Exploring Innovations in Human Milk Analysis in the Neonatal Intensive Care Unit: A Survey of the United States

Abstract

Introduction: Human milk (HM) is the ideal enteral feeding for nearly all infants and offers unique benefits to the very low birthweight (VLBW) infant population. It is a challenge to meet the high nutrient requirements of VLBW infants due to the known variability of HM composition. Human milk analysis (HMA) assesses the composition of HM and allows for individualized fortification. Due to recent U.S. Food and Drug Administration (FDA) approval, it has relatively recent availability for clinical use in the US.Aim: To identify current practices of HMA and individualized fortification in neonatal intensive care units (NICUs) across the United States (US) and to inform future translational research efforts implementing this nutrition management method.Methods: An institutional review board (IRB) approved survey was created and collected data on the following subjects such as NICU demographics, feeding practices, HM usage, HM fortification practices, and HMA practices. It was distributed from 10/30–12/21/2020 via online pediatric nutrition groups and listservs selected to reach the intended audience of NICU dietitians and other clinical staff. Each response was assessed prior to inclusion, and descriptive analysis was performed.Results: About 225 survey responses were recorded during the survey period with 119 entries included in the analysis. This represented 36 states and Washington D.C., primarily from level III and IV NICUs. HMA was reported in 11.8% of responding NICUs. The most commonly owned technology for HMA is the Creamatocrit Plus TM (EKF Diagnostics), followed by the HM Analyzer by Miris (Uppsala, Sweden). In NICUs practicing HMA, 84.6% are doing so clinically.Discussion: Feeding guidelines and fortification of HM remain standard of care, and interest in HMA was common in this survey. Despite the interest, very few NICUs are performing HMA and individualized fortification. Barriers identified include determining who should receive individualized fortification and how often, collecting a representative sample, and the cost and personnel required.Conclusions: Human milk analysis and individualized fortification are emerging practices within NICUs in the US. Few are using it in the clinical setting with large variation in execution among respondents and many logistical concerns regarding implementation. Future research may be beneficial to evaluate how practices change as HMA and individualized fortification gain popularity and become more commonly used in the clinical setting.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

“…Strategies for individualized breast milk fortification include adjusted and targeted fortification, as well as combinations of both methods. Results from a recent national survey of U.S. NICUs demonstrated that only 12% of respondents currently utilize human milk analysis, whereas 41% employ adjusted fortification methods and 98% use modular macronutrient products [44].…”

“…Coordination with lactating mothers is also necessary to obtain accurate milk samples that are reflective of average macronutrient content. This process may involve large, multidisciplinary care teams including pharmacy or milk laboratory technicians, registered dieticians, lactation consultants, and physicians [44].…”

Associations of Macronutrient Intake Determined by Point-of-Care Human Milk Analysis with Brain Development among very Preterm Infants

“…The current standard of nutritional care for these infants is a human milk diet, based on the established health benefits of human milk, with fortification added to meet this population’s high nutrient needs [ 8 ]. Standard fortification—adding a fixed quantity of multicomponent fortifier based on average reference values for macronutrient content—is practiced routinely, but this strategy does not achieve target nutrient intakes for all infants [ 9 ]. Due to variability in actual human milk content, up to half of very preterm infants receiving standard fortification do not meet recommended intakes of protein and/or energy [ 10 , 11 ].…”

“…The advent of commercially available devices that use infrared spectroscopy to analyze small milk volumes at the point-of-care overcomes these obstacles, making human milk analysis clinically feasible in the NICU [ 12 ]. Emerging research is investigating the potential of this technology to improve outcomes for preterm infants [ 9 ]. The underlying premise is that knowledge about actual milk composition can eliminate gaps in macronutrient delivery, thereby reducing undernutrition and its adverse consequences, including neurodevelopmental impairment.…”

Taking Human Milk Fortification to the Next Level

“…In addition, infants in the intervention group had less feeding intolerance, higher BUN levels, and lower triglycerides 7. However, incorporating targeted fortification into standard practice in NICUs may be challenging since it requires the purchase of expensive equipment as well as trained personnel to analyze the HM and determine the fortification recipe for each infant and currently only 12% of US NICUs utilize targeted fortification 16. In addition, because MOM changes throughout the day, analysis of a single sample rather than a pooled 24-hour sample may not be an accurate assessment of nutritional content.…”