Breast milk feeds

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Early breast milk from mothers who have delivered preterm contains a higher concentration of protein, calories, calcium, sodium, and iron than the breast milk of mothers delivering at term. After 2 weeks – 1 month of lactation, mothers of premies produce breast milk more like that of term mothers. Because of the unique nutritional aspects of early preterm breast milk, efforts should be made to feed the breast milk produced in the initial 2 weeks of lactation first to the infant starting enteral feeding.

Indeed, manufacturers of human milk fortifiers have designed the fortifiers to be added to breast milk produced after the first 2 weeks.

Freezing and then thawing breast milk has little effect on the nutritional components of breast milk, but does decrease the cellular and host defense properties of the milk. Therefore, after the first 2 weeks worth of milk have been fed, fresh breast milk should be given to the infant when available instead of freezing the fresh milk and giving the infant thawed older milk.

The fat in breast milk readily adheres to plastic in syringes and tubing. Continuous drip breast milk feeding with a horizontally-oriented syringe and long tubing can result in the loss of 48% of the fat in breast milk. As fat is the main source of calories in breast milk, this loss can severely impair infant nutrition and growth.

Whenever possible, breast milk should be fed by bolus rather than continuous OG to minimize nutritional losses. If the infant cannot tolerate bolus feeding, decrease the fat losses from continuously administered EBM to 8% by:

1) Orienting the syringe vertically with the tip up

2) Using short extension tubing, and

3) Fully emptying every syringe (the fat is the last component to empty).

For infants on breast milk feeds who are experiencing inadequate growth, "hind milk" can be fed preferentially if the mother produces adequate milk volumes. The fat content of "hind milk" may be 2 – 3 times greater than foremilk but contains similar amounts of nitrogen, minerals, and electrolytes.

Mothers who’s milk production exceeds their infant’s needs by ~30% can fractionate their milk. Foremilk is defined as the milk produced in the first 2-3 minutes of pumping after letdown. The milk expressed during the remainder of the pumping session is the hind milk fraction. These fractions should be collected in separate bottles, and the bottles labeled accordingly.

If both fractions are available, nurses should feed the hind milk to the infant first. Mothers who produce > 750mL of breast milk per day may be able to exclusively feed hind milk.

References:

American Academy of Pediatrics. Pediatric Nutrition Handbook, 4^th ed. 1998. pgs. 69-71.

Greer FR, McCormick A, Loker J. Changes in fat concentration of human milk during delivery by intermittent bolus and continuous mechanical pump infusion. J Pediatr 1984; 105: 745.

Valentine CJ, Hurst NM, Schanler RJ. Hindmilk improves weight gain in low-birth-weight infants fed human milk. J Pediatr Gastroenterol Nutr 1994; 18: 474-77.

Discussed at Collaborative Pathways meeting 9/12/01.