Breast milk fortifiers

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Breast milk fortifiers

• Staffan Polberger
• Department of Paediatrics
• University of Lund, Sweden

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Target groups for fortified breast milk

• Preterm infants lt 32 weeks? lt 30 weeks?
• SGA infants?
• Cardiac malformations - extra energy (liquid fat)?

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Survival of preterm infants, Lund 2000-01

0.71 0.63 0.96 0.75 0.89 0.94
0.96 0.97 Survival rate
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Feeding of preterm infants

• Own mothers milk (preterm milk)
  fortification
• Banked milk (if possible preterm milk)
  fortification
• Preterm formula
• Parenteral nutrition - supplementary

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Fortification of human milk - preterm infants

• 1919 Ylppö 1 fat
• 1948 Jorpes casein hydrolysate
• 1949 Hess defattad cows milk
• 1980 Lucas human milk formula
• 1982- Hagelberg human milk preparations
• Schanler etc
• 1985- Tönz cows milk preparations
• Modanlou etc

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Fortification of human milk

• Human milk preparations (research)
• Cows milk preparations (commercial)

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Why?

• Unfortified human milk is rarely adequate for
  nutrition of preterm infants lt 32 weeks (protein,
  energy, calcium, phosphorus etc)

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Goal of nutrition of VLBW infants

• achieving a postnatal growth that
  approximates the in utero growth of a normal
  fetus at the same postconceptional age appears
  to be the most logical approach...
• American Academy of Pediatrics 1985

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Goal of nutrition of VLBW infants

• not because growth per se is important, but
  rather because poor growth is a marker of
  inadequate nutrition, which in turn can impair
  cognitive development
• Thus, poor growth is a potential for impaired
  cognitive development.
• Ziegler 2001

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Recommended intakes VLBW infants

• Protein 2.9 - 4.0 g/kg/day (ESPGAN) 3.5 -
  4.0 g/kg/day (AAP)
• Energy 110 - 165 kcal/kg/day (ESPGAN) 120
  kcal/kg/day (AAP)

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Commercial fortifiers for preterm infants

• Powdered preparations to be dissolved in milk
• Protein
• Energy (lipids, carbohydrates)
• Minerals (sodium, calcium, phosphate)
• Trace elements, (vitamins)

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Human milk fortifiers
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Fortification of human milk

• Blind (full strength to all)
• Semi-quantitative (own or banked term?)
• Individualized
• Intake - milk analyses (protein, energy)
• Metabolic outcome (serum urea)

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Variation of macronutrients in human milk

• Enormous variability in the composition of
  milk expressed by mothers of preterm infants
• Hibberd et al. Arch Dis Child 198257658
• Lucas et al. Arch Dis Child 198459831
• Michaelsen et al. JPGN 199011229
• Polberger et al. JPGN 199929332
• Weber et al. Acta Paediatr 200190772

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Human milk analyses

• MID IR (infrared analysis)
• Protein (Kjeldahl)
• Lipids (Röse-Gottlieb)
• Carbohydrates (Luff-Schorl)
• Energy (calculated)

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Human milk analyses

• High precision
• Low cost ( 15)
• Ordinary mail (preservative added)
• Results available the following day

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Human milk analyses

• Own mothers milk Weekly samples
  24-hour collections (not spot
  samples) Well-shaken samples
• Banked milk Prior to routine heat
  treatment Well-shaken samples

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• Efficacy of fortification - modest
• Short-term studies (growth, metabolism)
  promising,
• Long-term studies (neurodevelopment) missing
  (one exception)
• Ziegler EE. Breast-milk fortification.
• Acta Paediatr 200190720

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• Individualized fortification is widely believed
  to be the the best solution to the variability
  problem. The idea to analyze milk and to fortify
  it in such a way that each infant always receives
  the amount of nutrients that he or she needs is
  simple and very attractive.
• The trouble is that implementation is difficult.
  
• Ziegler 2001

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Individualized feeding of preterm infants 1

• Target group lt 32 weeks
• Individual selection of banked milk according to
  protein (and energy) content
• Feeding own mothers milk in chronological order
• Protein fortification is not introduced until
  enteral intake can not be further increased
  (usually at 2-3 weeks of age)

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Individualized feeding of preterm infants 2

• Individualized fortification to optimal protein
  and energy intakes
• Fortification is continued during the whole
  tube-feeding period
• Use of markers of protein status (serum urea,
  transthyretin prealbumin) for metabolic
  evaluation

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Serum markers of protein status

• Suggested optimal serum levels in healthy
  growing preterm infants (lt 31 gestational weeks)
• Serum urea 1 - 3 mmol/L
• Serum transthyretin 90 - 140 mg/L prealbumin

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Nutritional status

• To optimize the nutritional management of the
  premature infant consider together the
  neonates nutritional status
• Growth parameters
• Nutrient intakes
• Biochemical indices
• Clinical condition
• Anderson DM, Clin Perinatol 200229313

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Postdischarge nutrition of preterm infants

• Several studies have examined the effects on
  growth and development of nutrient enriched
  postdischarge formula in preterm infants and
  found improved growth but no effects on
  development.

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Postdischarge nutrition of preterm infants

• Few studies have examined the effect of
  nutritional interventions on the breastfed
  preterm infant. This is due in part to reluctance
  to interfere with the mother-infant dyad, and
  because of the other non-nutritional benefits of
  breast-feeding.
• Griffin IJ, Clin Perinatol 200229327

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• When assessing nutrition of preterm and other
  sick newborn infants
• Consider the quality of breast milk or
  formula, not only the quantity

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• NUTRITION of preterm infants
• is not only a matter for nurses
• but also for DOCTORS!

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