Standard fortification of preterm human milk fails to meet recommended protein intake: Bedside evaluation by Near-Infrared-Reflectance-Analysis

Human Milk Calorie Guide: A Novel Color-Based Tool to Estimate the Calorie Content of Human Milk for Preterm Infants

Fixed-dose fortification of human milk (HM) is insufficient to meet the nutrient requirements of preterm infants. Commercial human milk analyzers (HMA) to individually fortify HM are unavailable in most centers. We describe the development and validation of a bedside color-based tool called the 'human milk calorie guide'(HMCG) for differentiating low-calorie HM using commercial HMA as the gold standard. Mothers of preterm babies (birth weight ≤ 1500 g or gestation ≤ 34 weeks) were enrolled. The final color tool had nine color shades arranged as three rows of three shades each (rows A, B, and C). We hypothesized that calorie values for HM samples would increase with increasing 'yellowness' predictably from row A to C. One hundred thirty-one mother's own milk (MOM) and 136 donor human milk (DHM) samples (total n = 267) were color matched and analyzed for macronutrients. The HMCG tool performed best in DHM samples for predicting lower calories (<55 kcal/dL) (AUC 0.87 for category A DHM) with modest accuracy for >70 kcal/dL (AUC 0.77 for category C DHM). For MOM, its diagnostic performance was poor. The tool showed good inter-rater reliability (Krippendorff's alpha = 0.80). The HMCG was reliable in predicting lower calorie ranges for DHM and has the potential for improving donor HM fortification practices.

Corrected fortification approach improves the protein and energy content of preterm human milk compared with standard fixed-dose fortification

OBJECTIVE

To evaluate whether a pragmatic corrected fortification (CF) model achieves recommended target protein and calorie content of human milk (HM) for preterm infants when compared with standard fixed-dose fortification (SF).

DESIGN

In this prospective non-interventional study, we enrolled mothers of infants with birth weight ≤1500 g fed exclusive HM. Infants with chromosomal or intestinal disorders were excluded. A total of 405 HM samples from 29 mothers and 45 donor milk samples were analysed for macronutrient content using a real-time HM analyser. A stepwise CF model was derived based on published data on HM calorie and protein content corrected for lactation stage and milk type. We applied both models to the measured protein and calorie content for all HM samples and compared the proportion of samples achieving target nutrient requirement in each group.

RESULTS

Target protein and calorie content of feed was achieved in 68% of HM samples with CF, compared with 5% samples with SF model (p<0.0001). For mother's own milk, none of the samples met the target macronutrient range with SF fortification during later lactation periods (≥week 5). With SF, over 40% of infants had poor growth (decline in weight z-score ≥0.8 SD) by 8 weeks. The final feed osmolality was acceptable for all fortification steps of the CF model.

CONCLUSION

The proposed CF model significantly improved the final protein and calorie content of HM with acceptable osmolality. It provides a proactive option to improve nutrient intake in premature infants.

Human milk bank and personalized nutrition in the NICU: a narrative review

The number of infants born preterm including extremely premature babies is rising worldwide, particularly in low- and middle-income countries, which challenge neonatologists and milk banks for the provision of the most adequate nutrition for successful infant's growth and development. The benefits of mother's own milk (MOM) have been extensively recognized, but the use of donor milk (DM) is a commonly routine practice in preterm neonates admitted to the NICU. Pasteurized mature milk from milk banks is not the same composition than the mother's colostrum and premature milk, the characteristics of which protect the infant from the risk for necrotizing enterocolitis, late-onset sepsis, and other comorbidities associated with prematurity. The development of a personalized nutrition unit (PNU) allows to obtain DM from mothers who have their infants admitted to the NICU and produce an excess of milk, a practice that matches MOM by gestational age and the stage of lactation, ensuring an adequate composition of DM to target the nutritional requirements of premature infants.Conclusion: This narrative review presents salient data of our current knowledge and concerns regarding milk feeding of preterm infants in the NICU, with special emphasis on personalized DM as a result of establishing a PNU. What is Known: • Donor milk bank is mature or pooled milk from lactating mothers at different stages of lactation. • Milk composition varies by gestational age and stage of lactation. What is New: • Donor milk from mothers delivered prematurely have the most adequate composition for preterm infant feeding. • Personalized nutrition for premature infants with preterm donor milk is feasible.

Targeted Breast Milk Fortification for Very Low Birth Weight (VLBW) Infants: Nutritional Intake, Growth Outcome and Body Composition

Despite improvements in nutritional management, preterm infants continue to face high rates of postnatal growth restriction. Because variability in breast milk composition may result in protein and energy deficits, targeted fortification has been advocated. We conducted an interventional study to compare body composition and growth outcomes of very low birth weight infants fed targeted protein-fortified human milk (HM) with those fed standard fortified HM. If mother’s own milk was not available, donor milk was used. Weekly analysis of HM with mid-infrared spectroscopy was conducted and additional protein was added to the fortified HM to ensure a protein intake of 4 g/kg/day. Weekly anthropometric measurements were done. Prior to discharge or at 37 weeks, corrected age skinfold thickness (SFT) measurements as well as body composition measurement using air displacement plethysmography were done. Among 36 preterm infants enrolled, those in the targeted group (n = 17) received more protein and had a larger flank SFT at study end than those in the standard group (n = 19). A pilot post-hoc analysis of subjects having at least 30 intervention days showed a 3% higher fat-free mass in the targeted group. Use of a targeted fortification strategy resulted in a higher protein intake and fat-free mass among those receiving longer intervention.

Optimizing individual nutrition in preterm very low birth weight infants: double-blinded randomized controlled trial

OBJECTIVE

In preterm neonates fed human milk, fortification may be adjusted by (1) optimization, based on growth rate and serum nutrient analyses, or (2) individualization, based on serial milk nutrient analyses. The primary aim was to determine whether individualized plus optimized nutrition (experimental) improves velocity of weight gain and linear growth from birth to endpoint (36 weeks postmenstrual age or discharge) when compared with optimized nutrition alone (controls).

