Human Milk fortifiers

Breast milk alone does not provide adequate calories, protein, calcium, phosphorus, sodium, iron, or vitamins for the VLBW infant. All infants receiving breast milk feeds who were < 1500g birthweight should have a human milk fortifier added to their feeds after they have reached at least 100cc/kg/d or full enteral feeding volumes.

Larger premature infants (1500 - 1800g) birth weight may also have a human milk fortifier added to their feeds to increase nutritional intake if needed. Once these babies are ready for discharge, they may have their breast milk supplemented with a transitional formula powder; or, once fed ad lib, they may be able to tolerate large enough milk volumes to receive adequate nutrition from breast milk alone.

Commercial human milk fortifiers increase the amounts of energy, protein, sodium, vitamins, and minerals, especially calcium and phosphorus, consumed by the breast fed preterm infant. Both powdered and liquid fortifiers are available. The powdered fortifier may offer some nutritional advantages and should be used if mother’s breast milk supply is generous and the baby tolerates it. As it is mixed 1:1, liquid fortifier can extend breast milk volume if it is in short supply.

Vanderbilt currently uses Ross Human Milk Fortifier. Ross HMF contains more protein and more MCT than the previously available product, and was shown in a randomized, controlled, double-blind clinical trial to result in better growth in weight, length, and head circumference.

1 packet of HMF added to 50 cc of breast milk creates ~ 22 kcal/oz milk

1 packet of HMF added to 25 cc of breast milk creates ~ 24 kcal/oz milk

Similac Natural Care (SNC) is a liquid human milk fortifier, 24 kcal/oz. Mixed 1:1 with breast milk, it creates 22 kcal/oz milk. More concentrated forms of SNC may be ordered from Dietary Services to increase the caloric density of milk further.

In micropremies with CLD who are fluid restricted to < 120 cc/kg/d, SNC may occasionally be used as a preterm formula as it provides the highest concentration of calcium to combat osteopenia of prematurity.

Adding a fortifier to breast milk dramatically increases the osmolarity of the feeds, which may contribute to feeding intolerance. A fortifier should be added gradually, in 2 kcal/oz increments, allowing a couple of days between increases to assess the baby’s tolerance.

References:

Reis BB, et al. Enhanced growth of preterm infants fed a new powdered human milk fortifier: a randomized, controlled trial. Pediatrics 2000; 106: 581-588.

Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews.   http://www.nichd.nih.gov/cochraneneonatal/kuschel/kuschel.HTM

Moody GJ, et al. Feeding tolerance in premature infants fed fortified human milk. J Pediatr Gastroenterology & Nutrition 2000: 30: 408-12.