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Quality of human milk expressed in a human milk bank and at home
Qualidade do leite humano ordenhado em banco de leite e no domicílio
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Uberlândia, Minas Gerais, Brazil, 2016.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Situations such as prematurity, newborn hospitalization in a neonatal unit, maternal diseases, or low milk production may lead to difficulties in establishing and maintaining breastfeeding (BF).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> Therefore, the use of donated human milk (HM) has become an efficient alternative for providing nutrition<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> to newborns in special conditions and a way of maintaining milk production by donor nursing mothers.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this sense, human milk banks (HMBs) are specialized services, responsible for actions of BF promotion, protection, and support, as well as the performance of activities of HM collection, processing, quality control, and distribution.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The process used to define the quality of expressed human milk (EHM) is the result of adequate hygienic-sanitary conditions, from expression to administration, and the joint evaluation of several parameters, including nutritional, immunological, chemical, and microbiological characteristics, thus providing confirmation of the final product's safety.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Brazil, as well as in other countries, HM milking is allowed in the donor's home, provided that the established hygiene, conservation, storage, and transport standards are met.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3,5–7</span></a> This way, greater participation of donor nursing mothers is ensured and, consequently, a greater production of EHM.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of the importance of home milking as a strategy for collecting EHM and the lack of studies on the safety of this type of milking, it was considered important to evaluate the quality of the EHM at home and in the HMB.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">A retrospective study was carried out by analyzing the records of the processing of the EHM samples in the year 2014 evaluated by the HMB of Hospital de Clínicas de Uberlândia, Universidade Federal de Uberlândia (HCU-UFU), Minas Gerais, Brazil. This study was approved by the Ethics Committee on Research with Human Beings of the institution where it was carried out, Opinion No. 1,289,959, of October 21, 2015.</p><p id="par0035" class="elsevierStylePara elsevierViewall">To define the sample size, the calculation was performed using the G*Power<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> program (Statistical power analyses, G*Power 3.1, Germany), and the minimum total sample size was defined as 84 samples. It was decided to collect the data from 100 samples of EHM, representing 50 samples in each group (group 1: milking at home; group 2: milking at the HMB).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Simple random sampling was used for the selection of the analyzed EHM samples. Initially, the records of the nursing mothers registered in 2014 were identified and separated by place of milking, and two selections were carried out by drawing lots. In the first, fifty mothers were randomly selected in each group, and each mother had, on average, six samples of EHM; in the second, one of the EHM samples of each previously selected mother was selected by drawing lots.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Of the selected EHM samples, the results of the titratable acidity evaluation were initially collected, which identify the level of acidity expressed in degrees Dornic (°D) of raw EHM.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,3</span></a> The HM has an original acidity with values ranging between 1 and 4<span class="elsevierStyleHsp" style=""></span>°D, but under conditions that favor the proliferation of microorganisms of the primary and secondary microbiota, lactic acid is produced and, consequently, there is an increase in the EHM acidity.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> Acidity ≥8<span class="elsevierStyleHsp" style=""></span>°D disqualifies the EHM for consumption.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,3,9</span></a> The Dornic acidity measurement is, therefore, a way to classify and select the donated HM before its pasteurization, using a simple and inexpensive test.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The EHM samples that attained titratable acidic value <8<span class="elsevierStyleHsp" style=""></span>°D were pasteurized and submitted to the microbiological quality control, based on the classical procedure for the presence (positive) or absence (negative) of total coliforms.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> The use of this procedure is recommended because it is simple, economically feasible, and safe, minimizing the possibility of false-negative results.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> Thus, the results of the microbiological culture of the EHM samples that attained values of titratable acidity <8<span class="elsevierStyleHsp" style=""></span>°D were collected. The samples that showed titratable acidity results ≥8<span class="elsevierStyleHsp" style=""></span>°D were replaced by the next sample from the same nursing mother with titratable acidity <8<span class="elsevierStyleHsp" style=""></span>°D, or a new drawing of lots was performed to select a new sample.