STUDY DESIGN

Double-blinded parallel group randomized trial in 120 neonates <29 weeks gestational age (GA) or <35 weeks and small for GA (birth weight < 10th centile).

RESULT

Weight-gain velocity (13.1 ± 2.1, n = 57 controls, vs. 13.0 ± 2.6 g kg^-1 day^-1, n = 59 experimental, P = 0.87), linear growth (0.9 ± 0.2, n = 55, vs. 0.9 ± 0.2 cm week^-1, n = 52, P = 0.90) and frequency of weight/length disproportion (2% vs. 2%, P = 0.98) were similar in both groups.

CONCLUSIONS

Individualized plus optimized nutrition does not improve weight gain, linear growth, or weight/length disproportion at endpoint versus optimized nutrition alone.

Modifications of Own Mothers' Milk Fortification Protocol Affect Early Plasma IGF-I and Ghrelin Levels in Preterm Infants. A Randomized Clinical Trial

The aim was to investigate the effect of two own mother’s milk (OMM) fortification protocols on (a) IGF-I and ghrelin plasma levels at 35 post-conceptional weeks (PCW, T2) and whether this effect is maintained after elimination of the differences in OMM fortification, and (b) growth until 12 months corrected age. Forty-eight OMM-fed preterm infants (GA 24–32 weeks) were randomly allocated to the fixed-fortification (FF) group (n = 23) and the protein-targeting fortification (PTF) group (n = 25) targeting the recommended daily protein intake (PI). Plasma IGF-I and ghrelin were assessed at 35 (T2) and 40 (T3) PCW while growth was longitudinally assessed until 12 months corrected age. PTF group had lower IGF-I and higher ghrelin than FF group at T2, while receiving lower daily protein and energy amounts. PI correlated positively to T2-IGF-I and inversely to T3-ghrelin while energy intake (EI) correlated inversely to T2- and T3-ghrelin. Group and PI were independent predictors of adjusted T2-IGF-I, while group and EI were predictors of adjusted and T2-ghrelin. Growth parameter z-scores were comparable between groups up to 12 months corrected age. Modifications of OMM fortification have a transient effect on early plasma IGF-I and ghrelin levels in preterm infants in a way consistent with the previously recognized protein-energy/endocrine balance, indicating a potential programming effect.

Treatment with the essential amino acid L-tryptophan reduces masticatory impairments in experimental cerebral palsy

Purpose Children with cerebral palsy (CP) often exhibit difficulties in feeding resulting from deficits in chewing. This study investigates the therapeutic potential of L-tryptophan (TRI) to reduce deficits in chewing in rats subjected to an experimental model of CP.Methods A total of 80 Wistar albino rats were used. Pups were randomly assigned to 4 experimental groups: Control Saline, Control TRI, CP Saline, and CP TRI groups. The experimental model of CP was based on the combination of perinatal anoxia associated with postnatal sensorimotor restriction of the hind limbs. TRI was administered subcutaneously during the lactation period. Anatomical and behavioral parameters were evaluated during maturation, including body weight gain, food intake, chewing movements, relative weight and the distribution of the types of masseter muscle fibers.Results The induction of CP limited body weight gain, decreased food intake and led to impairment in the morphological and functional parameters of chewing. Moreover, for a comparable amount of food ingested, CP TRI animals grew the most. In addition, supplementation with TRI improved the number of chewing movements, and increased the weight and proportion of type IIB fibers of the masseter in rats subjected to CP.Conclusion These results demonstrate that experimental CP impaired the development of mastication and that TRI supplementation increased masticatory maturation in animals subjected to CP.

Diet, weight gain, and head growth in hospitalized US very preterm infants: a 10-year observational study

BACKGROUND

The benefits of human milk for hospitalized preterm infants are well documented, but the extent to which current human milk diets adequately support growth is uncertain.

OBJECTIVES

1) To quantify differences in weight gain and head growth between very preterm infants fed human milk compared with infant formula; and 2) to describe trends in the magnitude of these differences over time.

METHODS

We studied infants from 777 US NICUs in the Vermont Oxford Network database. We included all surviving infants 23-29 weeks of gestation or 401-1500 g birth weight (maximum gestational age 32 wk) and excluded infants discharged >42 weeks of gestation or with congenital anomalies. In diet-growth analyses, we included infants born 2012-2016 (n = 138,703) to reflect current practice. In trend analyses, we included a 10-y cohort (n = 263,367). We categorized diet at NICU discharge/transfer as: 1) human milk only (no formula or fortifier); 2) human milk with formula or fortifier (mixed); or 3) infant formula only. Outcomes were weight and head circumference z-score change from birth to discharge relative to a fetal reference.

RESULTS

Diet at discharge/transfer was human milk only for 18,274 (6.6%), mixed for 121,621 (44%), and formula only for 137,067 (49%). Weight deviated more from the fetal reference for infants fed both human milk diets compared with formula only (weight z-score change for infants fed human milk only, -0.88; mixed, -0.82; formula only -0.80; P < 0.0001 for diet overall). There were also differences by diet in head z-score change (human milk only, -0.52; mixed, -0.49; formula only, -0.45; P < 0.0001 for diet overall). The magnitude of these differences has diminished substantially over 10 y.

CONCLUSIONS

Very preterm infants receiving human milk compared with infant formula diets have a slower weight gain and head growth at hospital discharge.

What should be the protein target for adjustable Human Milk fortification in premature infants?

Objective:

To assess the short- and long-term effects of the adjustable fortification (ADJ) regimen on growth parameters in premature infants and to evaluate the amount of protein supplements given to reach the targeted blood urea nitrogen (BUN) levels.

Methods:

In this retrospective study, preterm babies who were born at ≤32 weeks gestational age and fed with human milk, were evaluated in two groups. Infants in Group-I were fed only standard fortification (STD). Infants in Group-II were fed the ADJ regimen. The study was conducted between 2011 and 2016.

