Mariana Oliveira

@AntoineBachy this is a critical topic, and in my view, current practices in many centers may overemphasize theoretical microbiological risks at the expense of the well-established benefits of mother’s own milk (MOM) for preterm infants. Based on more than 40 years of experience in a tertiary NICU in southern Brazil—and systematic data collection since 2011 within the Vermont Oxford Network—we have adopted a deliberately non-interventionist approach regarding bacteriological screening and CMV management of MOM. Answering to your questions: Patient Selection & Duration: We do not perform routine bacteriological screening of MOM in any subgroup, including extremely preterm or VLBW infants. Screening is reserved exclusively for cases with clinical suspicion of infection, particularly sepsis-like syndromes. In our experience, routine surveillance has not demonstrated sufficient benefit to justify its risks, costs, and unintended consequences. Frequency & Uncertainty: We do not perform periodic microbiological testing. Instead, risk mitigation relies on strict adherence to standardized protocols for milk expression, storage, and handling, as defined by the Brazilian Human Milk Bank Network. We believe this preventive approach is more effective than intermittent culturing, which may create both false reassurance and unnecessary interventions. Bacteriological Thresholds: We do not routinely culture MOM in our NICU. However, when microbiological control is applied—particularly within human milk banks—it follows well-defined technical criteria rather than arbitrary thresholds. According to Brazilian standards, screening targets Gram-negative bacilli, defined as aerobic or facultative anaerobic, non-spore-forming, oxidase-negative microorganisms capable of growing in the presence of bile salts or surfactants, and fermenting lactose with acid, gas, and aldehyde production at 35°C within 24–48 hours, often with β-galactosidase activity. This reflects a targeted safety strategy, focusing on clinically relevant pathogens. Importantly, these criteria are embedded within a structured quality-control system for donor milk and do not support routine bacteriological screening of MOM in NICU settings. The CMV Challenge: We do not perform routine CMV screening in mothers and do not apply Holder pasteurization to MOM based on serostatus. This is consistent with current understanding that postnatally acquired CMV infection differs significantly from congenital disease and is not a contraindication to breastfeeding, as stated by the American Academy of Pediatrics. Our preventive strategy is internally consistent: we ensure CMV-safe blood transfusions (CMV-negative or leukoreduced) for extremely preterm infants (<30 weeks), addressing a well-established route of transmission that is sometimes overlooked when focus is placed primarily on breast milk. Across decades of practice, severe CMV disease associated with MOM has been exceedingly rare in our unit. When it occurred, it presented as a sepsis-like syndrome and responded well to short-course antiviral therapy. Resource Management: We consider preservation of MOM a priority. Milk disposal is minimized and limited to exceptional, clinically justified situations. Protocols that lead to frequent discard or excessive processing risk not only reducing the biological value of milk but also discouraging maternal participation and contributing to pumping fatigue—which, in our view, directly conflicts with the principle of primum non nocere. It is important to highlight that Brazil has the largest human milk bank network in the world, supported by robust, standardized national regulations governing collection, processing, pasteurization, and distribution of human milk. These include: Clearly defined microbiological screening criteria (focused on Gram-negative pathogens) Standardized Holder pasteurization (62.5°C for 30 minutes) for donor milk Mandatory post-pasteurization microbiological quality control Notably, even within this highly regulated system, routine CMV screening is not performed, and pasteurization is primarily reserved for donor milk—not MOM, which is only pasteurized if the production exceeds the maximum freezing time for storage. Our position is that routine bacteriological screening and CMV-driven pasteurization of MOM are not supported by current evidence and may result in more harm than benefit. A strategy centered on preventive practices, standardized handling, and clinical vigilance is, in our experience, safer, more sustainable, and better aligned with the unique biological value of human milk. We recognize that practices vary across settings, but we would strongly encourage reconsideration of protocols that prioritize theoretical risks over demonstrated benefits. I would love to know how other NICUs face these challenges and let me know if I can help with anything else.

Thank you for the paper, @Annika

I’d love to hear from the 99NICU community about your go-to references. 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!

