The role of breast milk fortifier in the post-discharge nutrition of preterm infants

Abstract

Infants born prematurely are often discharged from hospital before 37 weeks post-menstrual age. While breastfeeding will meet all the nutritional requirements of full-term infants, these preterm infants may need enhanced levels of protein, minerals and possibly energy to ensure optimum growth, bone mineralisation and neurological development. To meet these additional nutrient needs in the neonatal unit, it is currently recommended that multinutrient breast milk fortifier is added to maternal breast milk. There may also be benefits in continuing to provide fortified milk after discharge, potentially including improved growth and preserving breastfeeding, and this is increasingly becoming a recognised practice in some neonatal units. This article presents the discussion and consensus of a multidisciplinary panel of neonatologists, neonatal dietitians, a GP and a neonatal outreach sister. The aim is to develop guidance on providing safe and effective nutritional supplementation for preterm infants after discharge in order to maintain optimal growth. This guidance is aimed at community healthcare staff and is based on the limited evidence available, using shared best practice and expertise.

Complementary feeding in preterm infants: a position paper by Italian neonatal, paediatric and paediatric gastroenterology joint societies

“…Additional studies were identified from conference proceedings, trial registries and the reference lists of the selected papers. As a result, 62 manuscripts were selected for this position paper, including 8 systematic reviews [3,18,[21][22][23][24][25][26], 8 narrative reviews [27][28][29][30][31][32][33][34], 27 observational studies [19,, 4 controlled trials [61][62][63][64], 1 case report [65], 3 commentaries [66][67][68], 1 operational protocol [69], 3 reports [70-72], 1 consensus [73], 2 recommendations [74,75], 2 guidelines [76,77] and 3 nutritional reference values [78][79][80]. One or more recommendations/statements were drafted for each topic.…”

“…Similarly to in-hospital nutrition, also at home the main options are human milk (HM), raw or fortified, and formula milk adapted for preterm infants. Despite the fact that fortified HM may help ensure adequate growth [33,53], the use of fortifiers at home may be troublesome, hence parents should be carefully informed on the importance of continuing fortification after discharge from hospital to improve growth and support breastfeeding, [73] in a period when feeding and sucking competency on the breast are usually improved [53]. Hence, mother's milk supplementation is often discontinued, exposing the infant to the risk of nutritional deficits and decreased weight gain soon after discharge [34,53].…”

Guidelines for enteral nutrition in infants born preterm: 2023 update by the Portuguese Neonatal Society. Part II. Enteral feeding in specific clinical conditions and feeding after discharge

“…Cessation of MOM fortification after discharge is not consensual. Some suggest stopping fortification at around 6 to 12 weeks post term age, while others suggest discontinuing only once infants have achieved some catch-up growth 39 .…”

“…MOM fortification is advisable in infants fed non-fortified HM discharged with unsatisfactory growth, or if weight gain becomes suboptimal after discharge (LOE 4) 32,38 . In these cases, fortification can be discontinued at 6-12 weeks post term age (LOE 4) 39 .…”

Evidence summary of human milk fortifier in preterm infants

“…Breast milk fortifier (6), also known as breast milk nutritional supplement, is a multinutrient additive rich in protein, energy, vitamins, iron, and minerals which usually comes in a liquid or powder form. In the United States, United Kingdom, and other developed countries, breast milk fortifier has been used as an intervention to meet the nutritional needs of premature infants in neonatal intensive care units, neonatal care units, and after discharge (13,14). Milk is usually given at 6-48 hours after birth.…”