Results:

There were 123 infants in the STD group and 119 in the ADJ group. The mean gestational age of the patients in Group-I was 29.7±1.8 weeks, and mean birth weight was 1266.1±347.1 g. The mean gestational age of the patients in Group-II was 29.5±1.9 weeks, and the mean birth weight was 1217.5±345.5 g. The daily increase in weight and weekly increase in HC were significantly higher in the ADJ group infants. Weight and HC of infants in the ADJ group were significantly higher at 40 weeks. At one year corrected age, weight, length, and HC measurements of both groups were similar. In Group-II, 63% of patients required additional protein supplementation up to 1.6 g/day to achieve the target BUN levels.

Conclusion:

A higher protein intake through the ADJ regimen improves the physical growth rate of premature infants in the NICU and after discharge. However, sometimes, the targeted growth and BUN values cannot be achieved despite the administration of protein at the recommended increased doses. Increasing protein supplementation up to 1.6 g/day is safe, feasible, and beneficial for these infants.

Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification

Evidence indicates that human milk (HM) is the best form of nutrition uniquely suited not only to term but also to preterm infants conferring health benefits in both the short and long-term. However, HM does not provide sufficient nutrition for the very low birth weight (VLBW) infant when fed at the usual feeding volumes leading to slow growth with the risk of neurocognitive impairment and other poor health outcomes such as retinopathy and bronchopulmonary dysplasia. HM should be supplemented (fortified) with the nutrients in short supply, particularly with protein, calcium, and phosphate to meet the high requirements of this group of babies. In this paper the European Milk Bank Association (EMBA) Working Group on HM Fortification discusses the existing evidence in this field, gives an overview of different fortification approaches and definitions, outlines the gaps in knowledge and gives recommendations for practice and suggestions for future research. EMBA recognizes that "Standard Fortification," which is currently the most utilized regimen in neonatal intensive care units, still falls short in supplying sufficient protein for some VLBW infants. EMBA encourages the use of "Individualized Fortification" to optimize nutrient intake. "Adjustable Fortification" and "Targeted Fortification" are 2 methods of individualized fortification. The quality and source of human milk fortifiers constitute another important topic. There is work looking at human milk derived fortifiers, but it is still too early to draw precise conclusions about their use. The pros and cons are discussed in this Commentary in addition to the evidence around use of fortifiers post discharge.

Turkish Neonatal Society guideline on enteral feeding of the preterm infant

Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.

Strategies of Increased Protein Intake in ELBW Infants Fed by Human Milk Lead to Long Term Benefits

Objective: The aim of this observational study was to evaluate the effects of two different protein intake regimes on feeding tolerance, in-hospital growth, anthropometric data and psychomotor outcome up to 24 months corrected age (CA) in extremely low birth-weight (ELBW; birth weight <1000 g) infants. Methods: During the period 2008-2013, 52 ELBW infants admitted at birth to two Neonatal Intensive Care Units of Emilia Romagna (Italy) were fed according to different protocols of protein fortification of human milk: an estimated protein intakes at maximum fortification levels of 3.5 gr/kg/day in the Standard Nutrition Population-SNP group (n = 26) and 4.8 g/kg/day in the Aggressive Nutrition Population-ANP group (n = 26). During hospitalization, infants' growth, biochemical indices of nutritional status, enteral intake, feeding tolerance, clinical history and morbidity were evaluated. After discharge, anthropometric data and psychomotor outcome, evaluated by Revised Griffiths Mental Development Scales (GMDS-R) 0-2 years, were assessed up to 24 months CA. Results: During hospitalization, the ANP group showed significantly higher weight (18.87 vs. 15.20 g/kg/day) and head circumference (0.70 vs. 0.52 cm/week) growth rates compared to SNP, less days of parenteral nutrition (7.36 ± 2.7 vs. 37.75 ± 29.6) and of hospitalization (60.0 ± 13.3 vs. 78.08 ± 21.32). After discharge, ANP infants had a greater head circumference compared to SNP (45.64 ± 0.29; 46.80 ± 0.31). Furthermore, the General Quotient of GMDS-R mean scores in the SNP group significantly decreased from 12 to 24 months CA, while no difference was seen in the ANP group. Conclusions: Increased protein intake may provide short and long term benefits in terms of growth and neurodevelopment in human milk-fed ELBW infants.

Osmolality of a fortified human preterm milk: The effect of fortifier dosage, gestational age, lactation stage, and hospital practices

OBJECTIVE

The purpose of this study was to evaluate the dose-dependent effect of human milk fortifier (HMF) on the osmolality of various preterm human milks (PHMs) at different gestational and lactation stages, and with different storage and treatment conditions that are routinely used in neonatal intensive care units (NICUs).

STUDY DESIGN

Twenty-four mothers who had given birth to their baby before 28 or between 29 and 31 weeks of pregnancy participated in the study after 1-2 weeks or 3-4 weeks breastfeeding after delivery. The study was a prospective, multicenter, comparative, and noninterventional study. Osmolality of fresh or pasteurized human milk stored at 4°C was measured (cryoscopy) at baseline, and 24hours after adding Suppletine^® Human Milk fortifier (SHMF) at 3%, 4%, 4.5%, and 5% (w/v).

RESULTS

PHM without supplementation had an osmolality (mean±SD) of 301±8 mOsm/kgH₂O (n=40; 95% CI: [298; 303]). Adding 3-5% SHMF induced a linear increase of osmolality (P<0.001; r²=0.975). With 4% SHMF, the osmolality measure was 443±13mOsm/kg H₂O (95% CI: [439-447]). Neither a 24-hour storage at 4°C nor pasteurization induced a modification of osmolality compared to the fresh samples.

CONCLUSION

Whatever the origin and quality of milk as well as hospital practices, adding up to 4% (w/v) SHMF to PHM increases its nutritional quality and osmolality without exceeding 450mOsm/kgH₂O, which is generally recognized as safe.

The fortification method relying on assumed human milk composition overestimates the actual energy and macronutrient intakes in very preterm infants

Background

To achieve recommended nutrient intakes in preterm infants, the target fortification method of human milk (HM) was proposed as an alternative to standard fortification method. We aimed to compare assumed energy and macronutrient intakes based on standard fortified HM with actual intakes relying on measured composition of human milk (HM), in a cohort of HM-fed very preterm infants.