Good for you, Stefan. I don’t know about Sweden, but in Brazil you can still work regular, 6h, all weekdays shifts in the NICU and never work during night shifts or weekends/holidays at all. That’s the choice I’ve made when my kids were little and I have never regretted it. You find your way through doing everything you have to do during daytime and get the reward of a healthier lifestyle. And don’t worry: I still have to wake up at 5AM everyday to drive them to school, in time to arrive at the hospital at 7AM 😜

Hi @Greice Batista I work in a private hospital unit that does not have a human milk bank, but we do have a lactation center. Despite this, we have achieved excellent breastfeeding outcomes in our NICU. We begin with the most extremely premature infants, implementing a routine of prolonged oral immunotherapy as soon as the mother begins expressing milk, and we continue this practice until the infant transitions to full oral feeding. We have trained personnel to start early support for breastfeeding initiation for preterm mothers, and even when they start a little bit later (second or third day postpartum), most of them are successful in coming to volume. For these youngest babies (<30 weeks and/or under 1500 grams), we initiate an amino acid and glucose solution immediately upon their admission to the NICU. We wait for expressed breast milk to become available before starting enteral nutrition—typically within the first 72 hours. Our breastfeeding rate at discharge in this group (not exclusive, but predominant) is approximately 95%. For moderate to late preterm infants, we aim to initiate enteral feeding with breast milk within the first 48 hours of life. On average, these babies achieve full enteral feeds between 7 and 10 days of life, always prioritizing their own mother’s milk. When breast milk is unavailable, we begin with preterm infant formula. In this group, we rarely observe cow's milk protein allergy. We are more tolerant of frequent vomiting episodes (always monitoring weight gain) and continue encouraging mothers to express milk. The breastfeeding rate at discharge in this population is slightly lower, around 80%. I believe the most impactful change was the creation of a multidisciplinary team and the implementation of weekly breastfeeding-focused rounds. Through this initiative, we began daily monitoring of breastfeeding rates at discharge, stratifying infants by gestational age (<30 weeks vs. ≥30 weeks). This helped us identify lower breastfeeding rates at discharge, particularly among the more mature preterm infants. We then constructed a Dashboard, making this data available for everyone in the NICU. We are aware that certain characteristics of our population also facilitate our results: most mothers have private health insurance or are hospitalized as private patients, which means they are generally entitled to formal maternity leave and have easier access to the NICU. Their increased presence in the unit allows our team to provide ongoing guidance and support for breastfeeding. I recognize that this scenario may not always be feasible for patients in the public healthcare system (SUS)...

