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To the Editor.—
As usual for Schanler et al,1 their latest study is extremely well done, with careful outcome definition and randomization, standardized feeding protocols, and sophisticated statistical analysis. The sample size was based on expected differences in necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) from a prior study.2 Fortunately for the infants, but unfortunately for the study, the incidence of NEC was almost 50% less than anticipated. Because the rates of NEC were much less than predicted, the sample sizes were inadequate to detect a significant difference if present; the mother's own milk (MM) and donor milk (DM) groups had a 6% incidence of NEC, whereas the preterm formula (PF) group had an 11% incidence (see Table 2 in ref 1).
The article does not specify which patients from their general NICU population eligible for the study were approached or excluded from study because of parents declining, death before day 4, etc. Also, although probably appropriate when looking at the outcomes of NEC and LOS, the study period started when infants were receiving 
50 mL/kg enteral feeds (mean of 18 days). These early feedings were presumably maternal milk, although it is not specified. Both the DM and PF groups received 
50% of their enteral intake as their MM. There was no pure DM group. This significant amount of MM, and possibly the first few feedings being MM, may have washed out some of the differences in outcome.
Other interesting findings were the significant decrease in chronic lung disease with both MM and DM compared with PF (see Table 1 in ref 1) and the tendency (not statistically significant) for decreased ventilator days in both the MM and DM groups (see Table 2 in ref 1). Less retinopathy of prematurity was found in the MM group.
The growth parameters were also interesting, with length increment (cm per week) significantly shorter in the MM group versus the DM or PF groups. There was no difference in head-circumference increment between any of the 3 groups. Weight gain was slowest for the DM and fastest for the PF group as expected, but the authors do point out in their discussion that faster growth may not be better. They also point out that they did not study long-term outcomes such as IQ, blood pressure, obesity, etc.
There was a huge difference in skin-to-skin–contact time between the MM group and the other 2 groups (see Table 5 in ref 1). Skin-to-skin contact was highly correlated with the percentage of MM intake and not correlated with any infection-related events. It is interesting to note that despite help from lactation consultants in the NICU, only 27% of the mothers had enough milk to meet all their infant's needs.
I am interested in additional results from this study, such as nutritional chemical markers (serum urea nitrogen, prealbumin, alkaline phosphatase, calcium, phosphorus, etc.) and bone densities. I hope that they were collected in the routine management of these patients. Perhaps they will be described in a separate article.
On a purely editorial/presentation note, I find it curious that in each table the order of the groups is DM, PF, and MM. This presentation tends to visually obscure the possible dose-response effect found in several variables, some of which are significant and others of which are only trends. For several variables, DM outcomes are between those of MM and PF.
The authors concluded that fortified donor human milk did not offer any short-term advantages over PF and indeed resulted in slower weight gain. They therefore recommend that every effort be made to support mothers in the NICU providing their own milk for their infants. They again confirmed the decrease in NEC, other infections, and length of stay for infants fed their MM. Another recent prospective observational study of 99.6% of all eligible extremely low birth weight infants (<1000 g or <28 weeks' gestation) born in Norway in 1999 and 2000 demonstrated that very early feeding (96% fed by day 3 of life) with either MM or DM significantly reduced the risk of LOS.3
I think that we all can agree that MM is the best, but I am not ready to give up on pasteurized DM. In a recent systematic review, preterm infants who were fed donor human milk had a 4-times reduced risk of NEC compared with infants fed formula.4 Current research into alternate methods of heat treatment such as short-time high temperature may improve the survival of human milk factors better than current pasteurization methods. I believe that additional studies, perhaps a multicenter trial to find enough infants who receive only fortified donor milk, are needed.
REFERENCES
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