Methods

This study is a secondary retrospective analysis, in which assumed energy and macronutrient contents of daily pools of own mother’s milk (OMM) from 33 mothers and donated HM (DHM) delivered to infants were compared with the measured values using a mid-infrared HM analyzer. A fortification method consisting of modular protein and/or fat supplements added to standard fortified HM was used to provide the minimum recommended daily intakes of energy 110 Kcal/kg and protein up to 4.0 g/kg. Assumed nutrient intakes were compared with actual nutrient intakes from full enteral feeding to 35 weeks plus 6 days postmenstrual age, using the Wilcoxon matched-pairs signed ranks test.

Results

The composition of 1181 samples of daily pools of HM were measured. For 90.2% of study days, infants were exclusively fed OMM and in remaining days fed OMM plus DHM. Comparing with reported preterm OMM composition, measured protein concentration was significantly lower, and energy and other macronutrient concentrations were lower only from the second to third postnatal week. Using fortified HM, the actual median daily intakes of energy, protein, and fat were significantly lower (113.3 vs. 120.7 Kcal/kg, 4.45 vs. 4.73 g/kg, and 4.96 vs. 5.35 g/kg, respectively) and the actual protein-to-energy ratio (PER) significantly higher than what was assumed (4.2 vs. 4.0), without differences in carbohydrate intake.

Conclusions

When fortifying the HM, we used conservative target intakes trying not to exceed the osmolarity recommended for infant feeds. Actual energy, protein and fat intakes in OMM were significantly lower than assumed. This resulted in inadequate intake using our fortification method, that did not compensate the suboptimal measured energy and macronutrient contents of OMM delivered. Further studies comparing assumed with the gold standard target fortification are needed to determine safe upper limits of assumed fortification.

The Effect of Human Milk on Modulating the Quality of Growth in Preterm Infants

Introduction: Human milk is the optimal nutrition for preterm infants. When the mother's own milk is unavailable, donor human milk is recommended as an alternative for preterm infants. The association among early nutrition, body composition and the future risk of disease has recently attracted much interest. The aim of this study was to investigate the effect of human milk on the body composition of preterm infants. Materials and Methods: Very low birth weight infants (VLBW: birth weight <1,500 g) with a gestational age (GA) between 26 and 34 weeks were included. Clinical data, anthropometric measurements and nutritional intake in terms of the volume of human milk were extracted from computerized medical charts. The human milk intake was expressed as a percentage of target fortified donor human milk and/or target fortified fresh mother's milk, compared with the total volume of milk intake during the hospital stay. All included infants underwent anthropometric measurements and body composition analysis (expressed as fat-free mass percentage) at term corrected age (CA) by air-displacement plethysmography. A comparison between infants fed human milk at <50% (group 1) and infants fed human milk at ≥50% of the total volume of milk intake (group 2) was conducted. Multiple linear regression analyses were conducted to explore the modulating effect of fortified human milk on fat-free mass at term CA. Results: Seventy-three VLBW infants were included in the study. The mean weight and GA at birth were 1,248 ± 198 g and 30.2 ± 2.0 weeks, respectively. No differences were found regarding anthropometric measurements at birth, at discharge and at term CA between the two groups. The mean fortified human milk intake was 34.9 ± 12.5 and 80.9 ± 15.5% in groups 1 and 2, respectively (p < 0.001). A multiple regression analysis corrected for sex and birth weight demonstrated that intake of ≥50% fortified human milk was associated with a higher fat-free mass percentage at term CA than intake of <50% fortified human milk. Conclusion: The use of target fortified human milk modulated growth and improved growth quality in vulnerable preterm infants. Thus, the use of donor human milk should be encouraged when fresh mother's milk is insufficient or not available.

Individualized Fortification Influences the Osmolality of Human Milk

Background: Fortification of human milk (HM) increases its osmolality, which is associated with an increased risk of necrotizing enterocolitis. The impact of new fortifiers on osmolality is not well-known, nor are the kinetics regarding the increase in osmolality. Aim: To determine the optimum fortifier composition for HM fortification by measuring the osmolality of fortified HM made with three powder multicomponent fortifiers (MCFs) and a protein fortifier (PF). Methods: The osmolality of HM was assessed at 2 (H2) and 24 (H24) h after fortification to compare the effects of MCF (MCF1-3) and PF used in quantities that ensured that infants' nutrient needs would be met (MCF: 4 g/100 ml HM; PF: 0.5 g or 1 g/100 ml HM). To evaluate the early kinetics associated with the osmolality increase, the osmolality of HM fortified with MCF1 or MCF2 was also measured at 0, 1, 5, 10, 15, 20, 30, 40, 50, 60, 90, and 120 min after fortification. Results: The osmolality increased significantly immediately after fortification, depending on the type of fortification used and the quantity of MCF and PF used, rather than the time elapsed after fortification. The maximum value at H24 was 484 mOsm/kg. The mean increase in osmolality between H2 and H24 was 3.1% (p < 0.01) (range: 0.2-10.8%). Most of the increase (>70%) occurred immediately after fortification. Conclusion: When choosing a fortifier, its effect on HM osmolality should be considered. As most of the increase in osmolality occurred immediately, bedside fortification is not useful to prevent the increase in osmolality, and further research should focus on improving fortifier composition.

Growth and Nutritional Biomarkers of Preterm Infants Fed a New Powdered Human Milk Fortifier: A Randomized Trial

OBJECTIVES

The aim of this study was to assess growth and nutritional biomarkers of preterm infants fed human milk (HM) supplemented with a new powdered HM fortifier (nHMF) or a control HM fortifier (cHMF). The nHMF provides similar energy content, 16% more protein (partially hydrolyzed whey), and higher micronutrient levels than the cHMF, along with medium-chain triglycerides and docosahexaenoic acid.