What I would like neonatologists to know about the Norwegian RCT on Immediate SSC for Very Preterm Neonates A recent randomized clinical trial published in JAMA Network Open challenges assumptions about the neurodevelopmental impact of immediate skin-to-skin contact (SSC) for very preterm infants (28–31 weeks’ gestation). Conducted across three Norwegian neonatal units (2014–2020), the study compared 2 hours of SSC in the delivery room versus standard incubator care, following 108 stable preterm neonates until age 2–3 years. While the primary outcome—neurodevelopmental scores on the Bayley-III—showed no difference between groups, the trial confirmed SSC’s significant benefits for breastfeeding, with 84% of SSC infants breastfed at discharge versus 67% in standard care (p=0.04). Published in April 16th, 2025, these findings refine our understanding of SSC: though brief early contact may not independently alter long-term cognition, it remains a vital, low-risk intervention that supports bonding and lactation—key components of developmental care. The study underscores that clinical value isn’t solely defined by neurodevelopmental metrics, but by tangible, family-centered outcomes.This well-designed randomized clinical trial (RCT) from Norway provides important but nuanced evidence about the neurodevelopmental impact of immediate skin-to-skin contact (SSC) in very preterm infants (28-31 weeks GA). While the negative primary outcome has garnered attention, several key aspects warrant careful interpretation: Strengths: 1. Methodological Rigor: As one of the first RCTs specifically evaluating immediate SSC's neurodevelopmental outcomes in this gestational age range, the study addresses an important evidence gap. The intention-to-treat analysis and 80% follow-up rate bolster validity. 2. Clinical Realism: The intervention (2 hours of SSC in delivery room) reflects achievable practice in most tertiary centers, enhancing generalizability. The inclusion criteria (stable infants >1000g not requiring >40% O2) appropriately target the population most likely to benefit. 3. Breastfeeding Benefit: The significant improvement in breastfeeding rates at discharge (84% vs 67%, p=0.04) aligns with robust existing evidence, reinforcing SSC's role in lactation support. Limitations & Open Questions: 1. Power Considerations: With only 81 infants completing the primary outcome assessment, the study may be underpowered to detect smaller but clinically meaningful differences in BSID-III scores. The 95% CI for cognitive scores (-5.26 to 5.68) doesn't exclude potentially important effects. 2. Dose-Response Uncertainty: The single 2-hour SSC session represents a minimal intervention. Emerging evidence suggests neurodevelopmental benefits may require prolonged SSC (e.g., Kangaroo Mother Care protocols with daily SSC hours), particularly for more immature infants. 3. Outcome Timing: Assessment at 2-3 years may be premature. Some preterm neurodevelopmental differences (especially executive function, attention) often emerge at school age. The BSID-III has known limitations in predicting later cognitive function. Clinical Implications: 1. No Harm Shown: The null finding shouldn't discourage SSC implementation, given its other proven benefits (breastfeeding, bonding, physiological stability) and absence of adverse effects. 2. Targeted Counseling: Clinicians can reassure families that brief separation for stabilization doesn't appear to compromise neurodevelopment in stable late preterm/VLBW infants, while still advocating SSC when feasible. 3. Research Directions: Future studies should evaluate: Longer/more frequent SSC exposures Extremely preterm populations (<28 weeks) Advanced neuroimaging correlates School-age outcomes using more sensitive measures Conclusion: This study makes an important contribution by challenging assumptions about immediate SSC's neuroprotective effects in stable very preterms, while reinforcing its role in breastfeeding promotion. It highlights the complexity of neurodevelopment - while SSC remains a cornerstone of developmental care, its benefits may be domain-specific (affective vs cognitive) and dose-dependent. The findings should be interpreted as refining rather than refuting the value of SSC in neonatal practice. As a Brazilian researcher particularly interested in preterm breastfeeding, I would like to share some personal perspective on the SSC Study Findings: This study’s most critical takeaway isn’t that SSC "failed" to improve neurodevelopment—it’s that expecting just two hours of skin-to-skin contact to reshape long-term cognitive outcomes was an overly optimistic hypothesis to begin with. Neurodevelopment is shaped by a complex interplay of biological, environmental, and caregiving factors over years, not a single intervention in the delivery room. The fact that such a brief SSC exposure didn’t move the needle on Bayley scores at 2–3 years isn’t surprising; if anything, it underscores how simplistic it would be to assume that a one-time intervention could override the multitude of influences on a preterm infant’s brain development. What is remarkable—and far more clinically meaningful—is that this minimal, low-cost intervention still demonstrated clear benefits in breastfeeding and maternal-infant bonding. The significant increase in breastfeeding rates at discharge (84% vs. 67%) is a big deal—especially since breastfeeding itself is linked to better neurodevelopmental outcomes in preterms, reduced NEC risk, and long-term metabolic health. SSC and breastfeeding are deeply intertwined; SSC promotes early latch, maternal milk production, and parental confidence in handling their fragile infant. Trying to isolate SSC’s effects from breastfeeding seems nearly impossible—and perhaps missing the point. What this paper made me think is we shouldn’t dismiss SSC because it didn’t change Bayley scores. Instead, we should celebrate that something as simple as placing a stable preterm infant on their mother’s chest for two hours can: Improve breastfeeding success (a known protective factor for preterms) Enhance bonding (critical for parental mental health and infant stress regulation) Cost nothing (unlike high-tech NICU interventions) The study’s conclusion that SSC "should be encouraged in clinical practice" is exactly right—not because it’s a magic bullet for neurodevelopment, but because it’s a foundational practice that supports multiple positive outcomes. Future research should explore whether prolonged, repeated SSC (e.g., daily Kangaroo Care) has neurodevelopmental effects, but in the meantime, we have more than enough evidence to prioritize immediate SSC as a standard of care—not for what it might do someday, but for what it already does today. The bottom line is that if we expect every NICU intervention to show dramatic neurodevelopmental effects, we’ll overlook the power of small, humane practices that make a real difference to families. SSC isn’t about test scores—it’s about giving preterms and their parents the best possible start. That’s more than enough justification to keep doing it...

