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Human Milk Fortifiers

Educative presentation for medical graduates and postgraduates

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Human Milk Fortifiers

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  1. Human Milk Fortifiers - Dr CSN Vittal

  2. Background Human milk is the ideal feeding for all infants.  While the human milk is ideal for term infants; protein and mineral content of human milk is insufficient to meet the needs of the growing preterm infant. Particularly of concern in the smallest infants (ELBW < 1000 g and VLBW < 1500 g) who have the highest protein and mineral needs for growth.

  3. Background While TPN will provide supplemental amino acids, protein intake may be limited if unfortified breast milk comprises > 50% of total fluid intake.  As the mineral content of TPN is limited, preterm infants will accrue a mineral deficit until fortification of human milk is initiated.  Fortification of Human Milk is indicated in order to supply the nutrients required and support the rapid rate of growth and bone mineralization in the preterm infant. 

  4. Human milk fortifiers The primary goal of HMF supplementation is to optimize the nutritional status and to promote growth of the preterm infant comparable to that in utero.

  5. Commercial human milk fortifiers Predominantly a protein and mineral supplement.  Also typically contain additional calories, electrolytes and vitamins. 

  6. Liquid versus powdered fortifiers • The WHO writes: • “Liquid fortifiers are for use in a 1:1 ratio with human milk and contribute a significant proportion of the infant’s fluid intake. • Although they are designed to contain adequate quantities of all essential nutrients, mixing the mother’s own milk with an equal volume of liquid fortifier dilutes the constituents of the human milk, including nutrients, growth factors and anti-infective properties.”

  7. Liquid versus powdered fortifiers • About powdered fortifiers, the WHO writes: • “Powdered fortifiers may be insoluble in human milk, and unless the fortifier-milk mixture is well shaken, the nutrients may not be available for absorption.”

  8. Composition of human milk fortifier (HMF) per 2 g sachet

  9. Human milk fortifiers • Faerk J, Petersen S, Peitersen B, Michaelsen KF.  Diet and bone mineral content at term in premature infants.  Pediatr Res. 2000 Jan;47(1):148-56. • Martins EC, Krebs VLJ.  Effects of the use of fortified raw maternal milk on very low birth weight infants. J Pediatr (Rio J). 2009;85(2):157-162. Studies have shown that the addition of human milk fortifier is associated with short-term improvements in weight, length, and head circumference growth.  Other studies suggest human milk fortifier may improve bone mineralization and neurologic outcome. 

  10. Practical guidelines for HMFs use in preterm infants Currently, fortification of HM with HMF is a common practice to provide required energy and nutrients to the preterm infants. HMF is designed to supply additional calories, protein, calcium, phosphorus, zinc and other vitamins and minerals to preterm infants. HMF is designed for infants less than 37 weeks gestation or those less that 1500g at birth. Liquid and powder types of HMF are available in the commercial market. One packet (3.8g) of powdered HMF is mixed to 25 cc expressed HM. Liquid HMF can be mixed in any desired proportion with HM (typically 1:1 with HM) or 20 fed alternatively with HM feedings.

  11. Human milk fortifiers –Adverse Effects • Lucas A, Fewtrell MS, Morley R, Lucas PJ, Baker BA, Lister G, Bishop NJ.  Randomized outcome trial of human milk fortification and developmental outcome in preterm infants.  Am J ClinNutr. 1996 Aug;64(2):142-51. • DeCurtis M, Candusso M, Pieltain C, Rigo J> Effect of fortification on the osmolality of human milk. Arch Dis Child Fetal neonatal Ed. 1999;81:F141-F143. Lucas et al showed an increase in infections (43% versus 31%) and NEC (5.8% versus 2.2%) in infants fed fortified versus unfortified human milk; however the infants in the study received > 50% of their feeds from formula  Other studies with human milk fortifiers showed an increase in osmolality of the breast milk feeding after initiation of the supplement Temporarily delay gastric emptying and cause a short term increase in gastric residuals and emesis Recent changes in fortifier composition have minimized this effect by adding fat and reducing the carbohydrate content of the supplement.

