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Chen et al. Microbiome Res Rep 2025;4:8 https://dx.doi.org/10.20517/mrr.2024.44 Page 5 of 18

Figure 1. PRISMA 2020 flow diagram of the search and selection process. PRISMA: Preferred reporting items for systematic review and
meta-analysis protocols.

MOM or DHM, irrespective of the fortifier allocation.

The criteria that were used to stratify infants in one of the two feeding groups varied among the studies.
Studies used varying thresholds from a minimum of 50% [33,34,37] to 70% , 80% [32,35] , or by exclusively
[36]
receiving 100% MOM or 100% DHM of the total milk volume intake. In the study by Gregory et al.,
[31]
infants were also stratified based on whether they had received exclusively MOM, while those in the DHM
group switched from exclusively DHM (duration of 6 to 25 days) to PF once achieving full enteral
[19]
feeding . Eventually, four studies were grouped into Subgroup A [31-34] , and Subgroup B consisted of the
other four [19,35-37] . Six studies excluded children with NEC and/or sepsis [19,31,34-37] . Ford et al. reported an
[33]
overall NEC rate of 2.4% among the study infants . Piñeiro-Ramos et al. reported only one NEC case (5%)
in the DHM group .
[32]
A total of 389 infants were included, with analyses conducted on 1,832 unique fecal samples collected from
the second day of life up to the 90th day of life. The mean/median gestational age in the included cohorts
ranged from 27.9 to 31.1 weeks, and the mean/median birth weights ranged from 1,013 to 1,444 grams.
Cesarean section was the predominant mode of delivery in all but one study . Overall, there were no major
[35]
clinically meaningful differences in reported baseline characteristics between infants in the MOM and DHM
cohorts in each of the included studies.

Two studies used a cross-sectional approach, with one sample per individual [32,35] collected at the time of full
enteral feeding achieved, while the remaining six studies collected multiple samples at different time points
during admission.