Challenges in Implementing Exclusive Human Milk Diet to Extremely Low‐Birth‐Weight Infants in a Level III Neonatal Intensive Care Unit

Abstract

Problem: Extremely low‐birth‐weight (ELBW) infants require fortification of human milk (HM) to prevent growth failure. Bovine milk–based fortifiers (BOV‐f) may be associated with feeding intolerance and necrotizing enterocolitis. Evidence suggests that an exclusive HM diet (EHMD) using HM‐based fortifier (HM‐f) may improve these outcomes. Intervention: EHMD was introduced as a quality improvement project to improve feeding tolerance in ELBW infants. Method: Implementation included establishing EHMD feeding protocol and growth monitoring. We compared infants receiving HM with BOV‐f (n = 49) with infants receiving an EHMD (n = 15). The primary outcome was a reduction of no oral intake days due to feeding intolerance. Results: The EHMD cohort had a more advanced GA (28 vs 26 weeks; P = .03), more males (66.7% vs 42.9%; P = .02), and higher incidence of SGA (40.0% vs 18.4%; P = .16) compared with the HM‐f group. The EHMD cohort had fewer days with no oral intake (2 vs 5; P < .005), which is insignificant when adjusted for small for gestational age (SGA) (P = .26). The EHMD cohort vs. the HM‐f cohort had a significant decrease in weight and length z‐scores from birth to discharge (−1.09 vs −0.26 [P = .002]; −1.76 vs −0.83 [P = .02]). Inadequate weight gain persisted after adjustment for SGA. Interventions were performed to increase caloric intake and institute milk preparation changes. Conclusion: EHMD improved feeding tolerance in our ELBW infants. Observed growth failure might be skewed by SGA prevalence. We highlight that implementation of EHMD requires close growth assessment, especially for SGA infants.

Improved Outcomes and Reduced Costs: Exclusive Human Milk Diet for Very Low Birth Weight Infants at a Single Center

“…Our data provides further support of trends identi ed in other studies, [38][39][40]43,44 including that growth in weight, length, and head circumference on an EHMD diet is comparable to that on a formula or bovineforti ed diet. This contradicts other studies about growth outcomes related to breastmilk versus formula or bovine forti cation in this population 35,36 but may be attributable to forti cation in the post-EHMD group taking place an average of almost 8 days earlier than in the pre-EHMD group. There were no differences between groups in other parameters that may potentially be related to nutrition when evaluated at the time of transition off EHMD, including serum sodium and serum alkaline phosphatase, and there was even an improvement in the post-EHMD group in hematocrit and serum albumin.…”

“…Bushati C et al showed improved feeding tolerance but worse growth with EHMD compared to bovine-based forti cation of human milk. 35 Eibensteiner F et al published data from multiple centers demonstrating no difference in rates of NEC but worse growth velocity for babies receiving the EHMD diet compared to those on human milk forti ed with bovine-based forti er. 36 However, other studies suggest than an exclusive human milk diet (EHMD: MOM or DHM forti ed with human milk-based forti er) improves feeding tolerance and NEC without detrimental effects on growth compared to human milk forti ed with bovine-based forti ers and/or preterm formula.…”

Extremely low birthweight neonates with phenylketonuria require special dietary management

“…This is usually achieved with parenteral solutions of essential amino acids or enteral feeding with human milk supplemented with bovine or human milk‐based fortifiers 2 . High‐protein nutrition can be challenging in when ELBW neonates have phenylketonuria (PKU), due to the lack of a phenylalanine‐free amino acid solution for parenteral nutrition 3 . PKU is an autosomal recessive metabolic disease of phenylalanine metabolism that is caused by deficient activity of phenylalanine hydroxylase (PAH), an enzyme that converts phenylalanine into tyrosine.…”

Fats in Human Milk: 2022 Updates on Chemical Composition

“…10 The combination of HM-derived fortifiers with either DM or MOM, excluding any products cow's milk-containing products, has been labeled as exclusive HM diet. 11 Fat in HM is an important energy source for enterally fed growing term and premature infants. 12 Infants may have developmental limitations in utilizing milk-borne fats in the first few weeks after birth.…”