I would increase protein intake to 3.5 mg/kg/day and use a glucose rate of at least 5 mg/kg/min (never less than that). If with this adjustments my glucose levels were still around 20 mmol/L I would start continuous insulin.

The first thing I would ask is this baby on aminoacid infusion? How much?

I would love to do that. In any format you wish. Cesar Victora’s work is an inspiration for my daily practice in the NICU.

The relationship between breastfeeding and infant health has been extensively studied, with increasing evidence highlighting the influence of social determinants on breastfeeding practices. The findings of Ryan et al (2025) align with a longstanding body of research demonstrating that socioeconomic factors shape maternal and child health outcomes. Notably, Cesar Victora, a Brazilian epidemiologist, was a pioneer in this field, leading the first epidemiological study to establish a direct link between breastfeeding and the prevention of infant mortality. His research also reinforced that nutritional interventions within the first thousand days of life—spanning pregnancy to two years of age—yield far greater benefits than interventions introduced later in childhood. As he emphasized, investing in early nutrition is a cost-effective strategy to improve both immediate health outcomes and long-term human capital. Furthermore, Victora’s work played a foundational role in shaping global breastfeeding policies, including the World Health Organization’s (WHO) 1991 recommendations on exclusive breastfeeding. His studies demonstrated that exclusive breastfeeding contributes to improved cognitive development, higher educational attainment, and greater earning potential later in life—further reinforcing the long-term impact of early-life nutrition. Crucially, Victora also advanced research into the social determinants of health. His early work revealed that children living on smallholdings, where income distribution was more equitable and families had land ownership, exhibited better health outcomes compared to those from large estates. This insight underscored how structural inequalities influence child health, including breastfeeding practices. The current study by Ryan et al (2025) extends this line of inquiry, further demonstrating that breastfeeding is not only a biological process but also a socially determined behavior, shaped by economic, educational, and healthcare access factors. Victora’s contributions remain highly relevant in contemporary discussions on how to address these disparities and promote breastfeeding as a fundamental public health strategy. His book, “Epidemiology of Inequality”, published in 1988 should be a must read for all professionals involved in child health.

I think it helps that we have a hexavalent DTaP/IPV/ Hib/HepB combination. We observe temperature sometimes, but no serious adverse events. We don't have a specific protocol; we try to administer at the recommended time. If the baby is unstable, we might wait to administer, but they are usually fine at 8 weeks, @piatkat

That's very interesting graphic material. We have a routine of prescribing prolonged oropharyngeal colostrum, so whenever a mother delivers a preterm baby, we have a team ready to help this mother express colostrum as soon as possible. Even if the mother goes to the ICU, we have a designated team to support her. When we explain the importance of her colostrum to her baby care and that 2.5 ml are enough to provide oral care for the whole day (we apply .1 ml each side, every 2 h, with enteral feedings), their faces light up, and they say that volume they surely can provide. We don't use any graphic or written material, but this might be interesting to do.

Hi, @Greice Batista I'm also a Neonatologist from south Brazil, and we are reviewing our feeding protocols. About late preterm infants, we start with 30-40 ml/kg/d enteral feedings, and if the baby tolerates well, we progress the volume twice in one day (to 60 and then 80 ml/kg/day). We increase twice daily until they are on 150-160 ml/kg/day. We also stimulate breastfeeding, and they usually progress very well. Let me know if you want to share other practics and ideas...