Human milk feeding and direct breastfeeding improve outcomes for infants with single ventricle congenital heart disease: Propensity score matched analysis of the NPC-QIC registry
Authors: Elgersma Kristin M. , Wolfson Julian , Fulkerson Jayne A. , Georgieff Michael K. , Looman Wendy S. , Spatz Diane L. , Shah Kavisha M. , Uzark Karen , McKechnie Anne Chevalier 
Published: April 2023

Background

Infants with single ventricle (SV) congenital heart disease (CHD) undergo three staged surgeries/interventions, with risk for morbidity and mortality. We estimated the effect of human milk (HM) and direct breastfeeding (BF) on outcomes including necrotizing enterocolitis (NEC), infection-related complications, length of stay (LOS), and mortality.

Methods

We analyzed the National Pediatric Cardiology Quality Improvement Collaborative registry (2016–2021), examining HM/BF groups during stage 1 (S1P) and stage 2 (S2P) palliations. We calculated propensity scores for feeding exposures, then fitted Poisson and logistic regression models to compare outcomes between propensity-matched cohorts.

Results

Participants included 2491 infants (68 sites). Estimates for all outcomes were better in HM/BF groups. Infants fed exclusive HM before S1P had lower odds of preoperative NEC (OR=0.37, 95% CI=0.17–0.84, p=0.017) and shorter S1P LOS (RR=0.87, 0.78–0.98, p=0.027). During the S1P hospitalization, infants with high HM had lower odds of postoperative NEC (OR=0.28, 0.15–0.50, p<0.001) and sepsis (0.29, 0.13–0.65, p=0.003), and shorter S1P LOS (RR=0.75, 0.66–0.86, p<0.001). At S2P, infants with any HM (0.82, 0.69–0.97, p=0.018) and any BF (0.71, 0.57–0.89, p=0.003) experienced shorter LOS.

Conclusions

Infants with SV CHD in high HM and BF groups experienced multiple significantly better outcomes. Given our findings of improved health, strategies to increase the rates of HM/BF in these patients should be implemented. Future research should replicate these findings with granular feeding data and in broader CHD populations, and should examine mechanisms (eg, HM components; microbiome) by which HM/BF benefits these infants.

Clinical Perspective

What is new?

This is the first large, multisite study examining the impact of human milk and breastfeeding on outcomes for infants with single ventricle congenital heart disease.

All outcome estimates were better in high human milk and breastfeeding groups, with significantly lower odds of necrotizing enterocolitis, sepsis, and infection-related complications; and significantly shorter length of stay at both the neonatal stage 1 palliation and the subsequent stage 2 palliation.

All estimates of all-cause mortality were substantially lower in human milk and breastfeeding groups, with clinically important estimates of 75%–100% lower odds of mortality in direct breastfeeding groups.

What are the clinical implications?

There is a critical need for improved, condition-specific lactation support to address the low prevalence of human milk and breastfeeding for infants with single ventricle congenital heart disease.

Increasing the dose and duration of human milk and direct breastfeeding has strong potential to substantially improve the health outcomes of these vulnerable infants.