METHODS

In this controlled, multicenter, double-blind study, a sample of preterm infants ≤32 weeks or ≤1500 g were randomized to receive nHMF (n = 77) or cHMF (n = 76) for a minimum of 21 days. Weight gain was evaluated for noninferiority (margin = -1 g/day) and superiority (margin = 0 g/day). Nutritional status and gut inflammation were assessed by blood, urine, and fecal biochemistries. Adverse events were monitored.

RESULTS

Adjusted mean weight gain (analysis of covariance) was 2.3 g/day greater in nHMF versus cHMF; the lower limit of the 95% CI (0.4 g/day) exceeded both noninferiority (P < 0.001) and superiority margins (P = 0.01). Weight gain rate (unadjusted) was 18.3 (nHMF) and 16.8 g · kg · day (cHMF) between study days 1 and 21 (D1-D21). Length and head circumference (HC) gains between D1 and D21 were not different. Adjusted weight-for-age z score at D21 and HC-for-age z score at week 40 corrected age were greater in nHMF versus cHMF (P = 0.013, P = 0.003 respectively). nHMF had higher serum blood urea nitrogen, pre-albumin, alkaline phosphatase, and calcium (all within normal ranges; all P ≤ 0.019) at D21 versus cHMF. Both HMFs were well tolerated with similar incidence of gastrointestinal adverse events.

CONCLUSIONS

nHMF providing more protein and fat compared to a control fortifier is safe, well-tolerated, and improves the weight gain of preterm infants.

Optimizing Nutrition in Preterm Low Birth Weight Infants-Consensus Summary

Preterm birth survivors are at a higher risk of growth and developmental disabilities compared to their term counterparts. Development of strategies to lower the complications of preterm birth forms the rising need of the hour. Appropriate nutrition is essential for the growth and development of preterm infants. Early administration of optimal nutrition to preterm birth survivors lowers the risk of adverse health outcomes and improves cognition in adulthood. A group of neonatologists, pediatricians, and nutrition experts convened to discuss and frame evidence-based recommendations for optimizing nutrition in preterm low birth weight (LBW) infants. The following were the primary recommendations of the panel: (1) enteral feeding is safe and may be preferred to parenteral nutrition due to the complications associated with the latter; however, parenteral nutrition may be a useful adjunct to enteral feeding in some critical cases; (2) early, fast, or continuous enteral feeding yields better outcomes compared to late, slow, or intermittent feeding, respectively; (3) routine use of nasogastric tubes is not advisable; (4) preterm infants can be fed while on ventilator or continuous positive airway pressure; (5) routine evaluation of gastric residuals and abdominal girth should be avoided; (6) expressed breast milk (EBM) is the first choice for feeding preterm infants due to its beneficial effects on cardiovascular, neurological, bone health, and growth outcomes; the second choice is donor pasteurized human milk; (7) EBM or donor milk may be fortified with human milk fortifiers, without increasing the osmolality of the milk, to meet the high protein requirements of preterm infants; (8) standard fortification is effective and safe but does not fulfill the high protein needs; (9) use of targeted and adjustable fortification, where possible, helps provide optimal nutrition; (10) optimizing weight gain in preterm infants prevents long-term cardiovascular complications; (11) checking for optimal weight and sucking/swallowing ability is essential prior to discharge of preterm infants; and (12) appropriate counseling and regular follow-up and monitoring after discharge will help achieve better long-term health outcomes. This consensus summary serves as a useful guide to clinicians in addressing the challenges and providing optimal nutrition to preterm LBW infants.

"Bed Side" Human Milk Analysis in the Neonatal Intensive Care Unit: A Systematic Review

Human milk analyzers can measure macronutrient content in native breast milk to tailor adequate supplementation with fortifiers. This article reviews all studies using milk analyzers, including (i) evaluation of devices, (ii) the impact of different conditions on the macronutrient analysis of human milk, and (iii) clinical trials to improve growth. Results lack consistency, potentially due to systematic errors in the validation of the device, or pre-analytical sample preparation errors like homogenization. It is crucial to introduce good laboratory and clinical practice when using these devices; otherwise a non-validated clinical usage can severely affect growth outcomes of infants.

Preterm Human Milk Macronutrient and Energy Composition: A Systematic Review and Meta-Analysis

This study is a systematic review of the macronutrient and energy composition of preterm human milk to enable the practicing neonatologist to make informed nutritional decisions in preterm infants. Meta-analyses were conducted in all the studies that reported total energy, true protein, fat, and lactose. Protein content decreased massively (by one-half) and significantly from day 1 to 3 at week 10 to 12. There was a significant linear increase in fat, lactose, and energy content during the same timeframe. Theoretic calculations on energy and macronutrient intake of preterm infants must be made according to a lactation time-specific manner.

Neurodevelopmental outcomes and nutritional strategies in very low birth weight infants

The developing brain of the very low birth weight (VLBW) infant is highly sensitive to effects of the nutritional milieu during the neonatal hospitalization and after discharge. Strategies to optimize nutritional care play an important role in reducing long-term neurodevelopmental morbidities in this population. Currently available interventions to ensure that the unique nutrient requirements of the VLBW infant are met include various dietary fortification strategies and parenteral nutrition. In this article, we review evidence regarding nutritional strategies and their beneficial effects on neurodevelopment in VLBW infants. We also highlight gaps in current knowledge and areas of current investigation that hold promise for improving nutritional care and long-term outcomes.

Is targeted fortification of human breast milk an optimal nutrition strategy for preterm infants? An interventional study

Background

Fortifying human milk contributes to the prevention of postnatal growth failure in preterm infants. Because of the natural variability of human milk, targeted fortification of human milk has been advocated. However, data regarding the efficacy and safety of prolonged targeted fortification are scarce. We aimed to assess the safety of targeted fortification of human milk in preterm infants compared with standard fortification, as well as the effects on infant growth.