  12. Human milk fortifiers –No Effect on… • Jocson MA, Mason EO, Schanler RJ.  The effects of nutrient fortification and varying storage conditions on host defense properties of human milk.  Pediatrics. 1997 Aug;100(2 Pt 1):240-3. • Tarcan A, Gurakan B, Tiker F, Ozbek N.  Influence of feeding formula and breast milk fortifier on lymphocyte subsets in very low birth weight premature newborns.  Biol Neonate. 2004;86(1):22-8.  Epub 2004 Feb 20. the IgA content of human milk or on the concentrations of natural killer cell subsets in preterm infants fed the fortified milk.

  13. Guidelines for the Use of Human Milk Fortifier • Human Milk Fortifier (24 kcal/oz) is indicated for all breast milk fed infants weighing less than 2000 g.  • Infants weighing 2000 – 2500 g may also benefit from the addition of HMF, particularly if they are SGA or demonstrated poor intake and/or growth. • Human Milk Fortifier (24 kcal/oz) should be initiated when the infant is tolerating breast milk feeds of > 25 ml/day.  • Infants receiving 25 ml of breast milk on the first day of feeds should wait until day of life 3 or 4 before starting HMF. • Infants who have been tolerating breast milk + HMF feeds and are made NPO should be restarted on breast milk + HMF feeds. • Indications for using concentrated breast milk feeds (27 kcal/oz or 30 kcal/oz high protein) in infants include: • Fluid restriction < 140 ml/kg • Poor weight gain (< 10 – 15 g/kg/d) on 120 kcal/kg of 24 kcal/oz Breast Milk + HMF • Metabolic bone disease (alkaline phosphatase > 600 U/L) with poor bone mineralization on x-ray requiring increased intakes of calcium and phosphorus

  14. Monitoring Guidelines for Infants on Breast Milk + HMF Preterm infants fed breast milk + HMF are at risk for hyponatremia due to the limited sodium content of these feeds and increased urinary sodium losses.  Infants fed concentrated breast milk feeds (> 27 kcal/oz) are at risk for hypercalcemia and hyperphosphatemia secondary to the increased mineral content of these feeds.

  15. Monitoring Guidelines for Infants on Breast Milk + HMF • 24 kcal/oz Breast Milk + HMF • Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements.

  16. Monitoring Guidelines for Infants on Breast Milk + HMF • 27 kcal/oz Breast Milk + HMF • Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements. • Check ionized calcium and phosphorus weekly while patient is on concentrated breast milk + HMF.  • Contact NICU RD if ionized calcium is > 6.5 mg/dl or phosphorus is > 7.5 mg/dl for recommendations to reduce mineral intake with the use of term formula concentrate.

  17. Monitoring Guidelines for Infants on Breast Milk + HMF • 30 kcal/oz Breast Milk + HMF • Check electrolytes weekly until the electrolytes are stable (within normal limits) and the patient is no longer receiving IV fluids or oral electrolyte supplements. • Check ionized calcium and phosphorus weekly while the patient is on concentrated breast milk + HMF.  Contact NICU Dietician if ionized calcium is > 6.5 mg/dl or phosphorus is > 7.5 mg/dl for recommendations to reduce mineral intake with the use of term formula concentrate.

  18. Lactoengineering • As a viable alternative to fortifiers, many breastfeeding advocates propose ‘lactoengineering’ for preterm infants as opposed to fortifiers. • Hind milk, the higher fat milk obtained several minutes following milk ejection, has been shown to enhance growth rates when fed to the VLBW infant. • When it is known that the mother’s daily milk volume is more than double the infant’s daily volume needs, special instructions can be given for the collection and feeding of hind milk […]. • A creamatocrit, the length of the cream column separated from milk by centrifugation and expressed as a percentage of the length of the total milk column, can be performed when an accurate measure of the lipid content is required.

  19. Summary • The nutritional needs of the preterm infants will also be better served HMFs can be tailored to suit the individual, and when adequate biomarkers of risk and response have been developed for preterm infants.

  20. Thank You ! Dr CSN Vittal

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