</p><p id="par0055" class="elsevierStylePara elsevierViewall">All nursing mothers selected as donors received verbal and written instructions on how to milk and store the EHM, according to the recommendations of the National Sanitary Surveillance Agency (ANVISA) and the Brazilian Network of HMB (Rede BRH-BR).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The HMB HCU-UFU has a qualified team capable of conducting home visits, when the guidelines are reinforced and the hygienic-sanitary conditions of the environment are verified. The guidelines are: choose a quiet, clean, pet-free place close by; tie up the hair and put on a cap; remove rings, wristwatch, and bracelets; place a mask or cloth diaper over nose and mouth; always keep nails short and clean; sanitize hands and forearms to the elbow with running water and soap; clean the breasts only with filtered water before starting the milking; discard the first few streams of milk (0.5–1.0<span class="elsevierStyleHsp" style=""></span>mL); use a glass container with sterilized plastic cap (supplied by HMB) or boiled for 15<span class="elsevierStyleHsp" style=""></span>min (counting from the start of the boiling); store the bottles in a clean and closed place (cabinet or container); do not touch the inside of the bottle or cap; express the milk directly into the bottle, placing it under the areola; at the end of the milking, close the bottle and immediately freeze it in the upright position; on the next milking, in case of complementation of the previously collected volume, use another flask or glass container boiled for 15<span class="elsevierStyleHsp" style=""></span>min to collect the milk and put it inside the one that is already frozen; do not fill the entire bottle, leaving the milk volume approximately 2–3<span class="elsevierStyleHsp" style=""></span>cm below the edge; identify the container (full name of the nursing mother and date and time of milking); keep containers with milk in the freezer up to a maximum of ten days; store the milk separately from other foods; where no exclusive storage is available, the human milk must be placed inside another impermeable container (plastic bag or container); in case of milking using a suction pump, the latter should be sanitized after milking with plenty of running water and liquid soap, and before each milking, place the pump in hypochlorite solution (1 tablespoon) with filtered water (1<span class="elsevierStyleHsp" style=""></span>l) during 60<span class="elsevierStyleHsp" style=""></span>min (this solution should be changed every eight hours), and then rinse under running water; the frozen milk must be transported to the HMB inside a thermal box with ice.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The HM expressed at home is collected by the HMB HCU-UFU team; it is transported using their own car and trained employees for safe and adequate transportation.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">For the statistical analysis, generalized estimating equations (GEE) were used with an unstructured working correlation matrix to compare the estimated marginal means (EMM) of two values of titratable acidity (repeated measures) of EHM from two sites (fixed factors: residence and HMB); the random factors considered were the donor and the donated sample itself; since the distribution of the response variable is different from the normal distribution, it was decided to use the model with gamma response with log binding.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> To compare the observed frequencies of microbiological culture results in both groups, the chi-squared test of independence was used with Cramer's V correction.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> For all analyses, the level of significance was set at 5%.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Titratable acidity</span><p id="par0075" class="elsevierStylePara elsevierViewall">The mean values of titratable acidity of HM samples expressed at home varied between 3<span class="elsevierStyleHsp" style=""></span>°D and 9.5<span class="elsevierStyleHsp" style=""></span>°D, and between 3<span class="elsevierStyleHsp" style=""></span>°D and 10.5<span class="elsevierStyleHsp" style=""></span>°D in the samples collected in the HMB, with only 2% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1) in each group showing a titration grade ≥8<span class="elsevierStyleHsp" style=""></span>°D, considered inadequate for consumption (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,3,9</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">No main effect was observed for the collection site, with EMM<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4.64; 95% CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>±0.29 at home and EMM<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4.39; 95% CI<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>±0.33 at the HMB (Wald <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.14, df<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.285).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Microbiological cultures</span><p id="par0085" class="elsevierStylePara elsevierViewall">Of the analyzed HM samples collected at home, 6% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3) had a positive microbiological culture for total coliforms; and of those analyzed samples expressed at the HMB, 2% (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1) had positive cultures.