Methods

We conducted an interventional study during hospital stay in healthy very low birth weight preterm infants who were exclusively fed human milk. Pools of human milk collected for 24 h were analysed using mid-infrared transmission spectroscopy. Targeted fortification of human milk was performed by adding macronutrients to native human milk to obtain optimal ratios of fat (4.4 g), carbohydrates (8.8 g), and protein (3 g) per 100 ml. The intervention period lasted 4–7 weeks. Weekly weight and daily growth rates were compared with those of a standardized fortification group of very low birth weight preterm infants who received standard fortified human milk (n = 10). The osmolality as well as the metabolic and gastrointestinal tolerance were monitored. Intergroup differences were evaluated using the Mann–Whitney U-test.

Results

A total of 10 preterm infants (birth weight 1223 ± 195 g; gestational age 29.1 ± 1.03 weeks) were enrolled and 118 samples of pooled milk were analysed. On average, 1.4 ± 0.1 g of protein, 2.3 ± 0.5 g of carbohydrate, and 0.3 ± 0.1 g of fat per 100 ml were added to the milk. Osmolality values after target fortification were within recommended limits (376 ± 66 mOsml/kg). Weekly weight gain (205.5 g; 95 % CI 177–233 vs 155 g; 95 % CI 132–178; p = 0.025) and daily growth rates (15.7 g/kg/day; 95 % CI 14.5–16.9 vs 12.3 g/kg/day; 95 % CI 10.7–13.9; p = 0.005) were higher in infants receiving target fortification than in infants receiving standardized fortification. The infants receiving targeted fortified milk consumed similar volumes as infants in the standardized fortification group (148 ± 4.5 vs 146 ± 4 ml/kg/day). No signs of either gastrointestinal or metabolic intolerance were observed.

Conclusions

Target fortification appears to promote growth in very low birth weight preterm infants without any detrimental effects.

Trial registration NCT02716337

A new formula for premature infants: effects on growth and nutritional status

OBJECTIVE

Nutritional management influences immediate survival as well as subsequent growth and development of low birth weight and very low birth weight infants. Preterm infant formula (PTF) is used when there is an inadequate supply of mother's milk or when the mother is unable to breastfeed and donor breast milk is unavailable. The purpose of this prospective multicenter study was to evaluate short-term effects on nutritional status (auxological and biochemical parameters) in a population of premature infants who received a preterm infant formula.

METHODS

Ninety-seven preterm infants with a birth weight between 500 g and 2000 g and a gestational age of 25-34 weeks postmenstrual age were randomly assigned to received a new preterm infant formula (Nutribèn Pre), and their nutritional status were compared to 75 fortified human milk (FHM) fed infants.

RESULTS

No significant differences were observed between FHM and Nutribèn Pre fed infants in terms of growth, feeding tolerance and biochemical profiles.

CONCLUSION

Nutribèn Pre is a valid, effective and safe alternative for the nutrition of preterm infants.

Human milk fortifier with high versus standard protein content for promoting growth of preterm infants: A meta-analysis

OBJECTIVE

To compare the growth of preterm infants fed standard protein-fortified human milk with that containing human milk fortifier (HMF) with a higher-than-standard protein content.

METHODS

Published articles reporting randomized controlled trials and prospective observational intervention studies listed on the PubMed®, Embase®, CINAHL and Cochrane Library databases were searched using the keywords 'fortifier', 'human milk', 'breastfeeding', 'breast milk' and 'human milk fortifier'. The mean difference with 95% confidence intervals was used to compare the effect of HMF with a higher-than-standard protein content on infant growth characteristics.

RESULTS

Five studies with 352 infants with birth weight ≤ 1750 g and a gestational age ≤ 34 weeks who were fed human milk were included in this meta-analysis. Infants in the experimental groups given human milk with higher-than-standard protein fortifier achieved significantly greater weight and length at the end of the study, and greater weight gain, length gain, and head circumference gain, compared with control groups fed human milk with the standard HMF.

CONCLUSIONS

HMF with a higher-than-standard protein content can improve preterm infant growth compared with standard HMF.

Positive effect of human milk feeding during NICU hospitalization on 24 month neurodevelopment of very low birth weight infants: an Italian cohort study

The aim of this study was to determine the effect of human milk feeding during NICU hospitalization on neurodevelopment at 24 months of corrected age in very low birth weight infants. A cohort of 316 very low birth weight newborns (weight ≤ 1500 g) was prospectively enrolled in a follow-up program on admission to the Neonatal Intensive Care Unit of S. Orsola Hospital, Bologna, Italy, from January 2005 to June 2011. Neurodevelopment was evaluated at 24 months corrected age using the Griffiths Mental Development Scale. The effect of human milk nutrition on neurodevelopment was first investigated using a multiple linear regression model, to adjust for the effects of gestational age, small for gestational age, complications at birth and during hospitalization, growth restriction at discharge and socio-economic status. Path analysis was then used to refine the multiple regression model, taking into account the relationships among predictors and their temporal sequence. Human milk feeding during NICU hospitalization and higher socio-economic status were associated with better neurodevelopment at 24 months in both models. In the path analysis model intraventricular hemorrhage—periventricular leukomalacia and growth restriction at discharge proved to be directly and independently associated with poorer neurodevelopment. Gestational age and growth restriction at birth had indirect significant effects on neurodevelopment, which were mediated by complications that occurred at birth and during hospitalization, growth restriction at discharge and type of feeding. In conclusion, our findings suggest that mother’s human milk feeding during hospitalization can be encouraged because it may improve neurodevelopment at 24 months corrected age.

Implementation of a human milk management center

Current hospital practices surrounding the use of human milk and fortification are suboptimal. Safety of milk preparation should be a priority, as should optimization of the milk to meet the nutritional needs of hospitalized infants. This article describes the implementation of a human milk management center (HMMC) at a children's hospital. This centralized center allows for milk to be safely prepared under aseptic technique. In addition, the HMMC staff can analyze milk composition. The widely variable nutrient composition of human milk has been well established and, therefore, should be considered when fortifying human milk. The HMMC staff have the ability to perform creamatocrits on milk, conduct human milk nutrient analysis, and make skim milk for infants. The processes for developing an HMMC are also detailed in this article.

