

With this tailored approach, she was able to partially breastfeed her baby for eight months, which meant the world to her. For us, it was a powerful reminder that with the right information—and interprofessional collaboration—we can often make breastfeeding possible even in complex medical situations. This case was one that helped me shape my personal practice when it comes to breastfeeding support and orientation. It also highlighted how important it is to have trustworthy, up-to-date resources on medication safety in lactation.

So I’m curious: what resources do you rely on to check whether a medication is compatible with breastfeeding?
Have you managed similar cases you would like to share, and what tools or references were most helpful (e.g., online databases, institutional guidelines, books, lactation pharmacology experts)?

Would love to learn from your experience!

Breastfeeding mothers having propofol sedation at surgery, may have green discoloration of the breast milk, I just read a short clinical pharma column in the Swedish Medical Journal.

I found this longer case report from Canada about this, it seems propofol metabolites can discolour biological fluids other than urine. The authors advice no breast feeding until the color has normalised.

Rare thing but still interesting to know and be aware of!

https://pmc.ncbi.nlm.nih.gov/articles/PMC6306180/

I would love to read your thoughts on how you manage moderate/late preterm infants admitted in the NICU who do not have enough mother's milk. How do you feed them? Do you prefer to keep them on IV fluids/PN until MOM is available? Do you have unlimited donor milk to use for every baby? How is your level of concern about cow's milk allergy (CMA)?

I work in a teaching hospital in South Brazil and I'm an enthusiast (aren't we all?) on improving breastfeeding rates in the NICU.

How things work here: we have a limited resource of human donor milk, so we prioritize it to newborns under 32 weeks (when MOM is not available, of course). For babies older than that, when MOM is not available, we are using hydrolyzed formula in the first 24 hours - as an intention to try to avoid early exposure to cow's milk protein.

I am very aware that we don't have good evidence for that. In the ESPGHAN position paper on CMA (https://www.espghan.org/knowledge-center/publications/Gastroenterology/2024-Diagnois-and-Management-of-Cows-Milk-Alergy), it might seem OK to give hydrolyzed formula, and I like the thoughts on how offering this different type of formula might help parents to see it as something temporary.

The thing is sometimes babies keep on receiving hydrolyzed formula for longer than 24 hours, and we also do not have enough of that.

New thoughts on CMA prevention seem to go on a way that probably continue exposure to CMP might help prevent allergies. So, probably, offering hydrolyzed formula to babies who will stay longer in NICU might not be a good idea. Maybe later on I'll start a new topic on CMA in NICU too :)

We are a medium sized hospital in Germany with a donor milk bank. We are managing the procedures manually right now and are looking for a digital /software solution.

Any suggestions for a usable software?

Yours Nele Howold