</p><p id="par0090" class="elsevierStylePara elsevierViewall">No difference was identified between the observed and expected values for the association between the collection site and the microbiological culture result (<span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.04, df<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.307, <span class="elsevierStyleItalic">φ</span><span class="elsevierStyleInf">c</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.102).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Titratable acidity values <8<span class="elsevierStyleHsp" style=""></span>°D were identified in both collection sites in 98% of the analyzed EHM samples. This value is close to that found in other studies, ranging from 88 to 99.2%<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4,9,13</span></a> without differentiating milking sites; 96%<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,14</span></a> in samples of HM expressed exclusively at home; and 78%<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> in samples collected only at the HMB. The variation found in the results suggests the importance of hygienic-sanitary control in all processing steps, regardless of the collection site.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> The entire process of home collection under the responsibility of the HMB of this study was evaluated in a previous study, which confirmed the quality control of the process.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The microbiological culture was positive in 6% of the EHM samples at home and in 2% of the samples collected at the HMB. In other studies, the evaluation of microbiological culture indicated positive results in 5%<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> and 5.6%<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> of the samples of EHM in HMB; 7%<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> positive in HM samples expressed at home, without using strict hygiene criteria during milking and storage; and 2%<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> positive when the hygienic-sanitary criteria were established for home milking. Considering that the presence of the coliform group indicates non-compliance with the recommended hygienic-sanitary procedures, HM may be a vehicle for pathogenic microorganisms and, therefore, pasteurization and microbiological control are important to ensure safe use of EHM.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">No statistically significant differences were found in the titratable acidity and microbiological culture evaluations of the EHM between the two collection sites; therefore, there was no interference of the collection site in the quality of the EHM, which may be a result of compliance with hygienic-sanitary recommendations established for HMB.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> Thus, the importance of milking in compliance with these recommendations is emphasized as an indicator of milk quality control.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Milking at the donor's home is allowed and encouraged,<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">3,5–7</span></a> and it is a safe and effective way to obtain HM in larger volumes, maintaining sufficient HM stocks in HMB to meet the demands.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> However, it is necessary to provide adequate guidance to the milk donors on milking and storage of milk and to ensure safe transportation.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">1,3,5</span></a> This study demonstrated the quality and safety of home milking when compared to collection at a HMB, according to the quality and safety criteria of the EHM, through the titratable acidity and microbiological culture evaluation.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The study suggests that home milking is safe for obtaining HM, providing that the hygienic-sanitary standards are observed. It should be emphasized that the study was carried out in a HMB accredited to the BLH-BR Network (Brazilian Network of Human Milk Banks), which encourages home milking, guarantees donor guidance, conducts systematic evaluation and home visits, and has its own car and trained personnel for the safe transport of EHM.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1062793" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1011146" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1062792" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1011145" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Titratable acidity" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Microbiological cultures" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-19" "fechaAceptado" => "2017-05-17" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1011146" "palabras" => array:5 [ 0 => "Human milk" 1 => "Breast milk expression" 2 => "Milk banks" 3 => "Housing" 4 => "Quality control" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1011145" "palabras" => array:5 [ 0 => "Leite humano" 1 => "Extração de leite" 2 => "Bancos de Leite" 3 => "Habitação" 4 => "Controle de qualidade" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the quality of the human milk expressed at home and at a human milk bank.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This a retrospective, analytical, and observational study, performed by assessing titratable acidity records and the microbiological culture of 100 human milk samples expressed at home and at a human milk bank, in 2014. For the statistical analysis, generalized estimating equations (GEE) and the chi-squared test were used.