An intention to achieve better postnatal in-hospital-growth for preterm infants: adjustable protein fortification of human milk

OBJECTIVE

We assessed the effect of human milk (HM) fortification with extra protein supplement by an adjustable protein fortification method according to the weekly blood urea nitrogen (BUN) levels on growth in hospitalized preterm infants.

METHOD

A prospective observational intervention study in 58 preterms born ≤32 weeks of gestation and fed with breast milk was conducted. Preterms who were given a commercial HM fortifier which provides an additional protein of 0.8 g/3 scales according to the standard feeding strategy served as a historical control group. Infants who were given extra protein in addition to the HM fortifier with another commercial protein supplement which provides an additional protein of 2.2g/1 scale comprised the intervention group. Additional protein supplementation was adjusted according to BUN levels weekly in the intervention group. Weight gain velocities (g/kg/day), length, head circumferences (HC) gain velocities (mm/day) and daily growth indexes for weight, height and HC (percentage per day) were calculated.

RESULTS

The median amount of daily enteral protein intake [4 (3.4-4.6) vs. 2.78 (2.1-3.1) g/kg/day, p < 0.0001] was significantly higher in the interventional group. Length (p = 0.008) and HC (p < 0.0001) gain velocities were significantly higher in the intervention group. Daily growth indexes for weight (2.2% vs. 1.8%, p = 0.026), for length (0.4% vs. 0.3%, p = 0.027) and for HC (0.48% vs. 0.36% per day, p = 0.003) were significantly higher in the intervention group.

CONCLUSION

A higher protein intake by adjustable protein fortification method without energy or volume change leads to improved postnatal in-hospital-growth in very low birth weight infants.

Benefits of donor milk in the feeding of preterm infants

Mother's own milk is widely recognized as the optimal feeding for term infants, but also provides health benefits that are of vital importance for sick and preterm infants in neonatal intensive care units (NICUs), even though the growth and neurodevelopmental needs of very premature infants are best met by appropriate fortification of human milk (HM). When mother's milk is unavailable or in short supply, donor milk (DM) represents the second best alternative and, although some nutritional elements are inactivated by the pasteurization process, it still has documented advantages compared to formula. Occasionally, the concern that the use of DM might decrease breastfeeding is being raised, but reports exist in literature showing that the use of donor HM in the NICU increases breastfeeding rates at discharge for VLBW infants. The demonstrated benefits of HM highlight the importance of educating health care professionals in breastfeeding support.

Human milk and the premature infant

Human milk is the preferred feeding for both term and preterm infants. While being considered optimal for term infants, human milk, even from mothers delivering preterm infants, is lacking in protein, energy, sodium, calcium, and phosphorus, resulting in poorer growth and nutrient deficiencies when compared to formulas designed for these high-risk infants. Further, the lack of growth is associated with long-term adverse consequences. Since human milk has unique properties in promoting gastrointestinal maturation and immunological benefits, it is prudent to implement strategies to fortify it appropriately to realize its benefits which include reduced rates of necrotizing enterocolitis, fewer episodes of sepsis and urinary tract infections, and improved visual and neurocognitive development. Donor human milk is being widely used when mothers' own milk is not available or is in short supply. While it retains some of the biological properties and clinical benefits of mothers' own milk, it requires additional care in fortification, especially if the donor milk is from a pool of term human milk. As nutritional strategies improve, the ultimate goal is to minimize extrauterine growth restriction and promote appropriate growth after regaining birth weight.

Human milk fortification with differing amounts of fortifier and its association with growth and metabolic responses in preterm infants

BACKGROUND

Fortification of human milk (HM) is a common clinical practice to adapt breast milk to the nutritional needs of very low birth weight (VLBW) infants. The optimal method for HM fortification remains to be determined, and a variety of protocols are currently used in neonatal intensive care units.

OBJECTIVE

It is believed that standard fortification is insufficient to meet the needs of VLBW infants. Therefore, we designed a randomized prospective study that investigated the effects of varying levels of blind fortification on short-term growth and metabolic responses of preterm infants.

METHODS

Eligible infants were randomized into 3 groups: standard fortification (SF), moderate fortification (MF), and aggressive fortification (AF). Short-term growth, feeding intolerance, and urea, calcium, phosphorus, and alkaline phosphatase levels were assessed.

RESULTS

There were 26, 29, and 29 infants in the SF, MF, and AF groups, respectively. The baseline characteristics of the groups were similar. Daily weight gain and length at discharge did not differ among the groups; however, head circumference was significantly higher in the MF and AF groups compared with the SF group. Urea, calcium, phosphorus, and alkaline phosphatase levels were similar between the groups.

CONCLUSION

We demonstrated that blind fortification of HM, even with higher amounts than recommended by manufacturers, did not cause any measured adverse effects on the metabolic response of preterm infants. Anthropometric measurements (except head circumference) were not different between the different dosages of fortification.

Variability in human milk composition: benefit of individualized fortification in very-low-birth-weight infants

BACKGROUND

Preterm infants fed fortified human milk (HM) grow more slowly than those fed preterm formulas. These differences could be related to the variability in the macronutrient composition of expressed HM, resulting in inadequate nutrient intake in relation to the estimated needs of the preterm infants.

OBJECTIVES

The aim of this article was to show the variability in HM composition from an infant's own mother's milk (OMM) or pooled HM from the milk bank. The second objective was to evaluate the advantages of individual fortification on nutritional intakes over standard fortification.

DESIGN

The macronutrient composition of 428 OMM, 138 HM pools from single donors, 224 pools from multiple donors, and 14 pools from colostral milk was determined by using a mid-infrared analyzer. Individualized fortification was performed after analysis of the milk samples in 2 steps: adjustment of fat content up to 4 g/dL, followed by the addition of an HM fortifier to provide 4.3 g · kg(-1) · d(-1) according to the daily prescribed volume of feeding. Nutritional intakes resulting from the individualized fortification were compared with calculated intakes resulting from standard fortification (HM fortifier: 4 packets/dL).