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">When comparing the two sample groups, no significant difference was found, with 98% and 94% of the samples being approved among those collected at the milk bank and at home, respectively. No main interaction effect between local and titratable acidity records (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.285) was observed, and there was no statistically significant difference between the expected and observed values for the association between the collection place and the microbiological culture results (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.307).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The quality of human milk expressed at home and at the milk bank are in agreement with the recommended standards, confirming that the expression of human milk at home is as safe as expression at the human milk bank, provided that the established hygiene, conservation, storage, and transport standards are followed.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Avaliar a qualidade do leite humano ordenhado em domicílio e no Banco de Leite Humano.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudo retrospectivo, realizado por meio da avaliação dos registros da acidez titulável e dos resultados de cultura microbiológica de 100 amostras de leite humano ordenhado em domicílio e em um Banco de Leite Humano, no ano de 2014. Para análises estatísticas foram utilizadas as Equações de Estimação Generalizadas (<span class="elsevierStyleItalic">Generalized Estimating Equations</span> - GEE) e o teste Qui-quadrado.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Na comparação dos dois grupos de amostras, não foi detectada diferença significativa, sendo que 98% e 94% das amostras foram aprovadas entre as coletadas no Banco de Leite e em domicílio, respectivamente. Não foi observado efeito principal de interação entre local e grau de acidez titulável (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,285) e não se constatou diferença estatisticamente significante entre os valores observados e esperados para associação entre local de coleta e o resultado da cultura microbiológica (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,307).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusões</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A qualidade do leite humano ordenhado em domicílio e no Banco de Leite Humano estão de acordo com o padrão preconizado, comprovando que a ordenha de leite humano em domicílio é tão segura quanto a ordenha no Banco de Leite Humano, desde que sejam seguidas as normas de higiene, conservação, armazenamento e transporte estabelecidas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Borges MS, Oliveira AM, Hattori WT, Abdallah VO. Quality of human milk expressed in a human milk bank and at home. J Pediatr (Rio J). 2018;94:399–403.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study carried out at Universidade Federal de Uberlândia (UFU), Faculdade de Medicina, Programa de Pós-graduação em Ciências da Saúde, Uberlândia, MG, Brazil.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 852 "Ancho" => 2342 "Tamanyo" => 109232 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of the titration means of human milk samples at home and at the Human Milk Bank. Uberlândia, Minas Gerais, Brazil, 2016.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluación de la recolección domiciliaria realizada por un banco de leche humana de un hospital universitario de Brasil" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Menezes" 1 => "L. de Lima Cavalcanti" 2 => "A.M. de Morais Oliveira" 3 => "R. de Melo Costa Pinto" 4 => "V.O. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 8 | 19 |
| 2024 October | 57 | 30 | 87 |
| 2024 September | 43 | 29 | 72 |
| 2024 August | 28 | 29 | 57 |
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| 2024 March | 18 | 17 | 35 |
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| 2024 January | 20 | 29 | 49 |
| 2023 December | 13 | 21 | 34 |
| 2023 November | 15 | 26 | 41 |
| 2023 October | 19 | 33 | 52 |
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| 2023 August | 21 | 15 | 36 |
| 2023 July | 18 | 14 | 32 |
| 2023 June | 11 | 14 | 25 |
| 2023 May | 19 | 15 | 34 |
| 2023 April | 19 | 8 | 27 |
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| 2021 December | 16 | 25 | 41 |
| 2021 November | 12 | 17 | 29 |
| 2021 October | 18 | 20 | 38 |
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| 2021 July | 12 | 19 | 31 |
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| 2021 May | 19 | 15 | 34 |
| 2021 April | 26 | 15 | 41 |
| 2021 March | 16 | 16 | 32 |
| 2021 February | 9 | 7 | 16 |
| 2021 January | 12 | 7 | 19 |
| 2020 December | 15 | 11 | 26 |
| 2020 November | 17 | 16 | 33 |
| 2020 October | 7 | 10 | 17 |
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| 2020 July | 9 | 2 | 11 |
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| 2020 May | 14 | 6 | 20 |
| 2020 April | 14 | 13 | 27 |
| 2020 March | 9 | 2 | 11 |
| 2020 February | 14 | 11 | 25 |
| 2020 January | 12 | 13 | 25 |
| 2019 December | 12 | 7 | 19 |
| 2019 November | 6 | 3 | 9 |
| 2019 October | 9 | 13 | 22 |
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| 2019 June | 22 | 25 | 47 |
| 2019 May | 22 | 6 | 28 |
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| 2019 March | 21 | 10 | 31 |
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| 2018 December | 22 | 12 | 34 |
| 2018 November | 46 | 7 | 53 |
| 2018 October | 153 | 21 | 174 |
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| 2018 August | 42 | 19 | 61 |
| 2018 July | 30 | 8 | 38 |
| 2018 June | 5 | 8 | 13 |
| 2018 May | 2 | 10 | 12 |
| 2018 April | 1 | 6 | 7 |
| 2018 March | 2 | 9 | 11 |
| 2018 February | 0 | 5 | 5 |
| 2018 January | 1 | 3 | 4 |
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