RESULTS

The variability in contents of fat, protein, and energy was high for all types of HM samples. Compared with standard fortification, individual fortification significantly reduced the variability in nutritional intakes, allowing the maintenance of protein intake and the protein:energy ratio in the range of the nutritional recommendations.

CONCLUSIONS

The variability in expressed HM with respect to its protein and energy content is high. This variability persists after standard fortification, possibly resulting in under- or overnutrition. Because both over- and undernutrition confer risks in later development, individualized fortification optimizes protein and energy intake.

Establishment of micromethods for macronutrient contents analysis in breast milk

Commercially available milk analysers were originally developed for use in the dairy industry, but they are now used to analyse macronutrient content of breast milk in clinical studies and routine care of the premature or very low birthweight (VLBW) infants. Due to the different composition of cow and breast milk, these devices need to be validated against reference methods before they can be used in daily routine. However, current reference methods require a sample volume of 30-100 mL to analyse fat, protein and lactose. It is not feasible to obtain this volume of milk for research purposes, especially from VLBW infants as lactation may be delayed or impaired and the limited volume of breast milk must be provided to the infant. To support validation of milk analysers in both clinical and research settings, the aim of this study is to establish and validate micromethods for precise macronutrient analysis in small volume of breast milk and conduct a feasibility study of the micromethods as a post-validation. Methods include a modified Mojonnier ether extraction (fat), elemental analysis (protein) and ultra-performance liquid chromatography-tandem mass spectrometry (lactose). We were able to downsize volumes required for analysis of fat, protein and lactose to 1 mL, 260 μL and 100 μL; corresponding coefficients of variation are 1.7, 1.8 and 2.3%, respectively. The presented methods allow for reliable and precise analyses of macronutrients in ≤1.5 mL of breast milk and will be used to validate milk analysers.

The enigma to achieve normal postnatal growth in preterm infants--using parenteral or enteral nutrition?

AIM

To evaluate whether increasing the amount of amino acids and energy in parenteral nutrition combined with rapid increment of enteral feeding improves postnatal growth in preterm infants.

METHODS

Observational study; two consecutive year-cohorts of preterm infants; Cohort 2 received higher supplementation of parenteral amino acids and energy with more rapid enhancement of enteral feeding than Cohort 1. Nutritional intake, weight and head circumference (HC) were compared.

RESULTS

Cohort 2 [N: 79, gestational age (GA): 29.8 ± 2.2 weeks, birth weight (BW): 1248 ± 371 g] achieved full enteral feeds earlier (p < 0.001) and had a higher protein/energy intake during the first week (p < 0.001) than Cohort 1 (N: 68, GA: 29.5 ± 2.3 weeks, BW: 1261 ± 339 g). Both cohorts developed cumulative protein/energy deficits, but less in Cohort 2 (p < 0.01). Appropriate for gestational age infants (AGA) of Cohort 2 improved weight gain until week 5 (p < 0.01) compared to AGA of Cohort 1, nevertheless all infants demonstrated a decline in mean standard deviation score (>1) for weight at term. Small for GA infants failed to improve HC.

CONCLUSION

Improved parenteral intake may lead to improved short-term postnatal weight gain. Faster increase of enteral nutrition was well tolerated but failed to prevent nutritional deficits. Practising early enteral feeding with higher supplementation of nutrients may be needed and requires further study.

A new liquid human milk fortifier and linear growth in preterm infants

OBJECTIVES

To evaluate the growth, tolerance, and safety of a new ultraconcentrated liquid human milk fortifier (LHMF) designed to provide optimal nutrients for preterm infants receiving human breast milk in a safe, nonpowder formulation.

METHODS

Preterm infants with a body weight ≤ 1250 g fed expressed and/or donor breast milk were randomized to receive a control powder human milk fortifier (HMF) or a new LHMF for 28 days. When added to breast milk, the LHMF provided ∼20% more protein than the control HMF. Weight, length, head circumference, and serum prealbumin, albumin, blood urea nitrogen, electrolytes, and blood gases were measured. The occurrence of sepsis, necrotizing enterocolitis, and serious adverse events were monitored.

RESULTS

This multicenter, third party-blinded, randomized controlled, prospective study enrolled 150 infants. Achieved weight and linear growth rate were significantly higher in the LHMF versus control groups (P = .04 and 0.03, respectively). Among infants who adhered closely to the protocol, the LHMF had a significantly higher achieved weight, length, head circumference, and linear growth rate than the control HMF (P = .004, P = .003, P = .04, and P = .01, respectively). There were no differences in measures of feeding tolerance or days to achieve full feeding volumes. Prealbumin, albumin, and blood urea nitrogen were higher in the LHMF group versus the control group (all P < .05). There was no difference in the incidence of confirmed sepsis or necrotizing enterocolitis.

CONCLUSIONS

Use of a new LHMF in preterm infants instead of powder HMF is safe. Benefits of LHMF include improvements in growth and avoidance of the use of powder products in the NICU.

Digestion of Protein in Premature and Term Infants

Premature birth rates and premature infant morbidity remain discouragingly high. Improving nourishment for these infants is the key for accelerating their development and decreasing disease risk. Dietary protein is essential for growth and development of infants. Studies on protein nourishment for premature infants have focused on protein requirements for catch-up growth, nitrogen balance, and digestive protease concentrations and activities. However, little is known about the processes and products of protein digestion in the premature infant. This review briefly summarizes the protein requirements of term and preterm infants, and the protein content of milk from women delivering preterm and at term. An in-depth review is presented of the current knowledge of term and preterm infant dietary protein digestion, including human milk protease and anti-protease concentrations; neonatal intestinal pH, and enzyme activities and concentrations; and protein fermentation by intestinal bacteria. The advantages and disadvantages of incomplete protein digestion as well as factors that increase resistance to proteolysis of particular proteins are discussed. In order to better understand protein digestion in preterm and term infants, future studies should examine protein and peptide fragment products of digestion in saliva, gastric, intestinal and fecal samples, as well as the effects of the gut micro biome on protein degradation. The confluence of new mass spectrometry technology and new bioinformatics programs will now allow thorough identification of the array of peptides produced in the infant as they are digested.